Findings of negligence followed communication lapses in BC aneurysm case

Negligence is sometimes established on the basis of lapses in communication and patient care management that, in hindsight, could have been avoided. A recent BC court case concerned a patient who died because of a ruptured aneurysm. A Supreme Court judge found that some of the physicians involved had failed in their duty to diagnose the patient''s condition properly, or failed to communicate to one another significant signs of the patient''s illness, and failed to refer him in time to the medical specialists who could have diagnosed and treated his condition promptly.     

GENERAL ANESTHESIA FOR EYE OPERATIONS—A Consideration of Some Pertinent Factors Involved in Administration

In the administration of general anesthesia for surgical operations on the eye, care must be taken to consider the patient''s total physiological condition. A patient with eye problems may have generalized changes of more than moderate extent. Most patients are in the age group in which the incidence of cardiovascular and pulmonary problems is relatively high. If the patient is in a younger age group, perhaps diabetes or the collagen diseases must be suspected. Care must be taken to prevent undue strains to the eye during and immediately after the operation.Constant care and an awareness of possible complication is necessary for successful management in these cases.     

Aftercare of State Hospital Patients—The Role of the General Practitioner

Of all the problems facing patients released from a state hospital, the most serious one is adjustment. Failure here means a return to the hospital. The present aftercare program of the Department of Mental Hygiene does not and is not intended to meet all of the patient''s needs. It must rely upon other agencies to assist. It must rely upon the general practitioner to provide the continuity of care which is so important to successful rehabilitation.The general practitioner can often make return to a state hospital unnecessary by an accurate assessment of the patient''s problems, by effective intervention, by utilizing available consultation and by judicious referral. When services are not available, he can do much to make them available through the effective use of his professional channels.     

What Is So Special About a Family Physician?

Around a core of common, acute and chronic, recurrent health problems, a family physician must marshall the traditional episodic management for both inpatient and outpatient illness. He must also be especially adept at recently emerging routines of prevention and early detection. He provides individual and familial psychologic support and counselling, for both its therapeutic and preventive values. In addition, he must relate the individual care of his patient and the patient''s family to the community as a whole. In doing this he will use not only his own skills but those of lay health volunteers, trained allied health care professionals and skilled subspecialists in the limited medical disciplines.The proper preparation of family physicians for this complicated role has far-reaching implications for change in both medical education and medical practice.     

When families cannot "let go": ethical decision-making at the bedside.

Shared decision-making at the bedside is now a regular feature of medical practice. When disagreements arise between a patient and family members caregivers sometimes find themselves caught in a complex tangle of human relationships that strains monochrome ethical thinking. The patient''s expressed wishes are often compromised for the sake of the family''s needs. Conversely, a unilateral appeal for patient autonomy may prove insensitive to the hurt and the needs of the family. We describe a relatively unsuccessful attempt by a patient''s caregivers to buy time to maximize the interests of the patient and her family and discuss the way in which the family dynamics militated against the rather obvious solution of promoting the patient''s right to refuse treatment. The purpose of this article is not to evoke sympathy for health care professionals in dealing with such conflicts but rather to heighten awareness of the issues at stake and to stimulate thinking about ways and means to bring about a more favourable outcome than the one described here.     

Explanation and management of neurological disability.

Patients are often told of the diagnosis of a neurological disability in less than ideal circumstances such that they may not fully comprehend it. Clinicians must be able to sense when the patient''s understanding is imperfect even if superficially he or she appears to take in what has been said and its implications. A programme of further counselling is often required to follow this up. A critical look at current procedures will show how these problems arise. It is suggested that improvements in the care of neurologically disabled patients would follow from improved communication between the many agencies that the concerned in their care and from providing books and other material explaining disability and its treatment. A logical development would be for disabled living centres to be established adjacent to existing neuroscience units.     

Postpartum Idiopathic Brachial Neuritis in a Sport Medicine Physician

Idiopathic brachial neuritis is a distinctive condition that occurs most often in healthy individuals. It characteristically starts with an acute unilateral shoulder pain followed by a complex of symptoms, including weakness, paresthesias, and numbness. The cause of this syndrome is unknown and difficult to diagnose in the initial phase but may occur postsurgery, postinfection, posttrauma, or postvaccination. In this case, the patient''s inciting event appeared to be a cesarean section. There was no trauma to the shoulder or upper extremity by way of positioning during the procedure. Several months after denervation of the supraspinatus and infraspinatus muscles, electromyography revealed some improvement. The diagnosis was made through a combination of clinical evaluation, ultrasound, magnetic resonance imaging, and electromyography. With the exception of weakness, this patient experienced few symptoms. Treatment is symptomatic including anti-inflammatories, opiates, and neuroleptics for pain. There is some evidence that immunotherapy may help decrease the length of symptoms, but there is no strong evidence to support steroid use. Physical therapy, the foundation of therapy in this case, is a useful adjunct for rehabilitation. In general, this condition has a good prognosis for recovery, although often slow, even when there is complete denervation. This patient made a full recovery and has no lingering symptoms.     

