Respect For Patient Autonomy Research Articles

‘I haven’t discussed anything with anyone’: lived experience of long-term users of benzodiazepine receptor agonists regarding their treatment for substance use disorder

ABSTRACT Introduction Treatment for substance use disorder (SUD) to benzodiazepine receptor agonists (BZRA) can be challenging and lengthy. BZRA are prescribed for anxiety and insomnia, and though guidelines recommend an initial prescription duration of one to four weeks, this is frequently longer. Understanding the multiple challenges associated with withdrawing from BZRA and exploring the nuance and complexities from the patient’s perspective is crucial. Methods In this study, we explore the experiences of SUD to BZRA with nineteen users, who have subsequently either stabilized, reduced, or discontinued their usage. The data were analysed using Interpretative Phenomenological Analysis. Findings Our study identified five key themes regarding the long-term use of BZRA which address inadequate patient information, strict adherence to prescribed medication, minimal involvement in cessation plans, respecting patient readiness for tapering and personalized tapering approaches. Conclusion These findings indicate that patients’ blind trust in their providers can prevent them from voicing concerns, highlighting the importance of an authentic and collaborative relationship between the patient and healthcare provider, while respecting patient autonomy. The goal-oriented care approach could improve BZRA management by aligning treatment with individual goals, enhancing satisfaction, and addressing the complexities of long-term use and withdrawal.

Parental Acceptance of Fetal Tissue Donation

Human fetal tissue is essential for biomedical research, providing unparalleled insights into human development and disease. To assess changes in parental decisions to donate fetal tissue following termination of pregnancy after the introduction of the Dutch Fetal Biobank (DFB) and to identify factors associated with consent to donate. This cohort study collected data from all individuals assigned female at birth (hereafter referred to as participants) who underwent a termination of pregnancy at the Amsterdam University Medical Center from January 1, 2008, to December 31, 2022. No exclusion criteria were applied. Introduction of the DFB on September 1, 2017, which offers the option to donate fetal tissue after pregnancy termination. Rates of fetal tissue donation before and after DFB introduction and associations between patient characteristics (maternal age, race and ethnicity, socioeconomic status, gestational age, and reason for termination) and consent to donation were assessed using multivariable binary logistic regression modeling. Of a total of 1272 participants (mean [SD] age, 33.0 [5.4] years), 576 (45.3%) were nulliparous. The mean (SD) gestational age at termination was 18 weeks 3 days (26 days), and reasons for termination were primarily because of structural defects (567 participants [44.6%]), with only a small portion (58 participants [4.6%]) terminating for social reasons (eg, unwanted or unplanned pregnancy). Fetal tissue donations increased from 1.2% (8 donations among 663 terminations) before the DFB introduction to 21.7% (132 donations among 609 terminations) after its introduction. This rise was primarily due to a shift from collective cremation to donation, while individual cremation or burial rates remained stable. The consent rate was 30.3% (132 of 436) for participants informed about the donation option. No significant demographic differences were found between participants who consented and those who did not, except for gestational age; consent rates decreased with advanced gestational age (odds ratio per week, 0.88; 95% CI, 0.83-0.94). Higher consent rates were observed for terminations due to social reasons (odds ratio, 3.56; 95% CI, 1.40-9.10). These findings suggest that a substantial proportion of individuals may be willing to donate fetal tissue for biomedical research after pregnancy termination. Integrating donation options in posttermination counseling respects patient autonomy and could ethically increase tissue availability for research. Expanding biobanks and fostering international collaboration is crucial for standardizing practices and ensuring equitable research benefits.

