Ethical care at the end of life

In treating dying patients, who by virtue of their physical and emotional situation are frail and vulnerable, physicians must meet a high standard of professional, ethical care. Such a standard is based upon a philosophy of care that recognizes the patients' inherent worth as human beings and their uniqueness as individuals. The ethical and virtuous physician will practice in accordance with the principles of biomedical ethics that form the foundations of thought and treatment approaches in this area and will seek to do the best for the patient and the family. "Doing the best" includes respecting autonomy through gentle truth-telling, helping the patient and family to set treatment goals, and providing for symptom control, continuing attentive care and accompaniment throughout the course of the illness. Total care includes physical, emotional and spiritual aspects, is sensitive to cultural values and is best provided by an interdisciplinary team. Practices of symptom control in routine care and in crisis situations, as well as the cessation and non-initiation of treatment, will have as their goals the relief and comfort of the patient. The ethical physician will not act with the intention of bringing about the death of the patient, whether by ordering medication in excess of that required for symptom control, administering a lethal injection or any other means.     

Patients' views of direct access to specialists: an Israeli experience

CONTEXT: Surveys carried out among users of medical services can be a useful tool for health care organizations in designing proper services. Specifically, patients' views of direct access to specialists can be useful to health organizations considering the gatekeeper model. OBJECTIVE: To assess patients' opinions about direct access to specialists and referral to specialists through their primary care physician. DESIGN: An intercept survey, in which patients were interviewed at the randomly selected service provision sites, was carried out in 3 districts in Israel during 1995. A total of 1445 and 1289 patients were interviewed in primary care and specialty clinics, respectively. SETTING: Primary care and specialty clinics in 3 regions in Israel serving 750000 members of Kupat Holim Clalit, Israel's largest sick fund. PARTICIPANTS: Hebrew-speaking members of Kupat Holim Clalit who visited the primary care or specialty clinics in the 3 regions during the study period. MAIN OUTCOME MEASURES: Rate of preferences for direct access to specialists and preferences for referral through primary care physician. RESULTS: Fifty-two percent of the respondents preferred direct access to specialists, while 48% preferred a referral from their primary care physician. Multivariate logistic regression analysis indicated that the preference for direct access was significantly lower among patients older than 45 years (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.62-0.91); patients whose primary care physician was a specialist in family medicine (OR, 0.80; 95% CI, 0.67-0.97); and patients who were satisfied with their primary care physician (OR, 0.34; 95% CI, 0.27-0.44). Preference for direct access was significantly higher among more highly educated patients (OR, 1.38; 95% CI, 1.16-1.65) and patients residing in Jerusalem (OR, 2.46; 95% CI, 2.05-2.95) and those younger than 45 years who were dissatisfied with their family physician or a primary care physician who was not board certified. If direct access was not available, 33% of respondents would leave the sick fund and 48% would remain; 19% did not know. CONCLUSIONS: Informing sick fund members, particularly the younger and more educated among them, about the advantages of consulting with the primary care physician, as well as providing specialty training in family medicine to primary care physicians, may reduce patients' preference for direct access to specialists.     

Adolescent chemical dependence: Assessment, treatment, and management.

Presents the Comprehensive Assessment and Treatment Model for the assessment, treatment, and management of chemically dependent adolescents (CDAs). This model is based on the assumption that as the chemical dependence increases, functioning in all areas of life decreases. Outcome studies and follow-up questionnaires can be keyed to the domains of functioning contained in the model. The goals of therapeutic intervention with CDAs are abstinence followed by a sober state of mind with nonchemical coping skills. Achievement of these goals requires a continuum of care from inpatient structured treatment centers to outpatient private practice. The therapist should be able to use the appropriate level of care as indicated by the CDA's behavior. The therapist should also use individual and group psychotherapy, urine drug screens, and family therapy to achieve the goals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevention of violence

