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"Wasserman, Jason Adam"
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Prevalence of traumatic brain injury among the guests at a low-barrier homeless shelter
Objective
This study aimed at determining the prevalence of traumatic brain injuries (TBI) among guests staying at a low-barrier homeless shelter who represent an especially vulnerable subset of individuals experiencing homelessness.
Results
A total of 21 out of 35 shelter guests participated in the survey. We found that 17 (81.0%) had experienced at least one traumatic brain injury in their lifetime and 15 (71.3%) had TBI associated with loss of consciousness. In addition, 7 (33.3%) of the participants had experienced TBIs rated as moderate to severe. Of the participants with head trauma history, 16 (94.1%) experienced their injury before their first onset of homelessness. Compared to both the general population and the broader population of individuals experiencing homelessness, those in this sample were significantly more likely to experience TBI (95% CI 0.0000:0.2857; p < 0.001 and 95% CI 0.3333:0.7619; p < 0.015, respectively) and significantly more likely to experience severe TBI (95% CI 0.0000:0.09524; p < 0.001).
Journal Article
Paradoxical experiences of healthcare workers during COVID-19: a qualitative analysis of anonymous, web-based, audio narratives
To gain a deeper understanding of healthcare workers experiences during COVID-19 using an anonymous, web-based, audio narrative platform.
Data were collected from healthcare workers in the midwestern United States using a web-enabled audio diary approach. Participant recordings were analysed using a narrative coding and conceptualization process derived from grounded theory coding techniques.
Fifteen healthcare workers, in direct patient care or non-patient care roles, submitted 18 audio narratives. Two paradoxical themes emerged: 1) A paradox of distress and meaningfulness, where a harsh work environment resulted in psychological distress while simultaneously resulting in new rewarding experiences, sense of purpose and positive outlooks. 2) A paradox of social isolation and connection, where despite extreme isolation, healthcare workers formed intense and meaningful interpersonal connections with patients and colleagues in new ways.
A web-enabled audio diary approach provided an opportunity for healthcare workers to reflect deeper on their experiences without investigator influence, which led to some unique findings. Paradoxically, amid social isolation and extreme distress, a sense of value, meaning and rewarding human connections emerged. These findings suggest that interventions addressing healthcare worker burnout and distress might be enhanced by leveraging naturally occurring positive experiences as much as mitigating negative ones.
Journal Article
Capacity for Preferences: Respecting Patients with Compromised Decision-Making
When a patient lacks decision‐making capacity, then according to standard clinical ethics practice in the United States, the health care team should seek guidance from a surrogate decision‐maker, either previously selected by the patient or appointed by the courts. If there are no surrogates willing or able to exercise substituted judgment, then the team is to choose interventions that promote a patient's best interests. We argue that, even when there is input from a surrogate, patient preferences should be an additional source of guidance for decisions about patients who lack decision‐making capacity. Our proposal builds on other efforts to help patients who lack decision‐making capacity provide input into decisions about their care. For example, “supported,” “assisted,” or “guided” decision‐making models reflect a commitment to humanistic patient engagement and create a more supportive process for patients, families, and health care teams. But often, they are supportive processes for guiding a patient toward a decision that the surrogate or team believes to be in the patient's medical best interests. Another approach holds that taking seriously the preferences of such a patient can help surrogates develop a better account of what the patient's treatment choices would have been if the patient had retained decision‐making capacity; the surrogate then must try to integrate features of the patient's formerly rational self with the preferences of the patient's currently compromised self. Patients who lack decision‐making capacity are well served by these efforts to solicit and use their preferences to promote best interests or to craft would‐be autonomous patient images for use by surrogates. However, we go further: the moral reasons for valuing the preferences of patients without decision‐making capacity are not reducible to either best‐interests or (surrogate) autonomy considerations but can be grounded in the values of liberty and respect for persons. This has important consequences for treatment decisions involving these vulnerable patients.
Journal Article
Capacity for Preferences and Pediatric Assent
In the past thirty to forty years, clinicians and bioethicists have expanded the scope for children’s participation in decision‐making about their medical care, often under the banner of “pediatric assent.” The success of this movement was signaled perhaps most strongly by the creation of American Academy of Pediatrics guidance on pediatric assent in 1995. We agree with the AAP that both the best interests of the child patient and the need to respect the child patient are reasons to take seriously children’s treatment preferences. However, we argue that the AAP could provide a stronger and more stable ethical foundation for pediatric assent. Current policy documents invoke a conception of respect that is grounded in autonomy and cannot apply in most cases of pediatric assent. We argue that the mere fact that children have treatment preferences is a reason to support pediatric assent. We defend this claim by focusing on the importance of what we have called “capacity for preferences.” The notion of capacity for preferences underscores that the moral value of a patient’s preferences is not reducible to considerations of either autonomy or best interests.