Ethical Dilemmas in Home Palliative Care

Abstract Background In the past two decades, there has been a noticeable shift towards home-based care, reflecting the broader trend among OECD countries to prioritize a comprehensive approach to health and well-being. This approach emphasizes preventive and proactive measures, often relying on home-based care delivered by multidisciplinary teams providing both curative and palliative care. However, the unique nature of providing care in a home environment raises ethical questions among healthcare providers, necessitating high levels of attentiveness and sensitivity from the caregiving team to address them effectively. Research Objectives This study aims to identify ethical challenges encountered by a multidisciplinary team, as perceived by managers of an organization offering home palliative services in Israel. Methods A qualitative study was conducted, involving interviews with nine key managers to explore prevalent ethical issues in delivering home-based care. Findings Thematic analysis unveiled common ethical dilemmas in providing Home Palliative Care. These dilemmas include balancing patient preferences with professional obligations, addressing the needs of both patients and their families, navigating caregiver-patient relationships, understanding patients’ cultural backgrounds, and advocating for home care as the preferred option while considering alternative treatment approaches. Conclusions Home palliative care poses ethical dilemmas for caregiving teams. It’s imperative for organizations in the home care sector to devise strategies aimed at assisting teams in navigating these challenges while upholding the autonomy and dignity of patients within their home environment. Key messages • Home-based care faces ethical challenges, requiring strategies to balance patient preferences and professional duties. • Ethical home hospice care needs strategies that respect patient autonomy and dignity.

Implementation of Respect for Autonomy in Hospital Services Within the Indonesia National Health Insurance System

The principle of patient autonomy forms the foundation of medical ethics. However, its exploration within the context of national health insurance systems in developing countries remains under-researched. This study aimed to evaluate respect for patient autonomy within Indonesia's National Health Insurance (NHI/JKN) system. The study using a qualitative research interview analyzed thematically. Conducted in Depok, West Java, the study involved in-depth semi-structured interviews with 18 participants, encompassing patients from first-level health facilities (FLHF), general practitioners at FLHF, specialist doctors, and management of referral hospital (RH) officers, and staff members of the JKN. The data were transcribed and analyzed using a thematic approach. The study revealed substantial underutilization of respecting patient autonomy within medical contexts under the JKN. Five themes emerged: challenges in the referral system, knowledge and information dissemination, decision-making and autonomy, quality of healthcare services, and systemic constraints and impact. These themes highlight the lack of patient awareness, restricted medical choices, the dominant role of paternalism (a system in which the government or a person in a position of authority makes decisions for other people) in healthcare decisions, and improper informed consent process. The findings suggest that the principles of beneficence and paternalism often overshadow respect for patient autonomy in the JKN system. This raises concerns about the ethical aspect of patient treatment, particularly the need for greater focus on patient autonomy and shared decision-making to align more closely with global medical ethics practices. This study contributes to understanding autonomy in national health insurance systems in developing countries. It highlights the need for systemic reforms to enhance healthcare efficiency and effectiveness while respecting patient autonomy.

Cooperation in Return-to-work Interventions for Common Mental Disorders: An Ideal Theory Analysis of Actors, Goals, and Ethical Obstacles.

The rise in the number of people on sick leave for common mental disorders is a growing concern, both from a societal and individual perspective. One common suggestion to improve the return-to-work process is increased cooperation between the relevant parties, including at least the employer, the social insurance agency and health care. This suggestion is often made on the presumption that all parties share the common goal of reintegrating the patient-employee back into the workplace. In this paper we investigate this presumption by mapping out the ethical frameworks of these three key actors in any return-to-work process. We show that although the goals of these actors often, and to a large extent, overlap there are potential differences and tensions between their respective goals. Further, we emphasise that there may be other limitations to an actor's participation in the process. In particular the health care system is required to respect patient autonomy and confidentiality. There is also an inherent tension in the dual roles of health care professionals as therapists and expert witnesses in work ability assessment. In conclusion, there are potential tensions between the key actors in the return-to-work process. These tensions need to be addressed in order to enable an increased cooperation between actors and to facilitate the development of a feasible plan of action for all parties, including the employee.

Ethical and legal aspects in anesthesiology, ethical and legal issues, an overview

Introduction: The practice of anesthesiology plays a crucial role in medicine, ensuring the comfort and safety of patients during medical and surgical procedures. However, this specialty faces a series of ethical and legal challenges. This article provides an overview of these issues, considering the importance of respecting patient autonomy and compliance with legal standards. Methods: To conduct this review, the following descriptors were used to search the PubMed and MEDLINE databases: "Anesthesiology", "Ethical", "Questions", "Aspects", "Legal". These descriptors were combined using the boolean operator AND to ensure search accuracy. Initially, 165 relevant studies were identified. After excluding duplicates, editorials, and incomplete articles, 122 articles were considered for analysis. The final selection included the full reading of 24 articles, of which 13 were considered relevant to compose this review. Results: Anesthesiologists face complex ethical dilemmas, from obtaining informed consent to making decisions in emergency situations. Additionally, there are concerns about fair resource allocation and balancing risks and benefits. In the legal realm, there are comprehensive regulations related to professional liability, documentation of procedures, and the use of medications and equipment. Conclusion: The practice of anesthesiology requires a solid understanding of the ethical and legal aspects involved. It is essential to respect patient autonomy by obtaining their informed consent. Constant ethical reflection and compliance with legal regulations are fundamental to ensuring the delivery of high-quality care.