Primary care physicians can easily incorporate efforts toward the primary and secondary prevention of family violence into their practices. By designing a preventive effort using the phases of the family life cycle, a developmentally appropriate system of prevention is created. The anticipatory guidance at each (annual) visit acknowledges family transitions and assures the family that abuse is a health issue and that the physician is a resource for issues of violence prevention. Using the FLC, the first phase is Coupling, when there is a risk of partner violence that continues as long as there is a partnership. Pregnancy and childbirth bring concerns of child neglect and battery. Older children are at additional risk for child sexual abuse. As families age, risks develop for elder abuse, too. The regular discussion of these issues raises the awareness that the potential for family violence continues over the life span and allows the physician opportunities to assess the risk of violence in that family and make appropriate preventive referrals. Primary care physicians are optimally positioned to address violence and its prevention in the office: they know and care for family units over time. Physicians are respected and trusted advisors who can become effective in preventing violence.     

The post-suicide family and the family physician

It is estimated that there are 750,000 people each year who are intimately affected by suicide. Prominent among these are the family survivors and their family physician. This paper offers a time frame which divides the period following the suicide into three phases: Immediate (the first ten days after the suicide); Intermediate (after the first ten days through the first year); and Extended (from the first year until restitution occurs). It identifies the chief emotional reactions which occur in each phase, explores their psychodynamic origins, and proposes suggestions for appropriate management during each of the three periods. The goal of this plan of management is to enable the family physician to function in a supportive emphatic, and restorative manner for the post-suicide family.     

Inhibition of TNFalpha attenuates infarct volume and ICAM-1 expression in ischemic mouse brain

The family physician occupies a front-line position in the detection and treatment of emotional problems and psychiatric illnesses. The practice pattern of the family physician necessitates an efficient, effective model of psychotherapy The BATHE technique is a brief psychotherapeutic method that addresses the patient's background issues, affect and most troubling problem. The emphasis of the interview then shifts to how the patient is handling the problem and a demonstration of empathy by the physician. Some of the challenges in psychotherapy are presented, and cases in which the BATHE technique was used are described.     

Integrating mental health services into primary medical care

Primary care clinicians occupy a strategic position in relation to the emotional problems of their patients. Integrating mental health and primary medical services promotes available, coordinated, accessible, and less stigmatizing treatment by recognizing an indivisibility of the total person in illness and in health. Federal efforts to encourage Health Maintenance Organization (HMO) development as part of a national health program prompts serious attention to organizational arrangements for developing such an integrated program for medical-mental health care. We have found a team collaborative model in which mental health providers are members of a primary care team to be useful and promising. Supportive services are provided on a continuing basis through patterned relationships. Shared responsibility for patient care between physicians, nurse practitioners, physician assistants, and mental health workers provides built-in peer review and encourages intrateam consultation.     

Obsessive-compulsive disorder: diagnosis and treatment in the primary care setting

BACKGROUND: Obsessive-compulsive disorder is a common anxiety disorder found in 1 to 2 percent of the population. Obsessions are recurrent and persistent thoughts that cause marked anxiety or distress. Compulsions are repetitive behaviors or mental acts done to prevent or reduce anxiety. Patients might underreport symptoms or complain of coexisting depression or anxiety instead. The primary care physician is often the first to encounter this disorder in patients. METHODS: The authors cared for and observed a patient with obsessive-compulsive disorder at a family practice office and used her case to illustrate a literature review gathered by means of a MEDLINE search. RESULTS AND CONCLUSIONS: A combination of patient education, selective serotonin reuptake inhibitors, and behavioral techniques allow the family physician to maximize patient recovery and play a major role in the diagnosis and treatment of obsessive-compulsive disorder.     

