医疗行善与病人自主的冲突与解决——论"患者最佳利益"之实现

维护"患者的最佳利益"是当代医疗决策的伦理要求.但是,通过对"患者最佳利益"的综合分析发现,建立在尊重个-人权利基础之上的"患者最佳利益"将患者的个人决策置于医生的专业判断之上,呈现出与传统医学伦理观念相背离的状态.不过,"患者最佳利益"是有存在的可能性和实现的操作性的.基于患者的心智和理性状态的不同,提出不同的判断标准,并设想了与之配套的一些程序.     

论个体差异与诊疗决策

诊疗决策最优化的过程,本质上是针对特定的患者,制定最适合其个体差异的决策过程.对个体差异认知方式,经验医学基于对个体的不完全归纳,循证医学基于对群体随机、双盲、对照、大样本,人类基因组学基于对人类基因的差异表达、单核苷酸多态和复制变异的研究.最优化的治疗方案应体现关注患者心理、社会差异、关注生命质量、远离趋利性等人文特征;体现针对个体病患生物学特性差异、个体病程病期和个体最佳疗效差异等科学特征.     

腹膜透析相关性腹膜炎诊治的临床决策

腹膜透析相关性腹膜炎的治疗以前主要着眼于抗生素的选择,但其防治应该是从腹透管置管开始的整体策略,包括预防性抗生素的使用、患者的强化培训、腹膜炎的早期快速诊断、给药途径与疗程,以及拔管指征等.肾科医师临床决策是需要根据最新的治疗指南及研究进展,结合患者的个体特点进行综合判断,以期达到最佳的治疗效果.     

实质性善理论:临床伦理决策的基础

目前,人们一般认为病人或病人的代理人有权与医生共同参于医疗决策,这使我们有必要对“价值”问题展开讨论,因为在临床实践中,对价值的不同理解暗示着不同的决策模式.在三种最基本的价值理论中,快乐主义理论和欲望满足理论预示着病人主观的意识经验或偏好是病人最佳利益的决定因素,它们都不能单独作为临床伦理决策的合理基础.而实质性善理论试图为我们提供何种事物使生活变得更好的实质性判断,虽然这一理论还有广阔的讨论空间,但可以引导医生与病人在各种价值之间达到平衡,做出更为有效的临床伦理决策.     

论个体差异与诊疗决策

诊疗决策最优化的过程,本质上是针对特定的患者,制定最适合其个体差异的决策过程。对个体差异认知方式,经验医学基于对个体的不完全归纳,循证医学基于对群体随机、双盲、对照、大样本,人类基因组学基于对人类基因的差异表达、单核苷酸多态和复制变异的研究。最优化的治疗方案应体现关注患者心理、社会差异、关注生命质量、远离趋利性等人文特征;体现针对个体病患生物学特性差异、个体病程病期和个体最佳疗效差异等科学特征。     

疾病诊疗决策中如何具体融合患者的价值观

诊疗决策不仅依据循证医学、临床经验和个体化原则，必须同时充分理解和尊重患者的价值观，使得患者的价值取向与医学客观发展规律走向一致。并且在不影响社会利益的前提下，追求患者的最佳利益获取。     

紧急专断治疗相关主体的权利义务研究

在紧急情况下,医师一般应当尊重患者的自决权;如果有证据表明患者的决策不是基于其对生命健康的放弃,医师则有违反患者意志对其进行抢救的权利和义务。代理人的决策如果违背患者的利益,医师有权利和义务拒绝代理人的意见,而实施对患者最有利的医疗处置方案。     

腹膜透析相关性腹膜炎诊治的临床决策

腹膜透析相关性腹膜炎的治疗以前主要着眼于抗生素的选择,但其防治应该是从腹透管置管开始的整体策略,包括预防性抗生素的使用、患者的强化培训、腹膜炎的早期快速诊断、给药途径与疗程,以及拔管指征等。肾科医师临床决策是需要根据最新的治疗指南及研究进展,结合患者的个体特点进行综合判断,以期达到最佳的治疗效果。     

医患共同决策诊疗模式的现状分析

医患共同决策诊疗模式已经践行了许多年.系统检测,卓有成效.但是,在实践过程中仍然有很多问题存在.尽管许多医生认为自己已经使用了共同决策,但是研究显示出现实与感知的差异.由于我们的决策面对的是需要治疗的患者,而患者是存在个体差异的;同时,医学知识和技术是在不断发展和进步的,所以医生需要改变传统的决策方式,重视医学证据、可用资源和患者的价值取向.     