Assessing Medical Students' Understanding of Do-Not-Resuscitate (DNR) Orders.

The evolution of medical directives surrounding cardiopulmonary resuscitation (CPR) has led to the prominence of do-not-resuscitate (DNR) orders. These orders aim to respect patient autonomy and ensure dignified end-of-life care. While regulations in the United States emphasize patient choice and comprehensive discussions, Saudi Arabia's approach to DNR orders integrates Islamic principles alongside expert medical judgment. This study aimed to assess the awareness and comprehension of DNR orders among medical students at Umm Al-Qura University, Makkah, Saudi Arabia. This study employed a cross-sectional design at Umm Al-Qura University in 2023. Convenience sampling yielded a sample of 145 participants, encompassing medical students from all years (first-sixth) and medical interns. A self-administered online questionnaire assessed participants' knowledge, beliefs, and attitudes regarding DNR orders. The questionnaire specifically addressed their familiarity with DNR orders, their understanding of the Islamic perspective on DNR, and the factors influencing their attitudes toward DNR. Results: The majority of respondents (62%) were familiar with the term "DNR," but only 52% correctly defined it. Social media was the primary source of information about DNR for most respondents (56%). A significant portion of respondents (60.7%) agreed with the concept of DNR, and 54% had personal experience with the term. Patient dignity (54%), religious concerns (66.7%), and legal concerns (60.7%) were identified as important factors in DNR decisions. A majority of respondents (67%) agreed that it is acceptable to discontinue life support for DNR patients, and 49.3% believed that organ donation should be encouraged among patient families. The study found that as medical students progressed through their training (from pre-clinical to clinical years and internship), their acceptance and understanding of DNR orders generally increased. The study found that medical students possess some basic familiarity with DNR orders, but there is considerable room for advancement in their comprehension and acceptance of the topic. Addressing these knowledge gaps may lead to improved patient outcomes. The findings also underscore the need to equip future physicians with a comprehensive understanding of DNR orders, their ethical ramifications, and effective communication strategies for engaging with patients and their families.

Perceived autonomy support in individuals with Parkinson’s disease requiring emergency care: a cross-sectional pilot study

BackgroundIndividuals with Parkinson’s disease (PD) report a diminished perceived functional autonomy as their condition progresses. For those seeking emergency care, it is unknown whether the patient-physician relationship is instrumental in respecting patient autonomy. This study evaluated patient autonomy ideals in individuals with PD requiring emergency care and the perceived support for autonomy from emergency department physicians.MethodIndividuals with PD (n = 36, average age 78.1 years) were surveyed using the Ideal Patient Autonomy questionnaire (IPA) and the Health Care Climate Questionnaire (HCCQ). A multivariable regression analysis assessed whether patients’ Hoehn and Yahr stage and IPA questionnaire results predicted HCCQ items.ResultsThe IPA questionnaire revealed that individuals with PD in need of emergency care emphasize the significance of medical expertise (IPA ‘doctor should decide’ theme 0.71) in decision-making and their desire to be fully informed about all potential risks (IPA ‘obligatory risk information’ theme 0.71). The average HCCQ values showed a decreasing trend across Hoehn and Yahr stages 1 to 5: 6.19, 6.03, 5.83, 5.80, and 5.23, respectively. HY scale values also influenced HCCQ items related to the physician’s role.ConclusionIn our cohort, individuals with Parkinson’s disease tend to rely on medical expertise for decision-making and prioritize complete risk information during emergency care. However, this autonomy support diminishes as functional disability levels increase.

The additional photographed lesion in a teledermatology clinic for urgent suspected skin cancer.

This is an ethical dilemma case that discusses how to manage an additional photographed lesion in a teledermatology clinic for urgent suspected skin cancer. We discuss the ethical issues around maintaining the duty of care to the patient while operating within the scope of the service, respecting patient autonomy and upholding professional standards.

