Dilemmas In Care Research Articles

Hospital care for elderly COVID-19 patients.

Objective:to analyze the newspaper articles on hospital care for elderly COVID-19 patients in online newspapers.Method:documentary, retrospective, descriptive and exploratory research. The data were collected from articles published on open-access websites of 12 newspapers from the following countries: Brazil, Spain, United States, France, Italy and Portugal.Results:out of 4,220 newspaper articles identified in this regard, 101 were selected after applying the inclusion criteria, the majority coming from Italy. The data analysis revealed three thematic categories: the care for patients with COVID-19 in the health system; the work process of the health team and its concern with contagion; and ethical dilemma in care for the elderly during hospitalization.Conclusion:the COVID-19 pandemic presented itself quickly and was widely reported in all countries. The health systems need to reorganize for care to the global population, especially the elderly, considering their weaknesses and also the lack of prior professional training to offer care to this population.

Ethical dilemmas in clinical care during COVID-19 pandemic.

In a short span of a few weeks, the COVID-19 pandemic has affected the entire world like no other event in modern history. Healthcare institutions and providers have been at the forefront of containing the ravages of this disease, and are experiencing unprecedented challenges. Medical decision making has become all the more complex because of the moral weight of difficult decisions that need to be made. This paper discusses three areas where ethical decision making is extremely important: dealing with those patients with COVID-19 who no longer have access to their doctors; following ethical criteria for assigning risky duties to healthcare professionals; and in making life and death decisions while allocating scarce resources. This paper describes a national level guidance document for the COVID-19 pandemic that is designed to facilitate ethical decision-making.

Impact of a Team-based, Interprofessional Clinical Ethics Immersion on Moral Resilience

Noting that issues raised during clinical bioethics consults at a southeastern US hospital involve the application of basic ethical principles, the Clinical Bioethics Consultation Service developed and piloted an interprofessional ethics immersion. The goal of this 4-week immersion was to improve teamwork and collaboration, support resolution of basic ethical dilemmas, and develop on-site ethics scholars who apply basic ethical principles to challenging clinical situations. The impact of the immersion on ethical environment, team communication, and confidence in resolving of basic ethical dilemmas for interprofessional clinical teams was examined using follow-up interviews with seven of the eight participants from two ethics immersion offerings. Findings support that an interprofessional ethics immersion training is a valuable strategy to improve ethics knowledge and resolve common patient care dilemmas. The unique aspects of this ethics immersion, team-based and interprofessional, are important considerations for ongoing development of clinicians to address the daily challenges encountered in healthcare.

Personal Assistance to People with ASD in Czechia: Between Positive Discrimination and Ableism

Contemporary politics concerning those with Autism Spectrum Disorder (ASD) revolves around a contest between the medical perspective of autism as a pathology in need of a cure and the autism acceptance perspective, which maintains that autism is a normal human variation. Neither of these extremes provides a sustainable solution to the dilemma of empowerment and care for the people with ASD. Even more, each of the extremes runs the risk of reproducing ableism, a cultural status quo that privileges an able-bodied 'norm' and re-establishes hierarchies of ability upon people with ASD. The call for personal assistance, a pillar of independent life for people with disabilities, reframes the policy of the individual approach for people with ASD by ensuring better continuity between assessment and intervention. The current Czech policy concerning people with disabilities remains aligned with the approach introduced in the late 1980s that divides people with disabilities into categories according to the degree of their dependence instead of refining the approach in line with needs assessment and individualizing interventions. How do different actors respond to the obvious lack of personal assistance to people with ASD? This article examines the impact of governmental bodies responsible for disability policy, the regional authorities and civil society actors on reproducing post-socialist path dependence on medicalised assessment, the centralised approach to funding, and the univocity with residential care. We apply the 'Assessing Personal Assistance Schemes', a multi-faceted set of criteria aimed at monitoring the right to independent life, for indicating options concerning sustainable switching to personal assistance.