知情同意的风险决策能力评估探究

能力是知情同意的"守门人"概念,风险相关决策能力将患者的行为能力与具体决策风险结合起来,并充分考量其法律依据与医学特点。一般情况下,临床实践并不需要评估患者的决策能力。但是,当患者拒绝医生提出的最有利患者的建议,患者同意会伤害其本身利益的决策,以及患者前后决策相互矛盾且后期决策会伤害患者健康的情况下,需要评估。风险相关决策能力评估需要考察患者的沟通能力、信息理解能力、评估能力和道德推理能力。其道德合理性在于"行善"的价值辩护,在实践操作中需要借助个体的"实践智慧"。     

患者参与患者安全的国内外研究分析

患者是患者安全的主体和核心,保证患者安全,不仅是医护人员和医疗机构的责任,同时需要患者的参与。自1999年美国医学研究院发表了《孰能无错,构建更为安全的卫生保健体系》报告后,患者安全首次成为学术组织、公众媒体关注的焦点,其相关研究如雨后春笋般涌现,包括患者参与患者安全的研究。     

提高儿科研究生医患沟通能力的探讨

提高医患沟通能力,是建立良好的医患关系,构建和谐社会的必然要求。儿科医患沟通具有其特殊性,其面对的是病患儿及众多的家长,因此,在临床学习中强化医患沟通意识、掌握沟通技巧对儿科研究生尤显重要,本文就如何提高儿科研究生医患沟通能力进行探讨。     

Ethics in health care and medical technologies

In this paper a case is used to demonstrate how ethical analysis enables health care professionals, patients and family members to make treatment decisions which ensure that medical technologies are used in the overall best interests of the patient. The claim is made and defended that ethical analysis can secure four beneficial outcomes when medical technologies are employed: (1) not allowing any medical technologies to be employed until the appropriate decision makers are identified and consulted; (2) insisting that medical technologies be employed not merely to promote the medical interests of the patient but rather on the basis of their ability to contribute to the overall well-being of the patient; (3) challenging caregivers to reflect on the dynamic interplay between their conscious and unconscious values and consequent determinations of what is in the patient's best interests; and (4) providing a justification for selected interventions which makes possible rational dialogue between caregivers espousing different viewpoints about treatment options.     

Genetic Counselors' Judgments of Patient Concerns: Concordance and Consequences

The aims of this prospective study were to determine (a) the concordance between patient concerns and genetic counselors' judgments of these concerns, (b) the predictors of patient and counselor judgments, and (c) the relationship between concordance and patient outcomes. Patients' and counselors' views were sought before and after 131 routine genetic consultations. Before consultations, there was concordance about level of patient concern to within one point in 63% (82/131) of consultations and about type of patient concern in 60–84% of consultations. Lack of concordance in judging level and type of concern was associated with lower satisfaction with information and higher anxiety after the consultation. The biggest predictor of counselor judgment of concern was professional background: doctors judged patients to be more concerned than did nurses. Concordance of concern was predicted by counselors' experience in genetics: less experienced counselors overestimated patient concern. Future research needs to determine whether improving judgment of concern improves patient outcome.     

Exploring patient perspectives of prediabetes and diabetes severity: a qualitative study

Abstract

Objective: This qualitative study sought to identify and describe patients’ variant perceptions of disease severity after receiving a type 2 diabetes (T2DM) or prediabetes (preDM) diagnosis.

Design: Researchers interviewed 29 patients from two US medical centers to ascertain perceptions of severity. We used the constant comparative method from a grounded theory approach to identify themes from patients’ perspectives that inform their disease severity. This approach was used to help translate research to practice and ultimately identify intervention strategies informed by authentic experiences of preDM and T2DM patients.

Results: Perceptions of disease severity fell into two groups: high and low severity. Patients diagnosed with T2DM and preDM emerged in both groups and were comparative in terms of sample size, gender, and ethnic diversity. Several factors contributed to patients’ beliefs, including what they were told about the disease, observations from experiences within their own social network, and information from formal diabetes classes and their own research. The two perspectives diverged when patients described how their belief was informed by three thematic properties or personal factors: (i) fears; (ii) clinician communication; and (iii) social comparisons.