Program to optimise detecting growth hormone deficiency in children and increase adherence to replacement therapy

Background. The significance of this study lies in the fact that short stature is highly prevalent among children, affec­ting 1–5 % of the population and having diverse causes. The child’s growth potential in the long term is largely depends on the effectiveness of the diagnostic system and the level of adherence to the prescribed therapy. The purpose was to improve the diagnosis of growth hormone deficiency (GHD) in children and adherence to recombinant human growth hormone (rhGH) therapy based on information about the regional prevalence of the disease and barriers to adherence. Materials and methods. A follow-up study was conducted from 2012 to 2020 at the Odesa Regional Children’s Hospital. The cohort included 94 children with GHD. The prevalence was determined by calculating the ratio of the number of all detected GHD cases to the children population per 100,000. Adherence was measured using the Morisky Medication Adherence Scale. The statistical processing of the results was done using t-test and chi-square methods, and p-values less than 0.05 were considered statistically significant. Results. An assessment of GHD prevalence, the level of adherence and the frequency of continuity of rhGH therapy in children in the Odesa region at the end of 2014 revealed the incompleteness of regional diagnosis of the disease (in Odesa, 1 : 11,200; in the Odesa region, 1 : 10,800), as well as a low level of acceptable adhe­rence (in 57.4 %) and insufficient frequency of continuity of therapy (in 76.9 %). These data formed the basis of the regional program for optimizing the identification and management of GHD in children, which included organizational, medical and social measures. By the end of 2020, the prevalence of GHD in Odesa was 1 : 4,300, and in the Odesa region, 1 : 5,100. The rate of acceptable adherence to rhGH therapy increased to 80.0 %, and frequency of continuity of therapy to 91.1 %. Conclusions. The regional program designed to improve the detection and management of GHD in children has been found to improve the diagnosis of the disease, increase adhe­rence to rhGH therapy, and the frequency of continuity of treatment. High adherence to treatment is a bioethical issue because it signifies a good partnership between physicians, children, and parents and indicates respect for patient autonomy.

Ethical issues and proposed solutions in conducting practical assessment of medical students involving patients.

Practical assessment involving patients plays a vital role in medical education, allowing students to demonstrate their clinical competencies. However, there are significant ethical concerns associated with these assessments that require careful consideration and resolution. The primary ethical concerns include violation of patient autonomy, lack of written informed consent, power dynamics, cultural differences, potential harm to patients, breach of privacy and confidentiality, discomfort to admitted patients, financial loss to patients, impact on other patients' care, and delays in workup/procedures. To address these concerns, measures such as respecting patient autonomy, obtaining written informed consent, ensuring patient safety, exploring alternative methods, providing reimbursement, resource planning, creating a supportive environment, developing cultural competency, putting in place a feedback system, prioritising patient care, and implementing ethical oversight and monitoring are recommended. The formulation of a guideline could be a crucial starting point, and it should be integrated into a broader ethical framework that encompasses education and training, ethical oversight, ongoing monitoring, and a culture that prioritises ethical conduct.

Physician barriers and dilemmas in the execution of clinical trials impacting decision-making in the DAHANCA 35 proton therapy trial for head and neck cancer

BackgroundPhysicians manage multiple obligations, providing best-practice treatment and patient- centred care in the standard treatment pathway while contributing to clinical trials simultaneously. These multifaceted responsibilities may introduce barriers and dilemmas to clinical trial execution, potentially impacting the clinical trial decision- making process. This study explores physicians’ barriers and dilemmas in executing clinical trials and the impact on clinical trial decision-making. MethodQualitative semi-structured interviews were conducted with experienced oncologists. Moreover, participant observations were performed during clinical encounters involving discussions about clinical trials. The analysis followed a structured approach: (1) transcription of data, (2) inductive text coding, (3) exploration of patterns, and (4) interpretation, leading to the results. The results were discussed and validated by the study participants. ResultsThe results comprise (1) a description of the clinical practice, which presents the setting of clinical trial execution; (2) results regarding physicians’ barriers and dilemmas in executing clinical trials, leading to (3) the impact on clinical trial decision- making. The results involve barriers to time constraints for clinical trial tasks, dilemmas emerging from trial requirements or deviations from standard guidelines, and challenges with providing sufficient trial communication and adequate decision-making support, balancing between a paternalistic approach and respecting patient autonomy. ConclusionThe demanding obligations of clinical practice constitute a complex setting for executing clinical trials, resulting in numerous barriers and dilemmas that impact the decision-making process in clinical trials. The study emphasises the need for tailored clinical trial decision-making interventions to facilitate supportive, informed, and non-directive clinical trial decision-making.