Diagnosis and surgical management of Herlyn-Werner-Wunderlich syndrome

Abstract Abdominal pain in the adolescent population is rarely attributed to anatomic variance. Minimal consideration placed on this pathology can present a diagnostic dilemma and delay in care if such options are not investigated. Our case report describes the workup, step-by-step imaging and multidisciplinary approach to a twelve-year-old female who presented with abdominal pain at an outside facility, where she was originally diagnosed with a pelvic mass seeming to arise from the left ovary on ultrasound. Subsequent CT at the authors’ institution indicated a hydrometrocolpos and possible uterine and vaginal duplication; exam under anesthesia revealed uterine didelphys with obstructed left hemivagina. MRI confirmed the diagnosis of Herlyn-Werner-Wunderlich Syndrome and return to the operating room resulted in successful evacuation of the obstructed hemivagina by vaginal septum resection. Post-operatively, she is doing well, menstruating without difficulty, and has not had recurrence of symptoms. This case elucidates the need for consideration of Mullerian duct anomalies in female pediatric patients presenting with lower abdominal pain.

2503. Differences Between Experts and Community Clinicians in Selecting HIV Switch Regimens for Patients With Viral Suppression

BackgroundPatients and clinicians may consider switching suppressive HIV regimens for a variety of reasons, including simplification, improved safety and tolerability, drug interactions, or cost. Because switching treatment is a common clinical dilemma in current HIV care, we developed an online treatment decision support tool to assist providers on selecting a new regimen in a variety of patient scenarios.MethodsIn March 2018, 5 HIV experts provided treatment recommendations for more than 1300 unique HIV switch case scenarios based on a simplified set of variables: CVD, HLA-B*5701, HBV, drug resistance, current ART, and component requiring a switch. We then developed a decision support tool that enabled clinicians to specify a patient scenario using these variables and to select their currently intended approach. The experts’ recommendations for that specific case were then shown, and clinicians were asked if the recommendations changed their planned treatment.ResultsIn the 5 months following release of the tool, healthcare providers (HCPs) entered 932 patient case scenarios. A comparison of HCPs treatment plans vs expert selections in select patient case scenarios is shown in Tables 1 and 2. The data demonstrated several key areas of discordance, including the more frequent selection of the following options by HCPs vs. experts across a wide range of case scenarios: (a) Boosted regimens: 18% to 31% vs. 0% to 4% of cases; (b) TDF-containing regimens: 7% to 25% vs. 0% of cases; and (c) PI-based regimens: 9% to 23% vs. 0% to 4% of cases. In a subset of 88 patient case scenarios where HCPs’ intended treatment differed from experts and HCPs also self-identified the impact of the tool, 48% indicated that their treatment plan would change/agreed with experts after using the tool.ConclusionThis online HIV switch decision support tool shows substantial differences between experts’ and HCPs’ treatment choices for switching therapy in multiple case scenarios. Moreover, consensus expert selections in this online tool resulted in a change to the intended treatment plan for approximately one half of users, suggesting use of the tool can help optimize selection of a new ART regimen for patients switching in the setting of virologic suppression. DisclosuresAll authors: No reported disclosures.

Implementasi Prinsip Nilai dan Etika Pekerja Sosial dalam Penanganan Pengemis di IPSM Yogyakarta

Social work is as a help profession. It has a basic task in overcoming social problems, one of them is handling the beggars. The method used in this study was a qualitative method by describing the implementation of the value principles and ethics of social workers in handling the beggars through the Yogyakarta Society of Social Workers Association and the ethical dilemmas inside. The purpose of this study was expected to provide an overview of practices in the field as an effort to improve the quality of social work, increasingly to have adequate competence, both in terms of values and ethics in carrying out their profession. The results of this study indicated that in the implementation of the value principles and ethics of social workers with reviews of acceptance, individualization, disclosure of feelings, non-judgmental attitudes, objectivity, self determination, confidentiality and accountability. The whole principles had been practiced. However, during practicing in the field, there were ethic dilemmas in the application of the principles. They were dilemmas in client confidentiality, policy laws, management care and scarce and limited resources.

\u201cI go into crisis when \u2026\u201d: ethics of care and moral dilemmas in palliative care