Conclusions: Beliefs about severity are influenced by patients’ fears, interactions with clinicians, and experiences within their social networks. These findings show that when interacting with patients with T2DM or preDM, clinicians should elicit patient perceptions of disease severity so they may then tailor the discussion to address these perceptions and help patients grasp the severity of these conditions.     

Challenges of patient‐led mental health services to psychoanalytic clinicians

This paper considers implications to psychoanalytic psychotherapy of the British Government's decision to implement a patient choice agenda for state‐funded mental health services in England and Wales. It places the patient choice agenda in the context of consumerist society and argues that the complex nature of psychoanalytic psychotherapy leaves it more vulnerable than other psychological therapy modalities to compete in the current reality of ‘consumer’‐led public mental health, which, in turn reflects a profoundly changed social context from that to which psychoanalysis traces its roots. Unless psychoanalytic clinicians recognize and find ways to adjust to this context they will jeopardize the survival of psychoanalytic psychotherapy in an increasingly market‐orientated model of mental healthcare provision in the public sector, eager to promote more ‘consumer friendly’ psychological therapy models.     

Patient role orientations,doctor-patient fit,and visit satisfaction

Abstract

Two studies were conducted using the Patient-Practitioner Orientation Scale (PPOS), an instrument that measures the role orientations of patients. In the first, 297 students responded to a pool of 61 items concerning their attitudes about doctor-patient relationships (e.g., about power-sharing and the importance of physicians' supportiveness). The scale was reduced, and associations between PPOS scores and gender, race, country of origin as well as Health Locus of Control were found. In Study 2, 90 additional students filled out the PPOS, read two doctor-patient scenarios, and rated their satisfaction as if they had been the patient. In one, the physician exhibited a controlling style, and in the other a more open style. As predicted, patient-centered physicians generated higher satisfaction, and patients were most satisfied with a physician whose style matched their own role orientation. These studies suggest the potential usefulness of the PPOS as an indicator of patient attitudes and doctor-patient fit, and as an predictor of visit satisfaction.     

What is competent communication behaviour of patients in physician consultations? – Chronically-ill patients answer in focus groups

Many desirable outcomes depend on good patient-physician communication. Patient-based perspectives of what constitutes competent communication behavior with physicians are needed for patient-oriented health care. Therefore it was our main aim to identify competent patient communication skills from the patient’s perspective. We also wanted to reveal any differences in opinion among various groups (chronic ischemic heart disease, chronic low back pain, breast cancer). This study examined nine guideline-supported focus groups in rehabilitation centers. The criterion for study inclusion was any one of the three diagnoses. Enrolled in the study were N = 49 patients (32 women) aged M = 60.1 (SD = 12.8). The interview recordings were transcribed and subjected to content analysis. We documented 396 commentaries in these interviews that were allocated to 82 different codes; these in turn resulted in the formation of 12 main topics. Examples are: posing questions, being an active and participatory patient, being aware of emotions and communicating them. This study represents stage two (‘documentation of patient and clinician views’) in the seven-stage model of communication research. Findings reveal that chronically-ill patients name behaviours that contribute to successful discussion with a physician. These enable us to develop communication trainings and design-measuring tools used for patient-based communication skills.     

患者隐私杈的法学思考

结合法学理论、医疗实践和目前患者隐私权的法律保护现状,就侵权行为、民事责任的认定以及隐私权的限制等问题予以理论阐释,并提出了切实可行的保护措施,如建立健全相关法律法规、医务人员要增强法律保护意识等,以期为患者隐私权的保护提供有益的参考。     

面对临床无效治疗:思考与抉择

对于没有临床救治意义的病人 ,要不要继续治疗 ?这既是临床医疗问题 ,又是一个涉及社会、伦理、法规的问题。在社会多元化发展的今天 ,对于临床无效治疗无论放弃与否 ,都应当把维护病人的利益作为医疗活动的出发点。在此基础上 ,知情同意和尊重病人自主权是医务人员必须遵循的基本道德原则 ,同时也应当考虑卫生资源的有效分配和社会公众的健康利益