Patients in the persistent vegetative state: problems in their long term management.

Physicians responsible for the long term management of patients in the persistent vegetative state face several problems. These include deciding whether tube feeding is treatment or nutritional care, whether withdrawal of tube feeding is an appropriate form of management, what clinical advantage there is in active treatment; at what level of awareness can a patient be said to have a quality of life; and who should determine a patient''s right to die. These problems are determined more by social, legal, emotional, cultural, religious, and economic forces than by clinical facts.     

Drugs of abuse--opiates.

Treating opiate-dependent patients can be difficult for many physicians because the patients'' life-styles, values, and beliefs differ from those of the physicians. Primary care physicians, however, are often involved in the treatment of the medical complications of opiate abuse, and physicians must often manage a patient''s opiate dependence until appropriate referral to a drug abuse treatment program can be arranged. Treatment is guided by an understanding of the patient''s addictive disease, for which there are specific diagnostic criteria, and an understanding of the pharmacology of opiates of abuse and the medications used in treating opiate dependence. The opiate agonist, methadone, is useful for both detoxification and maintenance. The opiate antagonist, naloxone, is the treatment of choice for opiate overdose, and naltrexone, also an opiate antagonist, is a useful adjunct in subgroups of opiate-dependent patients for preventing relapse. New medications for the treatment of opiate dependence are being developed.     

Difficulties in diagnosing chronic constrictive pericarditis

This presentation calls attention to the many problems involved in the positive, aetiological and differential diagnosis of chronic constrictive pericarditis. We mention the difficulties in aetiological diagnosis in the absence of an episode of acute pericarditis in the past medical history and the clinical findings similar to vascular decompensated cirrhosis or idiopathic restrictive cardiomyopathy. ECG and two-dimensional echocardiography do not have an important role in diagnosis, and in the absence of computed tomography and magnetic resonance imaging, chest radiography, especially a lateral view, could establish the diagnosis. A delay in diagnosis creates difficulties in the surgical treatment, but this treatment improves the patient''s condition in the long term more than the short term.     

Cadaver nephrectomy: an operation on the donor's family.

Thirty-two relatives of cadaver kidney donors were interviewed six months or longer after the donor''s death. Most had positive attitudes to kidney transplantation that had been strengthened by experience, especially when they knew that they were fulfilling the donor''s wishes. Twenty-three of the relatives had gained some solace from knowing that others might benefit from their misfortune, but three claimed adverse effects. In identifying the factors that influenced them to grant permission or hesitate, relatives revealed defects in the way their permission had been sought. Twelve did not clearly understand the donor''s hopeless prognosis until then, and seven reacted adversely to the interviewers, finding them blunt and callous. Nevertheless, most were pleased that they had been asked. Doctors who care for unconscious, dying patients should try to give relatives explicit information on the patient''s condition, whether or not the patient is a potential kidney donor, and permission for organ recovery should not be sought until they understand that death is inevitable.     

Severe Gastrointestinal Haemorrhage: Haemangiomata Demonstrated by Selective Visceral Arteriography

Selective visceral arteriography was found to be invaluable in the management of two cases of severe gastrointestinal haemorrhage associated with cavernous haemangiomata (a large gastric haemangioma and a small jejunal haemangioma). It is suggested that arteriography may be indicated in cases where a previous laparotomy has not shown the cause of bleeding, when the patient''s general condition precludes a prolonged operation, and when superficial haemangiomata are found.     

Prevention of psychosocial problems in children with chronic illness.

Children with chronic illness and disability are at considerably increased risk of psychosocial problems, such as neurosis, attention deficit and poor adjustment to school. Health care professionals, especially primary care physicians, can do a great deal to prevent such problems in these children and their families. The approach outlined here is based on an understanding of the transactional model of development, in which the child interacts with--and to some extent creates--the social environment, and on a "noncategorical" concept in which common elements in chronic illness are recognized and emphasized. The physician''s role is to inform the family of the child''s condition as soon as possible, to offer hope, encouragement and guidance, to watch the child''s development, to maintain a shared view of the child and family, and, if possible, to ensure continuity of care.     