Post-operative thyroid status of patients with Graves'' disease is determined by the responsiveness of thyrocyte to TSH under the present thyroid gland remnant

OBJECTIVE: Differences in the perspectives of severely and persistently ill patients, their family members, and clinical care providers on key aspects of community-based care were examined to help inform community service planning and development. METHODS: A sample of 183 patients being considered for relocation from psychiatric facilities in Alberta, Canada, to community-based care, were interviewed, as were their primary clinical care providers. Family members of 130 patients were also interviewed. RESULTS: Among the 130 patient-family pairs, 41 percent disagreed about the desirability of relocation, with fewer patients favoring relocation than families. Forty-nine percent of the pairs disagreed about the desired proximity to the family of the relocated patient, with the patient desiring closer proximity than the family member in about half of these cases. Fifty-three percent of the pairs disagreed about the amount of financial and emotional support that the family would provide after relocation. In half of these cases, patients believed the family would provide a higher level of support than the family indicated it could. Among the patients, 49 percent preferred independent living, whereas only 10 percent of family members and 17 percent of clinical care providers preferred it. Fifty-five percent of patients expressed a clear desire to work, whereas care providers believed that only 12 percent of patients were employable. CONCLUSIONS: Persistently mentally ill residents of psychiatric facilities express clear preferences about key aspects of community-based care when they are asked, and these preferences often reflect different views from those expressed by either family members or clinical care providers.     

Patients' perspectives on the management of emotional distress in primary care settings

OBJECTIVE: To investigate how important treatment for emotional distress is to primary care patients in general and to primary care patients with depression, and to evaluate the types of mental health interventions they desire. DESIGN: Patient surveys. SETTING: Five private primary care practices. MEASUREMENTS AND MAIN RESULTS: Patients' desire for treatment of emotional distress and for specific types of mental health interventions were measured, as well as patients' ratings of the impact of emotional distress, the frequency of depressive symptoms, and mental health functioning. Of the 403 patients, 33% felt that it was "somewhat important" and 30% thought it was "extremely important" that their physician tries to help them with their emotional distress. Patient desire for this help was significantly related to a diagnosis of depression (p < .001), perceptions about the impact of emotional distress (p < .001), and mental health functioning (p < .001). Among patients with presumptive diagnoses of major and minor depression, 84% and 79%, respectively, felt that it was at least somewhat important that they receive this help from their physician. Sixty-one percent of all primary care patients surveyed and 69% of depressed patients desired counseling: 23% of all patients and 33% of depressed patients wanted a medication: and 11% of all patients and 5% of depressed patients desired a referral to a mental health specialist. CONCLUSIONS: A majority of these primary care patients and almost all of the depressed patients felt that it was at least somewhat important to receive help from their physician for emotional distress. The desire for this help seems to be related to the severity of the mental health problem. Most of the patients wanted counseling, but relatively few desired a referral to a mental health specialist.     

Psychosomatic medicine and transplantation medicine. Cooperation is useful and necessary

Transplantation represents a breaching of the bodily integrity of the patient, and can lead to anxiety, depression and an identity problem. In the post-transplantation phase also, the patient undergoes further stress associated with check examinations and treatment. Standardized surveys show that the fear of graft rejection remains with the patient for the rest of his/her life. The new situation also has an influence on partnership, family and the overall psychosocial setting. All this adds up to a need for psychosomatic care, support and, where indicated, appropriate treatment in every transplantation patient. The broad spectrum of possible measures available in this connection is discussed.     

Teaching Rwandan families to care for people with AIDS at home

AIDS causes disabling symptoms during its chronic and terminal phases. Families throughout the world, whether related to the patient by blood or affection, provide most of the personal care for him or her at home during these phases. Whether the family has access to advanced medical care or not, they can be taught simple comfort measures and nursing care skills that will improve the well-being of the patient. In Rwanda, a small country in east-central Africa, Red Cross volunteers were trained to teach these skills. The volunteers then returned to their villages to help local families. Six months later, 24 of these families were interviewed about the impact of the volunteers' visits. Families indicated they had benefited from being taught the caregiving skills. They also appreciated the emotional support attendant to the volunteers' visits. In summary, the training course enabled volunteers both to enhance family nursing care skills and to provide emotional support to families caring for people with AIDS at home. This training can also be used by volunteers to assist families caring for members ill with other endemic chronic infectious diseases.     