Patient autonomy in the era of the sustainability crisis.

In the realm of medical ethics, the foundational principle of respecting patient autonomy holds significant importance, often emerging as a central concern in numerous ethically complex cases, as authorizing medical assistance in dying or healthy limb amputation on patient request. Even though advocates for either alternative regularly utilize prima facie principles to resolve ethical dilemmas, the interplay between these principles is often the core of the theoretical frameworks. As the ramifications of the sustainability crisis become increasingly evident, there is a growing need to integrate awareness for sustainability into medical decision-making, thus reintroducing potential conflict with patient autonomy. The contention of this study is that the ethical standards established in the 20th century may not adequately address the challenges that have arisen in the 21st century. The author suggests an advanced perception of patient autonomy that prioritizes fostering patients' knowledge, self-awareness, and sense of responsibility, going beyond a sole focus on their intrinsic values. Empowering patients could serve as a tool to align patient autonomy, beneficence, and the aim to reduce resource consumption.

Balancing Acts: Navigating the Ethical and Legal Challenges of Genomic Medicine in Healthcare

This paper delves into the intricate relationship between the evolving field of genomic medicine and healthcare providers' legal and ethical responsibilities, with a particular focus on the duty to warn in the context of genetic risks. Through a critical examination of landmark cases such as Pate v. Threlkel and Safer v. Estate of Pack, this study underscores the expanding scope of healthcare providers' duties to include not just the patient but potentially at-risk family members as well. It highlights the legal, ethical, and practical challenges that arise when balancing patient confidentiality with the need to prevent harm through the disclosure of genetic information. The descriptive portion of the paper outlines the current legal precedents and the ambiguity surrounding healthcare providers' responsibilities. The prescriptive portion proposes the establishment of comprehensive, clear guidelines to support healthcare providers, particularly genomic counselors, in navigating these complexities. This includes recommendations for policy changes and the development of protocols that respect patient autonomy while addressing the preventive potential of genomic medicine. Through an analysis of legal frameworks and ethical considerations, this paper argues for a nuanced approach that equitably balances individual rights with the collective good, ultimately advocating for a future where genomic medicine is integrated into patient care in an ethically responsible and legally sound manner.

Искусственный интеллект в медицине: этические проблемы коммуникации между врачом и пациентом

A serious challenge to the patient-oriented model of interaction between doctor and patient is posed by objective circum-stances: the constantly increasing number of patients and rising healthcare costs and, therefore, the inability to provide the attention and care necessary for the patient. A likely response to the emerging "crisis of care" in medicine appears to be the use of digital technolo-gies in clinical practice and healthcare organization. In particular, one of the possible options for using the potential of digital technolo-gies in medicine is artificial intelligence systems (hereinafter referred to as AI).The article is devoted to the peculiarities of communica-tion between a doctor and patients in the conditions of using artificial intelligence in clinical practice. The author identifies both the prospects for the introduction of artificial intelligence and difficulties in the process of communication between a doctor and a patient. The purpose of the article is to analyze the mechanism of influence of artificial intelligence on the process of communication between a doctor and a patient, to assess the impact of digital technologies on the basic values that develop in the process of clinical communica-tion – respect for patient autonomy, trust, confidentiality. The main expected positive consequence of the use of AI in medicine is the freeing up of time for direct communication with the patient. However, there is a risk that it will be used to increase patient flow, espe-cially in the commercial medical sector. It is concluded that, despite the widespread use of digital technologies, society remains wary of such innovations, especially when it concerns personal data. As a result, the level of trust and willingness to use AI systems is low. When introducing AI, it is necessary to take into account the feasibility and appropriateness of using these technologies in the provision of medical care, since, along with the effectiveness and accuracy of diagnostic results and treatment, the process of communication with a doctor remains extremely important for the patient, the opportunity to share their medical history and, during this communica-tion, form trust necessary for joint decision-making.

When describing harms and benefits to potential trial participants, participant information leaflets are inadequate.