Journal Article
The Medicalization of Homelessness and the Sociology of the Self: A Grounded Fractal Analysis
The purpose of this chapter is to illustrate the centrality of the tabula rasa concept of self for the medical model of homeless service provision. Using four years of ethnographic data analyzed with a grounded fractal methodology, we illustrate the logical interconnections between the particular phenomena of homeless service institutions and broad cultural contexts. While social science has been somewhat critical of the medicalization of homelessness, its shared supposition about the self has relegated it to structural critiques that offer little to the currently homeless and those who want to help them. In contrast, we illuminate a path toward the development of an alternative pedagogy of individualism that is more directly responsive to the problematics of the medical model of homeless service provision.
Book Chapter
The capacity to designate a surrogate is distinct from decisional capacity: normative and empirical considerations
The capacity to designate a surrogate (CDS) is not simply another kind of medical decision-making capacity (DMC). A patient with DMC can express a preference, understand information relevant to that choice, appreciate the significance of that information for their clinical condition, and reason about their choice in light of their goals and values. In contrast, a patient can possess the CDS even if they cannot appreciate their condition or reason about the relative risks and benefits of their options. Patients who lack DMC for many or most kinds of medical choices may nonetheless possess the CDS, particularly since the complex means-ends reasoning required by DMC is one of the first capacities to be lost in progressive cognitive diseases (eg, Alzheimer’s disease). That is, patients with significant cognitive decline or mental illness may still understand what a surrogate does, express a preference about a potential surrogate, and be able to provide some kind of justification for that selection. Moreover, there are many legitimate and relevant rationales for surrogate selection that are inconsistent with the reasoning criterion of DMC. Unfortunately, many patients are prevented from designating a surrogate if they are judged to lack DMC. When such patients possess the CDS, this practice is ethically wrong, legally dubious and imposes avoidable burdens on healthcare institutions.
Journal Article
Comparative treatment of homeless persons with an infectious disease in the US emergency department setting: a retrospective approach
BackgroundResearch has long documented the increased emergency department usage by persons who are homeless compared with their housed counterparts, as well as an increased prevalence of infectious diseases. However, there is a gap in knowledge regarding the comparative treatment that persons who are homeless receive. This study seeks to describe this potential difference in treatment, including diagnostic services tested, procedures performed and medications prescribed.MethodsThis study used a retrospective, cohort study design to analyse data from the 2007–2010 United States National Hospital Ambulatory Medical Care Survey database, specifically looking at the emergency department subset. Complex sample logistic regression analysis was used to compare variables, including diagnostic services, procedures and medication classes prescribed between homeless and private residence individuals seeking emergency department treatment for infectious diseases. Findings were then adjusted for potential confounding variables.ResultsCompared with private residence individuals, persons who are homeless and presenting with an infectious disease were more likely (adjusted OR: 10.99, CI 1.08 to 111.40, p<0.05) to receive sutures or staples and less likely (adjusted OR: 0.29, CI 0.10 to 0.87, p<0.05) to be provided medications when presenting with an infectious disease in US emergency departments. Significant differences were also detected in prescribing habits of multiple anti-infective medication classes.ConclusionThis study detected a significant difference in suturing/stapling and medication prescribing patterns for persons who are homeless with an infectious disease in US emergency departments. While some findings can likely be explained by the prevalence of specific infectious organisms in homeless populations, other findings would benefit from further research.
Journal Article
It’s Worth What You Can Sell It for: A Survey of Employment and Compensation Models for Clinical Ethicists
This article reports results of a survey about employment and compensation models for clinical ethics consultants working in the United States and discusses the relevance of these results for the professionalization of clinical ethics. This project uses self-reported data from healthcare ethics consultants to estimate compensation across different employment models. The average full-time annualized salary of respondents with a clinical doctorate is$188,310.08 (SD=$ 88,556.67),$146,134.85 (SD=$ 55,485.63) for those with a non-clinical doctorate, and$113,625.00 (SD=$ 35,872.96) for those with a masters as their highest degree. Pay differences across degree level and type were statistically significant (F = 3.43; p < .05). In a multivariate model, there is an average increase of $2,707.84 for every additional year of experience, controlling for having a clinical doctorate (ß=0.454; p < .01). Our results also show high variability in the backgrounds and experiences of healthcare ethics consultants and a wide variety of employment models. The significant variation in employment and compensation models is likely to pose a challenge for the professionalization of healthcare ethics consultation.
Journal Article