Legal obligation of physicians to disclose information to patients.

Obtaining a patient''s consent is a routine daily process for physicians, although many are unaware of the scope of this legal obligation. In 1980 the Supreme Court of Canada changed the law relating to informed consent; promotion of patient autonomy shifted the focus from a standard of professional disclosure to one of a "reasonable patient." Physicians have a legal obligation to disclose to patients specific information, the scope of which is determined by a court on the basis of a reasonable patient''s expectation and the circumstances of the case. This gives rise to many controversies in the practice of clinical medicine. It is difficult for physicians to know which treatment risks require disclosure, since this is decided by a court in a retrospective analysis of the evidence. Will the court recognize exceptions to the duty of disclosing information? If several health care professionals are involved in a patient''s care who has the duty to disclose information? Can this duty be delegated? This paper provides physicians with guidelines that are consistent with the promotion of patient autonomy and comply with the doctrine of informed consent. In addition, it suggests ways of improving awareness of the doctrine and procedures to ease its application.     

The Coordination of Dentists and Physicians in Managing Adverse Oral Effects of Drug Therapy–Report of a Case

Because people are living longer and older people generally use more medications than do the young, it is extremely important that the dentist be aware of the medications that are being taken by his/her patients as well as the reasons for the medications. Frequently, it may be necessary to consult with the patient's physician(s) in order to better understand the patient's medication history. This paper describes a case in which a patient was inappropriately following a long-term course of antibiotic therapy when only a short-term regimen had been intended by the patient's physician. The long-term antibiotic use eventually predisposed the patient to oral candidosis. The dentist contacted the physician and referred the patient back to the physician for an alternative medical regimen. This case report emphasizes that patients may incorrectly interpret physician or dentist instructions concerning medication use. The dentist may be in an excellent position to identify medication errors and should contact the patient's physician whenever in doubt.     

Medical Care of the Alcoholic Patient

Alcoholism is an illness that constitutes a major health problem at all levels of society. The physician should accept his responsibility to prevent it and to care for the alcoholic. If he knows that one of his patients is drinking immoderately, he should warn him of the outlook. A patient''s acquired dependence on alcohol may be overt, or revealed only on examination for organic disease or emotional disturbance. The diagnosis may be accepted reluctantly, or denied despite positive evidence, but the patient should be persuaded to give up drinking. He may require psychiatric help or advice from a social worker. He may be so ill as to require treatment in hospital, and hospitals must recognize the urgency of such admissions. Discharge from hospital does not end treatment, for alcoholism is a chronic disease, requiring long-term planning, persistent follow-up and enduring sympathy by the physician, who must always be as available to his alcoholic patient as he is to his patient with diabetes, epilepsy or cardiac disease.     

Bioethics for clinicians: 2. Disclosure.

In the context of patient consent, "disclosure" refers to the provision of relevant information by the clinician and its comprehension by the patient. Both elements are necessary for valid consent. Disclosure should inform the patient adequately about the treatment and its expected effects, relevant alternative options and their benefits and risks, and the consequences of declining or delaying treatment. The clinician''s goal is to disclose information that a reasonable person in the patient''s position would need in order to make an informed decision. Therefore, clinicians may need to consider how the proposed treatment (and other options) might affect the patient''s employment, finances, family life and other personal concerns. Clinicians may also need to be sensitive to cultural and religious beliefs that can affect disclosure.     

THE HIGH SCHOOL FOOTBALL TEAM PHYSICIAN

Mutual confidence is necessary between the football coach and the team physician. The physician''s decision in the matter of a boy''s condition must always be final. The coach should also consider the physician''s advice in shaping his psychological appeals to the players in before-game and between-halves talks. The physician should be on his way to a man injured on the field as soon as the play is ended. It is up to him and not the trainer or coach to make the diagnosis. The physician must have the ability to make an immediate evaluation of the extent of injury and use appropriate measures to get the player off the field. To see a semi-conscious man with dangling head being half dragged off the field is far worse from the patient''s standpoint and from the spectator''s standpoint than removal by stretcher.     

Sexual Therapy of Patients with Cardiovascular Disease

Physical illness or disability inevitably has a damaging effect on sexual relationships. Physicians are usually unaware of the sexual consequences of illness on their patients, and lack experience in treating sexual dysfunctions.The report of treatment of a couple with serious cardiovascular disease illustrates the potential efficacy of brief sex therapy for improving the quality of a patient''s life. If a primary physician lacks the skills to conduct sex therapy, he may collaborate with nonphysician therapists. The physician''s knowledge of the physiological and psychological effects of a specific illness on his patient is essential to successful therapy. Often, simple education, encouragement or reassurance by the physician is enough to overcome the damaging effects of illness on a patient''s sex life.     

The confederation worm token.