BackgroundRecognising and knowing how to manage ethical issues and moral dilemmas can be considered an ethical skill. In this study, ethics of care is used as a theoretical framework and as a regulatory criterion in the relationship among healthcare professionals, patients with palliative care needs and family members.This study is a part of a larger project aimed at developing and implementing a training programme on “ethical communication” addressed to professionals caring for patients with palliative care needs. The aim of this study was comprehending whether and how the ethics of care informs the way healthcare professionals make sense of and handle ethical issues in palliative care.MethodsQualitative study employing a theoretically driven thematic analysis performed on semi-structured interviews.The research was conducted in a clinical cancer centre in northern Italy. Eligible participants were physicians and nurses from eleven hospital wards who assisted patients with chronic advanced disease daily and had previously attended a 4-h training on palliative care held by the hospital Palliative Care Unit.ResultsThe researchers identified five themes: morality is providing global care; morality is knowing how to have a relationship with patients; morality is recognizing moral principles; moral dimension and communication; and moral dilemmas are individual conflicts.ConclusionsEthics of care seems to emerge as a theoretical framework that includes the belief systems of healthcare professionals, especially those assisting patients with palliative care needs; moreover, it allows the values of both the patients and professionals to come to light through the relationship of care. Ethics of care is also appropriate as a framework for ethical training.

Artificial Intelligence and Autonomous Machines: Influences, Consequences, and Dilemmas in Human Care

Artificial Intelligence and Autonomous Machines: Influences, Consequences, and Dilemmas in Human Care

Ethical dilemmas in paediatric intensive care in the South African public healthcare sector

The shortage of resources in the public healthcare sector in South Africa (SA) means that healthcare providers face difficult choices in terms of rationing of care. This is particularly challenging in paediatrics. This article reviews the ethical and legal issues that arise in this regard. Principlism is the ethical framework most commonly used by clinicians, but perhaps other approaches, such as the ethics of caring, and ubuntu , would be more appropriate for the SA situation.

Etične dileme pri izvajanju zdravstvene nege v enoti intenzivne terapije

Uvod: Medicinske sestre v enotah intenzivnih terapij se soočajo z zahtevnostjo zdravstvene oskrbe kritično bolnih pacientov. Namen raziskave je bil ugotoviti etične dileme, ki se pojavljajo pri izvajanju zdravstvene nege v enotah intenzivne terapije.Metode: Uporabljen je bil sistematični pregled znanstvene literature. Vključena je bila literatura iz obdobja od 2007 do 2017. Pregled zajema naslednje baze: COBIB.SI, CINAHL in PubMed. Iskanje je potekalo z uporabo ključnih besed: »etične dileme«, »medicinske sestre«, »etična načela«, »kritično bolni pacienti«, »zdravstvena nega v intenzivni terapiji« v slovenskem in angleškem jeziku. Iz iskalnega nabora 78 zadetkov je bilo v končno analizo vključenih 14 člankov. Izvedena je bila vsebinska analiza spoznanj raziskav.Rezultati: Medicinske sestre med najbolj pogostimi etičnimi dilemami navajajo dileme v povezavi z zdravljenjem in aktivnostmi zdravstvene nege, organizacijo zdravstvene oskrbe in paliativno oskrbo. Med najbolj pogostimi etičnimi načeli navajajo neškodljivost, dobronamernost in avtonomijo kritično bolnih pacientov.Diskusija in zaključek: Ugotovitve raziskave prispevajo k prepoznavanju najbolj pogostih etičnih dilem pri izvajanju zdravstvene nege v enoti intenzivne terapije. Pomembno bi bilo podrobneje raziskati posamezne etične dileme medicinskih sester, ki se pojavijo v času izvajanja zdravstvene nege pri kritično bolnih pacientih.

An Ethical Analysis of Pharmacy Benefit Manager (PBM) Practices.

The high costs associated with pharmaceuticals and the accompanying stakeholders are being closely evaluated in the search for solutions. As a major stakeholder in the U.S. pharmaceutical market, the practices of pharmacy benefit manager (PBM) organizations have been under increased scrutiny. Examples of controversial practices have included incentives driving formulary status and prohibiting pharmacists from disclosing information on lower-cost prescription alternatives. Ethical investigations have been largely omitted within the debate on the responsibilities of these organizations in the health care system. Ethical analysis of organizational practices is justified based on the potential impact during health care delivery. The objective of this study was to analyze several specific PBM practices using multiple ethical decision-making models to determine their ethical nature. This study systematically applied multiple ethical decision-making models and codes of ethics to a variety of practices associated with PBM-related dilemmas encountered in the pharmaceutical environment. The assessed scenarios resulted in mixed outcomes. PBM practices were both ethical and unethical depending on the applied ethical model. Despite variation across applied models, some practices were predominately ethical or unethical. The point of sale rebates were consistently determined as ethical, whereas market consolidation, gag clauses, and fluctuation of pharmacy reimbursements were all predominantly determined as unethical. The application of using provider codes of ethics created additional comparison and also contained mixed findings. This study provided a unique assessment of PBM practices and provides context from a variety of ethical perspectives. To the knowledge of the authors, these perspectives have not been previously applied to PBM practices in the literature. The application of ethical decision-making models offers a unique context to current health care dilemmas. It is important to analyze health care dilemmas using ethics-based frameworks to contribute solutions addressing complexities and values of all stakeholders in the health care environment.

