重症监护病房与生命延长相关的伦理问题

重症监护病房(ICU)是集中收治急危重症患者的护理单元,通过应用先进的监护设备和诊治技术,为重症患者提供生命支持治疗,部分急危重症患者经过积极的救治,生命得以延续。然而当我们从ICU获得益处的同时,又常常会面临一系列与生命质量相关的伦理挑战。随着医学技术的发展,人们越来越担忧医学的非人性化趋势。在危重病患者救治过程中,转变医疗理念,以患者为中心,加强人文关怀,尊重患者的生命价值以及人格尊严,同时,医务工作者实施的治疗抉择必须经得起医学伦理准则的推敲。     

《医学与哲学》第22卷总目次

新的世纪　新的追求———新年献辞本刊编辑部 ( 1:1)…………………………………重症胰腺炎外科治疗观之辩汪训实 ( 1:3)……………………………重症加强监护医学与临床思维李树钧 ,郭照江 ( 1:6 )………………循证医学指导医疗实践李崇剑 ,徐　耕 ( 1:9)………………………循证医学及其在心血管疾病中的应用李春坚 ( 1:11)………………循证医学的实践与医学研究的方法夏邦顺 ( 1:15 )…………………论并发症的制约因素刘　虹 ( 1:18)…………………………………浅谈分子生物学与临床医学研究的结合陈　东 ,贺建业 ( 1:2 2 )……加强研究能…     

还原论对临床决策的影响

“看病贵”已经不仅仅是一个简单的医院职能问题了,从政治、经济、文化、社会、环境、医学、心理等各个领域,都对这个问题展开了广泛的探讨和研究,本文从哲学和医学发展史的角度,纵深剖析了还原论对医院临床决策的影响,指出当前医院的种种弊端在很大程度上是由于受到还原论的思维方式的不利影响,希望能够为临床决策的改进提供一条新的思路。     

重症医学科临床思维几点探讨

重症医学科危重病患者病情变化的错综复杂和诊治方法的特殊性对重症医学科医生的临床思维提出了新的要求,哲学的思维方法显得非常重要;本文对重症医学科医生临床思维中需经常面临的系统与局部、循证与经验、多学科协作、临床与人文之间的关系等重要问题进行初步的哲学思考。     

重症医学科临床思维几点探讨

重症医学科危重病患者病情变化的错综复杂和诊治方法的特殊性对重症医学科医生的临床思维提出了新的要求,哲学的思维方法显得非常重要;本文对重症医学科医生临床思维中需经常面临的系统与局部、循证与经验、多学科协作、临床与人文之间的关系等重要问题进行初步的哲学思考.     

亚低温在重型颅脑损伤患者救治中的应用与思考

重型颅脑损伤是致死、致残的主要原因之一。亚低温（MHT）的应用为重型颅脑损伤患者的救治提供了新的思路和方法,国内外多个临床试验证实了其在救治中的有效性和实用性。本文结合国内外相关诊疗指南、循证医学证据和文献,辩证探讨了MHT在重型颅脑损伤患者救治中的适应证及机制、操作方法及时间窗、并发症及临床决策问题。     

亚低温在重型颅脑损伤患者救治中的应用与思考

重型颅脑损伤是致死、致残的主要原因之一.亚低温(MHT)的应用为重型颅脑损伤患者的救治提供了新的思路和方法,国内外多个临床试验证实了其在救治中的有效性和实用性.本文结合国内外相关诊疗指南、循证医学证据和文献,辩证探讨了MHT在重型颅脑损伤患者救治中的适应证及机制、操作方法及时间窗、并发症及临床决策问题.     

现代医学目的之我见

现代医学目的之我见中山医科大学硕士生（广州５１００８９）钱朝南传统的观念认为，医学的目的是救死扶伤，防治疾病。这一观念导致的结果是，在整个医学的发展史中，人类正日益盲目地对一切疾病进行救治，从而使医学的发展也日益背离自然规律的要求。自然物种经过反复无...     

前景理论在重症医学临床决策中的应用

临床决策是每一个医生每天面临的工作,正确的临床决策不仅可以带给患者较好的结果,同时也可以让医生与患者及家属沟通更加良好。本文首先论述了重症医学的临床决策特点,每一个救治方案的收益与损失的权衡不仅仅是取决于患者病情,而且与决策者的风险偏好有明显关系。为了更好地解决这个问题,把诺贝尔奖获奖者丹尼尔的前景理论引入到重症患者的...     