To an increasing degree the psychiatrist is oriented to the community and general hospital either as consultant, therapist, or collaborator in overall patient management. In these new roles, he becomes a more comprehensive physician and also conveys psychiatric insights to his colleagues.Psychological factors and the patient''s personality “style” influence the development and course of every disease, complicating diagnosis and effective treatment. It is a basic requirement that a good working alliance be established between patient and physician. This is assisted by comprehensive history taking, which clarifies the lifesetting in which the illness began, the patient''s personality and his habitual reactions of emotional regression under stress. It will also point up errors introduced by the patient, omissions, and distortions in offering the subjective data which the physician must evaluate.Seven major personality types and appropriate physician responses are outlined: the dependent demanding oral patient, the orderly controlled obsessive, the dramatic seductive hysteric, the long-suffering masochist, the querulous paranoid, the overbearing narcissist and the aloof withdrawn schizoid.The non-psychiatrist can resolve complex and puzzling medical problems if he has an increased awareness of how emotional forces complicate illness and if he can exploit comprehensive history taking to the full.     

Agricultural medicine: fighting health hazards down on the farm.

The delegation of a medical act to persons other than physicians may be appropriate in certain restricted circumstances in the interests of good patient care and efficient use of health care resources. The CMA''s Guidelines for the Delegation of a Medical Act were established to help physicians when they decide to delegate a medical act to a person other than a physician. Such delegation does not absolve the physician of responsibility for the care of the patient; it merely widens the circle of responsibility for the safe execution of the procedure.     

Legal Liability to Volunteers in Testing New Drugs

Scientists test new drugs by giving them to volunteers. In spite of every precaution, the drug may harm the volunteer. Under Canadian law, can he recover damages against any of the persons connected with the test? He cannot succeed against the scientist if the latter had made complete disclosure of the risks and had then obtained the volunteer''s free consent. Where the subject of a test is a child or one of unsound mind, the guardian''s consent probably does not protect the scientist from a possible claim by the subject. Where a married woman is a volunteer, her husband''s consent is unnecessary. The volunteer cannot succeed against his family physician who referred him to the scientist unless the physician took an active part in an experiment that was conducted negligently or without a proper consent. The volunteer cannot succeed against the maker unless he has negligently prepared the drug or given misleading information.     

THE CHANGING OUTLOOK IN CORONARY DISEASE

The statistical prognosis for patients who survive a first attack of coronary thrombosis, as regards both life expectancy and ability to return to normal activity, has been greatly improved in recent years. In the light of advances in understanding of the physiology of the heart and improvements in therapeutic methods, physicians must reevaluate ideas of what a patient should be permitted to do after recovery from an initial attack. Often a return to normal pursuits may be better for the patient than drastic restriction of activity, particularly because of the psychological and emotional effects of invalidism.In deciding what advice to give on this score, the physician should consider in each case not only the actual amount of coronary circulation but such factors as the patient''s temperament, type of occupation and economic status. The goal should be to guide each patient back to usefulness within the limits of his cardiac reserve.     

PSYCHOTHERAPY—A Concept for the Nonpsychiatric Physician

Patients tend to repeat with their physician, as with other significant people in their lives, their earlier previous patterns of behavior. The physician as well as the patient is involved in the physician-patient relationship. He will tend to respond to his patients in accordance with his earlier life experiences and his characteristic repetitive behavioral pattern. For both physician and patient, the relationship between them extends beyond the immediate reality situation.Psychotherapy is the utilization of psychological measures in the treatment of sick persons and the deliberate utilization by the physician of the physician-patient relationship for the benefit of the patient. The kind of psychotherapy that is practical and utilizable by the nonpsychiatric physician is that which uses education, reassurance, support and the management of the patient''s problems either directly or indirectly or through the intermediary of other people or agencies.The symbolic aspect of the physician-patient relationship is based essentially on the fact that a sick person, because of his anxiety and because of the threat to his physical and psychic integrity, is more dependent and more anxious than he would be if he were well, and therefore he has a correspondingly greater need for the authoritative and protective figure he finds in the physician.Psychotherapy is not directed exclusively to the treatment of flagrantly or obviously neurotic or psychotic patients. It should be and is directed to all sick persons. Limitations in psychotherapy are set by various determinants, among which are the nature of the precipitating factor in the illness, the nature of the sick person, the skill, knowledge and abilities of the physician, and the nature of the physician-patient relationship. In psychotherapy, as in all medicine, the physician should not do anything which may disturb the patient if the disturbance is of no value or if it cannot be followed through with special skills.     

IS IT NEUROSIS?

So-called “minor psychiatry,” the treatment of neurosis in persons who are not psychotic, may well be undertaken by the general practitioner.The first duty of the physician in dealing with a neurotic person is to determine whether psychosis may develop. He must be patient and thorough in hearing the history of the case and should have full information on the patient''s life and family.A recent classification of the neuroses is given and the more generally recognized symptoms of these conditions are described.     