Conducting health policy analysis in primary care research: turning clinical ideas into action.

Healthcare guidelines play a prominent role in the day-to-day practice of primary care providers, and health policy research leads to the formation of these guidelines. Health policy research is the multidisciplinary approach to public policy explaining the interaction between health institutions, special interests and theoretical constructs. In this article, we demonstrate how primary care providers can conduct high-impact health policy research using Eugene Bardach’s eightfold policy analysis framework in a primary care context. In a medical case, a woman with a history of total hysterectomy had scheduled a visit for a Papanicolaou (Pap) smear screening test as part of a well-woman health check-up with a family medicine resident. Conflicting recommendations on Pap smear screening after total hysterectomy sparked an investigation using the US Preventive Services Task Force criteria for conducting a health policy analysis. We illustrate broadly how clinical care dilemmas can be examined by using Bardach’s broadly applicable health policy framework in order to inform meaningful policy change. Bardach’s framework includes (1) defining the problem, (2) assembling evidence, (3) constructing alternatives, (4) selecting criteria, (5) projecting outcomes, (6) confronting trade-offs, (7) decision-making and (8) sharing the results of the process. The policy analysis demonstrated insufficient evidence to recommend Pap test screening after hysterectomy and the findings contributed to national recommendations. By following Bardach’s steps, primary care researchers have a feasible and powerful tool for conducting meaningful health policy research and analysis that can influence clinical practice.

'That just breaks my heart': Moral Concerns of Direct Care Workers Providing Palliative Care in LTC Homes.

ABSTRACTThe literature on ethics in health care that explores the moral concerns of care providers typically focuses on registered health professionals and ethical dilemmas in acute and primary care. Far less attention has been paid to the long-term care (LTC) environment and non-registered, direct care workers. To address this gap, this research examined the moral concerns of personal support workers (PSWs) who provide direct care to residents. Data were collected during a 5-year participatory action research project to formalize palliative care programs in LTC homes. Eleven focus groups explored PSWs' experiences providing palliative care in LTC homes, their challenges and learning needs (n = 45). In-depth secondary analysis of these focus groups found that PSWs experienced moral dilemmas. Two main moral dilemmas were ensuring that residents don't die alone; and providing the appropriate care based on residents' wishes. Their organizational constraints coalesced around policies, hierarchy, time, and balancing residents' needs.

Teoretyczny i praktyczny problem pamięci w kontekście osobowej tożsamości pacjenta cierpiącego na chorobę Alzheimera – bioetyczne stanowisko Davida DeGrazii

The presented article illustrates David DeGrazia’s bioethical standpoint regarding the theoretical and the practical problem of memory in the context of the personal identity of a patient suffering from Alzheimer's disease. The first part of the article is a presentation of the theoretical problem of memory in the context of numerical and narrative identity being the center of the metaphysical theory of the human person. The second part of the article presents a practical memory problem in the bioethical case of a patient diagnosed with early stages of Alzheimer’s disease. The American bioethicist and philosopher David DeGrazia proposes that the theoretical solutions regarding the identity of the human person find their practical application in bioethics in resolving moral dilemmas in the health care. The final part of the article focuses on criticizing the possibilities of practical applications of theoretical solutions on the subject of the human person in the bioethical position of David DeGrazia.

Serve the People or Serve the Consumer? The Dilemma of Patient-Centred Health Care in China

Patient-centred medicine is being adopted as national policies in many countries, encouraged by positive outcomes of the practice at clinical and organisational levels. This study examines the patient-centred health care reform in China, which has adopted the approach as a national policy for two decades but has yet to achieve the intended goals. Focusing on conflicting interpretations of the nature of patients at national, organisational, and individual levels, this article argues that such conflicts lead to clashes between the political agenda of the state, priorities of health organisations, professional choices of individual practitioners, and expectations of patients in the process of implementing, practicing, and receiving patient-centred health care in China. It reveals that the national health authority has intended patient-centredness as a universal, anti-market, people-centred approach, based on the health ideology of serving the people. But hospitals, compelled by financial restraints, have implemented it as a market approach centring on patients as consumers. Medical professionals and patients also possess contradictory views towards whether a patient should be perceived as a consumer. The discordance in the interpretation of the patient identity has caused great confusion in the implementation and provision of patient-centred health care. The study points out that the success of patient-centredness as national policy cannot be assumed on the basis of its success at clinical and organisational levels. More efforts are needed to coordinate the fundamental understanding of patient-centredness by different actors.