ICU患者知情同意权的伦理问题思考

当前,重症监护(Intensive Care Unit,ICU)医生已逐步意识到重视患者知情同意权的重要性.然而,患者或其家属对医生的满意度似乎并未提高,医患之间仍存在很多不和谐的问题.试图从医学伦理学角度分析患者在履行知情同意权时存在的一些伦理问题,从而为构建和谐医患关系提供一种新的思路.     

Religion and medicine: A theoretical overview

Recent scholarly studies in history, sociology, anthropology, religion, and psychosomatic medicine, coupled with clinical experience in the care of patients, call for a reassessment of the interrelationships between religion and medicine. Six major areas of interaction between these forms of human experience are identified and outlined. Investigations into these interlinkages not only offer challenging new opportunities for discovery but also hold promise for the development of new, more effective forms of medical care and healing. This new understanding of the interconnections between medicine and religion has many implications both for health care practitioners and for professionals with specialized training in religious studies.Has studied and taught in the areas of religion, American and Western history, and the history of medicine and medical ethics. He is the author of a number of publications on history, ethics, and the interrelationships between religion and medicine.     

循证医学的辩证思维

随着临床医学的发展,临床医生面临着从理论知识加个人经验的医学模式向以科学证据为基础的医学模式转变。越来越多的卫生政策和诊疗指南的制定需要以高质量的研究结果为依据,如随机对照研究的结果,特别是随机对照研究的系统综述结论。循证医学模式要求医生在临床工作中不断提出问题并通过严格的科研设计来回答这些问题,同时强调不断进行知识更新,掌握最新研究证据以指导其临床工作。同时政府部门也鼓励发展循证医疗,因为它可通过研究有效的诊疗手段来提高卫生保健的效率。此外还有迹象表明法律决策过程中要参考是否遵循了研究证据和临床指南。知情的服务对象也促使临床工作者寻求研究证据作为依据,为了提高服务质量并且充分把握特殊专业领域的现状,临床工作者也需要不断了解新的依据信息。在众多的研究信息中,我们应对每项证据的研究方法、研究对象及观察的终点进行认真分析,确定该结论是否真实并适合我们的实际,从而制定有据可查的诊疗方案。     

NICE帕金森病指南与循证医学的人文精神

循证医学是一种人性化的医学实践方法,最近发布的英国国家临床最优化研究所(NICE)帕金森病(PD)指南,即《帕金森病诊断与管理指南——第二次咨询稿》,充分体现了PD诊疗决策中的人文关怀和循证医学的人文精神。作者从NICE指南的指导思想、医患交流及姑息护理阐述了PD诊治中的人文思想和循证医学对医学人文精神的不断追求。     

Morality in the valley of the moon: The origins of the ethics of neonatal intensive care

One of the first areas of ethical concern in medicine was the neonatal intensive care unit. Questions first seen in this context soon entered the discourse of bioethical debate. The history of the ethics of neonatal care is described from the context of neonatology, and the emerging principles are outlined.     

临床药师问诊与实践体会

问诊是临床医师的基本技能之一.医师通过问诊可以获得病史资料,从而做出临床决策.随着医学模式从传统的生物医学模式向生物心理社会医学模式转变和临床药学的蓬勃发展,药学服务模式从传统的以保障药品供应为中心向以患者为中心模式转变.药师从药房逐步走向临床,参与合理用药和提供药学服务,问诊也应成为临床药师的基本技能之一.本文通过笔者问诊实践,阐述问诊对于临床药师的重要性、药师问诊的内容及其与医生问诊的区别.     

医学生临床实习应掌握的几种哲学思维方式

为适应全球卫生事业的迅猛发展,面对医学教育落后于医学发展的现状,转化医学教育迫在眉睫。在第三代“以系统为基础”的教育改革中,培养医学生的哲学思维无疑是其重要环节之一。思维方式必须在医学生步入临床时就要开始正确培养,一旦开始阶段就养成不正确的思维方式、不但会导致医疗过程中的失误,而且再想改变将会有很大难度。本文通过对医学哲学重要性的探讨,剖析医学生哲学思维的不足,阐述了医学生,临床实习过程中应掌握的几种哲学思维方式。旨在提高医学生的哲学理念,促进以岗位胜任能力为导向的医学教育转型发展。     

What Factors Determine Disclosure of Suicide Ideation in Adults 60 and Older to a Treatment Provider?