MEDICAL HANDICAPS TO DRIVING—The Physician's Dilemma in Evaluation

The physician who examines a patient for impairment to driving must consider the welfare of the community which will be exposed to the patient''s driving in addition to the welfare of the patient himself. The medical opinion on physical and mental fitness to drive should be based upon consideration of:1. Extent and nature of driving exposure.2. Relation of organ system involved to medical requirements of the driving task.3. Duration of condition and nature of adaptability.4. Predicted speed of onset of medical crisis.5. Evaluation of the patient and his environment as a totality.An informed medical society traffic safety committee can be of great assistance to the practicing physician and to the Department of Motor Vehicles in evaluating medical hazards in driving in special cases. Most regulations concerning impairment to driving are currently based upon consensus of expert opinion since statistically valid data are not yet available.     

Reflection on family consent: based on a pregnant death in a beijing hospital

The ‘family consent’ process has been placed at the centre of Chinese clinical practice. Although there has been critical analysis of how the process functions in relation to the autonomy and rights of patients, there has been little examination of the perceptions and attitude of patients and their families and the medical professionals, in relation to moral dilemmas that arise in real cases in the bioethical discourse. When faced with a consent form in an emergency situation, the family member's capacity to act is reduced, as he/she becomes enmeshed in the hospital structure of tacit, socially‐imposed rules. In a questionnaires based on a real death case in 2008, 70.9% of the surveyed medical professionals (n = 3,665) disagreed with performing surgery without the consent of the family even if the patient's life was in danger, while 36.6% of the surveyed patients (n = 1,198) hold the same position. This work demonstrates the weakness of the family consent process as a safeguard of patient's autonomy. Finally, I argue that saving the patient's life should be the overriding obligation rather than the respect for the surrogate's autonomous choice at such a decisive moment.     

Informed consent and nudging

In order to avoid patient abuse, under normal situations before performing a medical intervention on a patient, a physician must obtain informed consent from that patient, where to give genuine informed consent a patient must be competent, understand her condition, her options and their expected risks and benefits, and must expressly consent to one of those options. However, many patients refrain from the option that their physician believes to be best, and many physicians worry that their patients make irrational healthcare decisions, hindering their ability to provide efficient healthcare for their patients. Some philosophers have proposed a solution to this problem: they advocate that physicians nudge their patients to steer them towards their physician's preferred option. A nudge is any influence designed to predictably alter a person's behavior without limiting their options or giving them reasons to act. Proponents of nudging contend that nudges are consistent with obtaining informed consent. Here I argue that nudging is incompatible with genuine informed consent, as it violates a physician's obligation to tell their patients the truth, the whole truth, and nothing but the truth during adequate disclosure.     

Emotional Reactions to Disfigurement from Cancer Therapy

Disfigurement not only produces current anxieties but reactivates childhood conflicts. The emotional reaction depends upon the disturbance to the patient''s major adaptations to life as well as the meaning of the organ to the patient. Fear of isolation and rejection by others may be more terrifying than fear of death. Emotional reactions include regression with marked dependency, anxiety, depression, hostility and, if severe, paranoid states, hypochondriasis, denial, counterphobic behaviour, obsessive-compulsive reactions and schizophrenic reactions. Management basically involves early establishment of a positive doctor-patient relationship. In such a relationship the physican should educate his patient, undercut guilt, accept transient regression and expression of anger, set limits on counterphobic behaviour, either support or gently question denial of reality, and support, without being overly sympathetic, a depressed patient. The nurse, social worker, psychiatrist and the patient''s family may be valuable members of the therapy team. Disfigurements of various body areas pose individual problems of management.     

Internet access

A 65-year-old man undergoes a routine checkup before retiring. His wife has urged him to have his prostate examined, because she has read about testing for prostate cancer and a friend has just died of this disease. During the rectal examination, the man''s physician discovers some firmness in the right lobe of the prostate gland. The patient has had no urinary symptoms and is in excellent general health. Sexual function is normal. There is no history of prostate cancer; his father died of a stroke at age 86 years. Testing shows that the patient''s prostate-specific antigen level is 9.3 ng/mL, and he is referred to a urologist. Transrectal ultrasound-guided needle biopsy reveals adenocarcinoma with a Gleason score of 7 (intermediate grade). At a follow-up meeting with his physician, the patient says, "I have been doing some research, and it appears that I should have treatment. However, what is less clear to me is what form of therapy is best--surgery or radiation treatment. Please tell me what you can about the state of the art with respect to surgery."     

Managing uncertainty in family practice.

Because patients present in the early stages of undifferentiated problems, the family physician often faces uncertainty, especially in diagnosis and management. The physician''s uncertainty may be unacceptable to the patient and may lead to inappropriate use of diagnostic procedures. The problem is intensified by the physician''s hospital training, which emphasizes mastery of available knowledge and decision-making based on certainty. Strategies by which a physician may manage uncertainty include (a) a more open doctor-patient relationship, (b) understanding the patient''s reason for attending the office, (c) a thorough assessment of the problem, (d) a commitment to reassessment and (e) appropriate consultation.