Psychological assessment of factors affecting pain

Use of traditional stimulus-response models of pain leads to differentiation between organic and psychogenic pain, which is often not helpful, if not dangerous, in treating chronic pain. Pain does not simply reflect bodily damage but also complex psychological malfunctioning. Viewing chronic pain as an obsessional state may often help in treating the entire patient and prevent the physician from being obsessed with the patient''s obsession. Psychological assessment of pain should focus on the role of psychological processes in the multifactorial causation of the illness causing the pain, notably their role in illness-proneness in general. Also, iatrogenic psychological distress, associatively precipitated psychological conflict and illness-perpetuating psychological processes should be looked for. A serious obstacle to progress with pain problems is not lack of hard data but conceptual confusion. Before medicine can meaningfully assess psychological factors in pain problems it must first learn to perceive psychological disturbances in medical and surgical patients.     

Fistules pulmonaires artério-veineuses

A case of multiple pulmonary arteriovenous fistulas is reported. Hereditary hemorrhagic telangiectasia is a characteristic associated finding, and in this instance affected 10 members of the patient''s family over four generations. This association suggests that the pulmonary condition in its congenital form is part of a generalized vascular dysplasia. Clinically, the patient experienced increased dyspnea and fatigue but cyanosis and polycythemia were not noted. After surgical excision of the fistula with conservation of as much pulmonary tissue as possible, prompt relief of symptoms was obtained. Furthermore, angiographic studies revealed that the small fistulas in the other lung did not enlarge. The presence of multiple fistulas is not a contraindication to surgery, and such fistulas should be excised to improve the patient''s condition and prevent further complications.     

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.     

Ethical conflicts in long-term care of the aged: nutritional problems and the patient-care worker relationship.

The patient-care worker relationship was analysed by observation and unstructured group discussion in four long-stay somatogeriatric wards at Saint Lars Hospital. Investigation centred on patients entering the terminal phase who could no longer be spoon-fed. The relationship was complicated and reciprocal, and failure by the care worker to interpret her role and the dying patient''s behaviour correctly led to emotional conflict and double-binding, with resultant anxiety for both herself and the patient. Infusions and tube-feeding prescribed in such cases were given not for the patient''s benefit but to relieve anxiety in care workers and relatives. Permitting the patient a natural, painless death from water deficiency may be preferable to prolonging pain and discomfort by intervening with infusion and tube-feeding.     

Problems of care in a private nursing home.

To assess problems of care in a private nursing home an observational study was carried out over two months, during which a research nurse worked as a member of the staff in a home caring for 25 patients aged 62-90. During the second month a consultant physician visited the home weekly to hold case conferences and assess each patient''s functional ability and drug regimen. Various problems in medical, nursing, and bureaucratic matters were identified--for example, staff failed to understand the appropriate response to various medical symptoms; no clear policy existed for managing pressure sores; and one patient''s anticoagulant state could not be assessed when industrial action meant that transport to take him to hospital was not available--and several changes in drug treatments were recommended. The problems that were identified were mainly due to poor communication between the home and general practitioners and hospitals and to the lack of guidance policy on common issues that arise in long term care. Such a policy could be produced by health authority staff, general practitioners, and representatives of nursing homes.     

Withholding the artificial administration of fluids and food from elderly patients with dementia: ethnographic study

ObjectiveTo clarify the practice of withholding the artificial administration of fluids and food from elderly patients with dementia in nursing homes.DesignQualitative, ethnographic study in two phases.Setting10 wards in two nursing homes in the Netherlands.Participants35 patients with dementia, eight doctors, 43 nurses, and 32 families.ResultsThe clinical course of dementia was considered normal and was rarely reason to begin the artificial administration of fluids and food in advanced disease. Fluids and food seemed to be given mainly when there was an acute illness or a condition that needed medical treatment and which required hydration to be effective. The medical condition of the patient, the wishes of the family, and the interpretations of the patients'' quality of life by their care providers were considered more important than living wills and policy agreements.ConclusionsDoctors'' decisions about withholding the artificial administration of fluids and food from elderly patients with dementia are influenced more by the clinical course of the illness, the presumed quality of life of the patient, and the patient''s medical condition than they are by advanced planning of care. In an attempt to understand the wishes of the patient doctors try to create the broadest possible basis for the decision making process and its outcome, mainly by involving the family.

What is already known on this topic

Debate has focused on whether it is beneficial to withhold the artificial administration of fluids and food from patients with advanced dementia

What this study adds

The course of dementia, the patient''s quality of life, and the patient''s current medical condition influence doctors'' decision making more than advanced planning of careDoctors try to create the broadest possible basis for the decision making process and its outcome, mainly by involving the family     

PSYCHOTHERAPY OF ALCOHOLICS—The Concept of Psychotherapeutic Motivation

The psychiatric patient''s compliance with requirements of therapy (attendance, responsiveness, verbalization, etc.) often is adopted by the therapist as the chief criterion of motivation for cure. By these standards alcoholics often are judged to be poorly motivated and unsuited to the therapist''s mode of therapy. In such cases, the method may have to be adapted to the case, and a more permissive attitude taken toward the patient''s apparent noncooperation.