The condition of an 81-year-old retired janitor, who was not previously your patient but is now under your care, is deteriorating in the ICU. A decision must be made about resuscitation. The patient is alert, cooperative, and, in your judgment, appears to have the capacity to make any necessary decisions. You discuss the treatment options, risks, and benefits with the patient, and, after much discussion, you ask him what he would prefer that you do. Is this the right question to ask?
No, because this question presumes that he wants to make the decision. Additionally, the patient may have assumed that he must make the decision because you asked. It is widely recognized that patients have the right to make decisions for themselves. But many mistakenly believe that because this right exists, patients must and will always choose to exercise it. There is a growing body of empirical evidence suggesting that in a variety of circumstances patients would prefer not to make decisions by them-selves. Rather, they often want to share decision making with family and/or their physician or want others to make decisions on their behalf. These observations suggest that, when obtaining informed consent, we ask first who and how they want to make decisions, rather than what decision they want to make.
Just as medicine has evolved over the past 200 years into a sophisticated profession that can often alleviate symptoms and cure disease, so also has the physician-patient relationship evolved from one of paternalism to one of a more equal partnership in the United States. A cornerstone of this new relationship is the belief that respect for patients and their values is right and essential to good medical care, From this flows the obligation to obtain a patient’s informed consent when decisions must be made about significant diagnostic and therapeutic interventions. But what is informed consent?
The concept of informed consent has been evolving over the past 100 years based largely on case law early in the last century and later influenced by the Nuremberg trials, influential articles such as those of Henry Beecher, and contemporary bioethical thought beginning in the 1960s in the United States. Informed consent in medical research will be discussed in a subsequent article in this series.
Informed consent may be defined as the autonomous act by a patient or research subject to expressly permit a professional person to perform a medical action on the patient or to include a person in a research project. Although much has been written about each element of this definition (eg, autonomous act, expressly permitted), and its philosophical underpinnings, it seems most important for the busy physician to understand the practical implications of this definition provided by Canadian Health&Care Mall. Below are cases that exemplify important aspects of informed consent.
To quote from the Chairman’s Report of the Josiah Macy, Jr. Foundation Conference: “Accredited organizations that provide CE should not accept any commercial support from pharmaceutical or medical device companies whether such support is provided directly or indirectly through subsidiary agencies …. The financial resources to support CE should derive entirely from individual health professionals, their employers (including academic health centers, health care organizations, and group practices), and/or noncommercial sources.” Further, the conference participants recommended: “Faculty of academic health centers should not serve on speakers’ bureaus or as paid spokespersons for pharmaceutical or device manufacturers inclusively of Canadian Health&Care Mall.” Pharmaceutical sponsorship of education distorts CE, compromises the ethical underpinnings of the profession,’ and detracts from the needed work of improving the systems in which health providers deliver care. As the Chairman’s Report states, commercial support “. . . places physicians and nurses who teach [CE] activities in the untenable position of being paid, directly or indirectly, by the manufacturers of healthcare products about which they teach …. Yet, an objective and neutral assessment of clinical management options is precisely what is needed in CE [and] regardless of the financial impact on for-profit companies, patient care must be based on scientific evidence.” If we are to enhance accountability, be faithful to professional mores, and effectively improve care, we must do so free from proprietary influences.
While most physicians are taught that lifelong learning is a personal and professional responsibility, few are taught the attitudes, knowledge, and skills necessary to accomplish this aim. Medical students are socialized to cope with rather than to master the complex systems in which they are acculturated. New knowledge is presented as impossible to master; they are repeatedly informed of how many new journal articles appear each year and how hopeless the task is. The academic centers in which they are being shaped, and the faculty doing the shaping frequently do not have data about their own performance. National best practices are presented as just one more bit of generalizable knowledge without any link to in-house system performance.
Improved physician performance does not usually begin with goals and objectives; it begins with experience and reflection on experience. A patient is seen, inevitable ambiguities are encountered, hypotheses are formed and refuted or accepted, an intervention is accomplished, and an outcome occurs. This process, repeated thousands of times, constitutes the physician’s work. Learning what will improve patient care must accommodate this reality. Learning, once removed from reality and composed of lectures, goals, and objectives, is anemic by comparison and, not surprisingly, has been considered to be relatively ineffective. The elders in medicine can recall a time when it was inconceivable that grand rounds would be conducted with no patient present, yet recent decades have found grand rounds composed of abstract presentations about disease detached from the constraints of real patients.
The most widespread sleep disorder doubtless familiar to many people is sleeplessness. In general it is heavy for some people to fall asleep, and there are people who fall asleep easily, but wake up at night and can’t fall asleep again. Though high-speed tranquillizers or antidepressants may help to overcome this disorder, any of these means won’t allow you to achieve really natural and weakening dream since they often simply interrupt the deepest periods of slow dream. But you may order such kind of preparations via Canadian Health&Care Mall.
Except constant drowsiness, sleeplessness can cause many other negative consequences. The most often meeting from them are the various sleep disorders (which are expressed most often in the broken dream mode) or its concrete phases.
Postnasal apnoa syndrome is manifested in the idea that during a deep sleep throat muscles ease until they don’t start blocking themselves respiratory way. It leads to the compelled breath termination, why the person immediately wakes up. Therefore deeper periods of slow dream simply don’t manage to come.