Correlates of patient disclosure of suicide ideation to a primary care or mental health provider were identified. Secondary analyses of IMPACT trial data were conducted. Of the 107 patients 60 years of age or older who endorsed thoughts of ending their life at least “a little bit” during the past month, 53 indicated they had disclosed these thoughts to a mental health or primary care provider during this period. Multiple logistic regression was used to identify predictors of disclosure to a provider. Significant predictors included poorer quality of life and prior mental health specialty treatment. Among participants endorsing thoughts of suicide, the likelihood of disclosing these thoughts to a provider was 2.96 times higher if they had a prior history of mental health specialty treatment and 1.56 times higher for every one‐unit decrease in quality of life. Variation in disclosure of thoughts of suicide to a mental health or primary care provider depends, in part, on patient characteristics. Although the provision of evidence‐based suicide risk assessment and guidelines could minimize unwanted variation and enhance disclosure, efforts to routinize the process of suicide risk assessment should also consider effective ways to lessen potential unintended consequences.     

Religion and Public Health: Moral Tradition as Both Problem and Solution

Despite strong religious influence in the development of medicine and medical ethics, religion has been relatively absent in the rise of preventive medicine and population health. Episodic, clinical medicine has a powerful hold on the religious imagination in health care. Nevertheless, Hebrew Scripture, elements of rabbinical teaching, and modern concepts of social justice all can be used to inspire action in health care that goes beyond clinical medicine. The Christian tradition can call upon the corporal works of mercy, virtue ethics, and Catholic social teaching, as well as the modern history Catholic sisters in the U.S. to do the same. By considering the moral imperative for public health, Jewish and Christian individuals and organizations reaffirm the notion that the human person is both sacred and social. This article suggests a need for religious traditions to consider their moral traditions anew with an eye toward prevention and population health.

     

The Use of Psychoeducation for a Patient with Hepatitis C and Psychiatric Illness in Preparation for Antiviral Therapy: A Case Report and Discussion

The standard of care treatment for chronic hepatitis C viral infection (HCV) is a combination of pegylated interferon alfa and ribavirin for 24-48?weeks according to the virus genotype. This therapy is known to have multiple neuropsychiatric side effects. A major concern when evaluating a patient for HCV treatment with a known history of a psychiatric disorder is the risk that the patient's psychiatric disorder will flare or become unmanageable. The possibility of precipitating depression, confusion, mania, psychosis, hallucinations, or suicidal ideation or attempt is frequently an obstacle to treatment. We present the case of a 50?year-old man with HCV and an extensive psychiatric history involving alcoholism, depression, and suicidality who participated in a psychoeducation group to help prepare him for treatment with pegylated interferon alfa/ribavirin therapy. Though the patient derived much benefit from the psychoeducation group, by the time of evaluation for HCV treatment two months after the group ended he had relapsed back into a depressive episode with suicidal thoughts. His acute psychiatric status made him unacceptable for pegylated interferon alfa/ribavirin therapy. Psychoeducation groups show promise for helping patients with chronic medical illness to be ready for and endure intensive medical treatment that has substantial psychiatric side effects. The challenge is to help patients overcome barriers to treatment, particularly psychosocial problems, because available treatments are increasingly effective.     

Risk for Suicidal Ideation and Attempt among a Primary Care Sample of Adolescents Engaging in Nonsuicidal Self‐Injury

One in five adolescents in the United States has engaged in nonsuicidal self‐injury (NSSI), one in eight have had serious thoughts of suicide, and one in 25 have attempted suicide. Research suggests that NSSI may increase risk for suicide attempt, yet little is known about the relationship between NSSI and suicidal ideation or attempts. In a primary care setting, 1,561 youth aged 14–24 years completed a brief, comprehensive, mental health screen as part of a routine well visit to determine which factors were most likely to predict suicidal ideation and attempt among youth engaging in NSSI. Results of recursive partitioning revealed that current depression and history of alcohol use best differentiated youth engaging in NSSI with low versus high risk for suicidal ideation and attempts. This simple algorithm is presented as a clinical screening tool that might aid medical providers in determining which youth would benefit from more intensive assessment and intervention.