Providing informed consent for trials requires providing trial participantswith comprehensive information about the trial, including information about potential risks and benefits. It is required by the ethical principle of respecting patient autonomy. Our study examines the variation in the way information about potential trial benefits and harms is shared in participant information leaflets (PILs). A total of 214 PILs and informed consent forms from clinical trials units (CTUs) and Clinical Research Facilities (CRFs) in Ireland and the UK were assessed by two authors independently,to check the extent to which they adhered to seven recently developed principles. Discrepancies were resolved by a third. Usage of the seven principles varied widely between PILs regardless of the intended recipient or trial type. None of the PILs used more than four principles, and some (4%) used none. Twenty-seven per cent of PILs presented information about all known potential harms, whereas 45% presented information on allknown potential benefits. Some PILs did not provide any potential harms or potential benefits (8%). There was variation in the information contained in adult and children PILs and across disease areas. Significant variation exists in how potential trial benefits and harms are described to potential trial participants in PILs in our sample. Usage of the seven principles of good practice will promote consistency, ensure informed ethical decision-making and invoke trust and transparency. In the long term, a standardised PIL template is needed.

NAVEGANDO NA INTERSECÇÃOBIOÉTICA, LEGISLAÇÃO E TECNOLOGIAS EMERGENTES NA SAÚDE

This paper explores the intersection between bioethics, legislation, and emerging technologies in health, highlighting the ethical and regulatory challenges that accompany technological advancements in this field. The central problem investigated is how to ensure that technological innovations in health are developed and implemented in an ethically and legally responsible manner, respecting patient autonomy, transparency, and fairness. The main objective is to analyze the relationship between technological advancements in health and their ethical and legal implications, seeking to propose solutions to the identified challenges. The analysis draws on studies by Amaral et al. (2020), Loureiro, Brey, and Nunes (2023), among others, emphasizing the need for specific bioethical regulations and the adaptation of existing legislation. The final considerations stress the importance of a collaborative and multidisciplinary approach to address these challenges, promoting ongoing dialogue among various stakeholders. This study underscores the need for continuous reflection on ethical and regulatory issues, aiming to develop a medical practice that benefits all in a fair and equitable manner.

How Do Women Vote: What Women Post About Home Birth Versus Hospital Birth on Popular Social Media Platforms.

The rates of home birth have been increasing; reliance on social media as a source of medical advice and support for patients has also been increasing. This is the first study that directly evaluates birthing people's perceptions, attitudes, and advice about planned home births expressed in public posts and comments on two popular social media platforms - Reddit and TikTok. Posts on each platform were searched from January 2017 through July 2022 using the terms "home birth" and "home vs. hospital birth". Included posts were from the United States written in English, with at least 10 comments and 10 upvotes or likes. Up to five themes were collected per post or comment and were categorized as supportive, opposing, or neutral. The Institutional Review Board (IRB) determined that the project did not include human subjects. Collectively, 777 posts and 47,452 comments wereevaluated for inclusion; 257 posts and 2,408 comments met the inclusion criteria for analysis. In posts, 69% supported, 20% opposed, and 11% were neutral toward home birth (n = 257). Similarly, in comments, 53% supported, 28% opposed, and 19% were neutral (n = 2,408). Supportive themes included concerns about the safety of hospital delivery and reassurance about home birth safety, enhanced patient control with home deliveries, positive personal stories reinforcing home birth, concerns about excessive interventions in hospital birth, and advice about preparing for home birth. Opposing themes included concerns about risks of home birth, negligence of those attempting it, reassurance that hospital birth does offer women control, greater financial costs of home birth and that medical interventions can be lifesaving. These results can help physicians recognize some of the women's concerns about hospital births and what information they may find on social media guiding them as they formulate their birth plans. Overall, this information helps with the goal of balancing patient safety with the need to respect patient autonomy.

Fostering relational autonomy in end-of-life care: a procedural approach and three-dimensional decision-making model

Respect for patient autonomy is paramount in resolving ethical tensions in end-of-life care. The concept of relational autonomy has contributed to this debate; however, scholars often use this concept in...

Respecting patient autonomy: legal and professional considerations.

In this month's Policy column, Iwan Dowie explores patient autonomy - a concept largely embedded within the community nursing setting. Through legal cases, a history of laws relating to patient autonomy are presented and its implications for community nurses discussed.