Integrating health care: The clear advantage for underserved diverse populations.

Integrating health care into primary and specialty physician practices and clinics has potential benefits for women; racial/ethnic minorities; and lesbian, gay, bisexual, transgendered populations, thus making a major contribution to the health disparities in America. Mounting evidence suggests that physical illnesses are accompanied and exacerbated by emotional, social, and cultural factors. Many of the chronic diseases, cardiovascular disease, HIV-AIDS, diabetes, and some cancers can be prevented and altered by behavioral changes and are thus considered behavioral diseases. In addition, nonadherence to medication is a significant factor in less-than-optimal treatment of any illness. Thus, medical treatment without coordinated attempts to also treat the behavioral and social factors compromises its effectiveness. Treatment is often complicated by the lack of timely diagnoses of issues such as domestic violence, substance abuse, and eating disorders. Furthermore, helping patients negotiate medical visits, treatment options, and disease prevention and management can be effectively addressed within an integrated primary care system of health delivery with better outcomes for minorities. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Treatment of child abuse

Standards of care have recently been established for the diagnosis and treatment of child abuse. This article addresses the key areas of treatment with which each primary care physician should be acquainted. As part of a community-based approach to this problem, the physician can positively impact the prognosis for the victimized child and his or her family.     

Skin cancer of the head and neck

The incidence of skin cancers is increasing at a rate greater than any other cancer occurring in humans. In this era of managed care, patients with a suspicious skin lesion may first present to their primary care physician for evaluation. Therefore, it is important for the primary care physician to be able to distinguish between benign and malignant pigmented lesions, to know how to evaluate such a patient, and to appreciate the importance of appropriate interdisciplinary management of these patients.     

Emotional disorders in primary care.

Individuals with emotional disorders are more likely to use primary medical care than specialty mental health services, but these disorders are likely to be undetected or inadequately treated. Recognition of the importance of primary medical care for the treatment of mental disorder has resulted in pressing new research priorities. One set of issues concerns the adequacy of existing nosological systems for conceptualizing emotional disorder in primary care and identifying need for treatment. Another concerns the difficulties translating efficacious treatment into effective strategies that can be integrated into the competing demands of primary medical care. Psychologists have played only a limited role in defining and addressing emerging questions. Irreversible changes in mental health services have created the need for the development of a psychosocial perspective for what would otherwise be defined as narrowly biomedical issues. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Injuries of the distal finger

The distal finger is the most commonly injured part of the hand. Adequate initial care should lead to speedy recovery and minimal residual disability. Inadequate initial care or neglect upon the part of the patient can result in a painful and prolonged period of disability. The primary care physician sees and treats the vast majority of these injuries.     

Early identification and intervention for children who are hearing impaired

Early identification of and intervention for all children who have hearing impairments remain unattained goals in the United States. Physicians typically are the first persons to obtain the medical and family history of infants and children and are the primary professionals confronted with parental concerns about hearing loss. Heightened awareness of the common causes of hearing loss in infants and children can facilitate prompt and appropriate referrals to audiologists when hearing loss is suspected. A strong and interactive relationship between physician and audiologist is needed to attain the common goals of providing the earliest and best possible diagnosis of and optimal management for hearing impaired pediatric patients.     

Social constructivist approaches for brief, episodic, problem-focused family encounters

Clinicians of many health care disciplines provide health care services to the family unit. Because of the multiple perspectives that individual family members bring to the health care encounter, family-focused primary health care presents special challenges for providers. The need to reconcile multiple individual family member perspectives requires that clinicians develop increasingly more sophisticated, effective, family intervention skills that can be used in busy primary care settings. Social constructivism can provide a means through which clinicians can quickly engage families in creating a consensus on health issues, thus leading to effective, efficient problem solving. This paper reviews the origins and principles of social constructivist thought and describes assessment questions and therapeutic stances that can be used to empower families to become active participants in the process of initiating their own health-related life changes. These approaches are useful for episodic, brief, problem-focused encounters with families in many primary care practice settings.