Artificial Intelligence and Autonomous Machines: Influences, Consequences, and Dilemmas in Human Care

In the field of robotics and in the health sciences, transitions have been occurring in the control of robots operating with predetermined logic and rules. Robotics in health care are influencing human caring dynamics in many ways such as enhancing dependency and surrender to machine technologies. Situations such as these are charged with possibilities of legal liabilities triggered by influences and consequences of advancing robotic technology dependency. The purpose of this paper is to identify, describe, and explain legal issues and/or dilemmas centered on robotics in healthcare while providing engaging opportunities to limit consequent legalities thus forming beneficial human health care outcomes. Laying bare these liabilities will provide critically informative data that can foster proactive encounters which can or may deter health care liabilities while ensuring quality healthcare outcomes. An attempt is made to re-conceptualize how to view agency, causality, liability responsibility, culpability, and autonomy for the new age of autonomous robots. While it is still not clear how this would turn out, a clear framing of the problem is the first step in the project.

Provider perceptions on the management of lupus during pregnancy: barriers to improved care.

More than half of pregnancies in women with systemic lupus erythematosus (lupus) result in adverse outcomes for the mother or the fetus. We sought to identify aspects of current rheumatologic care that could be improved to decrease the frequency of poor outcomes. Focus groups with clinical rheumatologists, based on the PRECEDE/PROCEED framework, identified factors that influenced care. A group of women with lupus on their reproductive journey contributed to our understanding of the dilemmas and care provided. Medically ill-timed pregnancies and medication non-adherence during pregnancy were identified by rheumatologists as the two key dilemmas in care. We identified several communication gaps as key modifiable barriers to optimal management. The approach to physician-patient communication was often unsuitable to sensitive discussions about pregnancy planning. The communication of treatment plans was frequently hampered by gaps in knowledge and both physician and patient confidence in the data, encouraging non-adherence among nervous patients. Finally, local rheumatologists and obstetricians/gynecologists providers frequently did not communicate, leading to varying treatment plans and confusion for patients. To decrease the frequency of ill-timed pregnancy and medication non-adherence it will be essential to empower rheumatologists, and women with lupus to have open and accurate conversations about pregnancy planning and management.

Under-recognised ethical dilemmas of diabetes care in resource-poor settings.

Ineffective diabetes management results in suboptimal glycaemic control and adverse health outcomes. In resource-poor settings, a combination of high burden of medication nonadherence in patients and therapeutic inertia amongst clinicians is largely attributed to the failure to achieve glycaemic targets in diabetic populations. The potential health risks from intensification of medical therapy for aggressive lowering of glucose levels in Type 2 diabetes patients represents an ethical dilemma between averting risk from overtreatment and preventing future harm from raised blood glucose levels. However, the ethical dilemmas experienced by clinicians in most of the developing world when contemplating prescription of additional oral hypoglycaemic agents or initiating insulin have received little attention from the medical community. Such ethical dilemmas unique to resource-poor settings often emerge from poor availability of drugs, diagnostics and physician consultation time for diabetic patients. Furthermore, existing evidence-based guidelines for diabetes management assume a standard of care which is lacking in such settings. This often compels the developing world clinicians when confronted with such diabetes-related ethical dilemmas to rely solely on their clinical judgement which could be ethically unjust and medically prone to error. Newer research needs to generate evidence to develop best practice guidelines for optimal therapeutic outcomes, while acknowledging the reality of limited healthcare services available in resource-poor settings.

OPIOID PRESCRIBING: A GENERATIONAL PERSPECTIVE

As our nation grapples with an epidemic that fractures families and wreaks havoc in communities, an aspect of the opioid crisis often goes unspoken. How has this complex patient care dilemma affected family medicine education? Can there be a teachable moment in our past to improve our future? The