Impairment and severity: how ED physicians decide to override an impaired patient's refusal

Attitudes of prehospital emergency care professionals toward refusal of treatment: A regional survey in Turkey

INTRODUCTION

Prehospital emergency medicine is a specific field of emergency medicine. The basic approach of prehospital emergency medicine is to provide patients with medical intervention at the scene of the incident. This special environment causes health professionals to encounter various problems. One of the most important problems in this field is ethics, in particular questions involving refusal of treatment and the processes associated with it.

OBJECTIVE

The objective of this study is to identify emergency health professionals' views regarding refusal of treatment.

METHODS

This study was conducted with 356 health professionals who were on active duty in prehospital emergency health services. The data were collected through a form which included 10 statements. The participants were asked to indicate their level of agreement with the statements given by rating them between 0 and 10.

ETHICAL CONSIDERATIONS

Before conducting the research, permission was received from the local ethics committee. Participants were given written information about the purpose of the study. Participants were assured that their participation was voluntary.

RESULTS

The healthcare professionals with fewer years of experience in the profession and female participants adopted an attitude of giving priority to providing care. Young participants, in general, respected patient autonomy. However, paradoxically, when it comes to emergency medical cases, they expressed an opinion closer to paternalism.

CONCLUSIONS

This study has found that prehospital emergency health professionals generally respect the patient's right to refuse treatment; however, they do not prioritize this right when there is a life-threatening situation or when the person does not have decision-making capacity. In these cases, prehospital emergency health professionals tended to adopt a more paternalistic approach.

How Do Perceptions of Asthma Control and Severity Relate to Indicators of Asthma Status and Treatment Recommendations by Pediatricians?

BACKGROUND: According to National Institutes of Health (NIH) guidelines, asthma control and severity are unique constructs. Little is known about how asthma control and severity are distinguished by pediatricians and if they influence treatment recommendations. METHODS: We conducted a random-sample survey of 500 pediatricians using patient vignettes with different asthma status indicators (recent hospitalization, parental report of bother from asthma, frequent symptoms, parental report of worsening asthma, and wheeze during physical exam) and a visual analog scale (VAS) to rate control and severity. Regression models assessed the independent effects of these indicators on asthma control and severity ratings, and the effects of these ratings on treatment recommendations. RESULTS: A total of 270 respondents provided usable data. Compared to patients with well-controlled asthma: (1) medication intensity influenced only severity ratings; (2) frequent symptoms and recent hospitalization influenced control and severity ratings; (3) wheeze and bother influenced control ratings only (p<0.001 for all comparisons); (4) a report of worse asthma did not significantly affect any ratings (p>0.2). Poorer VAS control ratings were associated with recommendations to step-up treatment (odds ratio [OR] 2.61, 95% confidence interval [CI], 2.2-3.1, p<0.001), but more severe VAS ratings were not (OR 1.02, 95% CI, 0.9-1.2, p=0.8). Recommendations to step-down treatment were associated with poorer VAS control ratings (OR 0.70, 95% CI, 0.6-0.8, p<0.001) and more severe VAS ratings (OR 0.82, 95% CI, 0.7-0.9, p<0.001). CONCLUSIONS: Pediatricians who step-up asthma treatment base their assessments on asthma control, while assessments of both control and severity factor into their decision to step-down asthma therapy.

Legal controls of the medical profession

PURPOSE OF REVIEW

The authors, after a brief historical review of the theme, review the articles published in the last year. The purpose is to verify how the field has moved on during this period, as a constant increase of legal and social controls on the medical profession is perceived.

RECENT FINDINGS

Surprisingly, very few articles treating directly the theme reviewed were found. The better part of the articles examined legal aspects of the medical profession in a nonsystematic way. Among the ones selected those that dealt with internal controls (produced by the professional categories such as the Clinical Practice Guidelines) and those that dealt with external controls (produced by other social groups) could be identified.

SUMMARY

The authors conclude that the existence of limits and internal and external controls is fundamental for a professional medical practice of quality. However, the excess of controls, which causes a defensive attitude, may negatively interfere in the quality of the care offered to patients.