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Just Doctoring
Just Doctoring draws the doctor-patient relationship out of the consulting room and into the middle of the legal and political arenas where it more and more frequently appears. Traditionally, medical ethics has focused on the isolated relationship of physician to patient in a setting that has left the physician virtually untouched by market constraints or government regulation. Arguing that changes in health care institutions and legal attention to patient rights have made conventional approaches obsolete, Troyen Brennan points the way to a new, more aware and engaged medical ethics. The medical profession is no longer isolated, even theoretically, from the liberal, market-dominated state. Old ideas of physician beneficence and altruism must make way for a justice-based medical ethics, assuming a relationship between equals more compatible with liberal political philosophy. Brennan offers clinical examples of many of today's most challenging medical problems--from informed consent to care rationing and the repercussions of the HIV epidemic--and gives his recommendation for a new ethical perspective. This lively and controversial plea for a rethinking of medical ethics goes right to the heart of medical care at the end of the twentieth century. This title is part of UC Press's Voices Revived program, which commemorates University of California Press's mission to seek out and cultivate the brightest minds and give them voice, reach, and impact. Drawing on a backlist dating to 1893, Voices Revived makes high-quality, peer-reviewed scholarship accessible once again using print-on-demand technology. This title was originally published in 1991. Many titles in the Voices Revived program are also newly available as ebooks, offered at a discounted price to support wider access to scholarly work.
eBook
Health Care Hotspotting — A Randomized, Controlled Trial
A Camden, New Jersey, “hotspotting” program is designed to prevent rehospitalizations among “superutilizers” of heath care services through home visits and telephone calls from nurses, social workers, and community health care workers who help coordinate outpatient care. In a randomized, controlled trial, the program did not reduce hospital readmissions.
Journal Article
Promoting integrated care in prostate cancer through online prostate cancer-specific holistic needs assessment: a feasibility study in primary care
Purpose
This study assessed the feasibility of implementing a novel model of integrated prostate cancer care involving an online prostate cancer-specific holistic needs assessment (sHNA) and shared digital communication between patients and their healthcare professionals (HCPs). The sHNA produces a semi-automated care plan that is finalised in consultation between the patient and their practice nurse.
Methods
Men living with and beyond prostate cancer were invited to participate in a 9-month non-randomised cluster controlled feasibility study. The intervention group was asked to complete the sHNA on three occasions. Data were collected using Patient Reported Outcome Measures (PROMs) at baseline, 10 and 24 weeks, and 9 months. Outcomes included recruitment, retention, acceptability, and engagement with the sHNA and PROMs.
Results
Fourteen general practices (8 intervention and 6 control), and 41 men (29 intervention and 12 control) participated. Initial patient engagement with the sHNA was high, with all but one receiving practice nurse-led follow-up and an individualised care plan. The sHNA proved useful in identifying ‘red flag’ symptoms, and helping practice nurses decide when to seek further medical care for the patients. There was a high level of acceptability for patients and HCPs. However, integration of care did not occur as intended because of problems linking hospital and general practice IT systems.
Conclusion
While the study demonstrated the feasibility of implementing the sHNA, it did not meet the a priori progression criteria; as such, undertaking a definitive randomised controlled trial is not appropriate until the identified methodological and technical issues have been addressed.
Journal Article
How to be a patient : the essential guide to navigating the world of modern medicine
\"From registered nurse and public health advocate Sana Goldberg, a timely, accessible, and comprehensive guide to the medical industrial complex that teaches readers how to be their own best advocate and get the care they deserve\"-- Provided by publisher.
Book
Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods
Background Handover of patient information represents a critical time period during a patient's hospitalisation. While recent guidelines promote standardised communication during these patient care transitions, significant variability in structure and practice persists among hospitals and providers. Methods The authors surveyed internal medicine residents regarding handover practices before and after introduction of a structured, web-based handover application. The handover application standardised patient data in a format suitable for both patient handovers and day-to-day patient management. Results A total of 80 residents were surveyed prior to the intervention (80% response rate) and 161 residents during the intervention (average 68% response rate for all surveys distributed). At baseline, residents perceived deficits in handover practices related to the variability of information transferred and correlated that variability to near-miss events. After introduction of the handover application, 100% of handovers contained an updated problem list, active medications, and code status (compared to <55% at baseline, p<0.01); residents perceived approximately half as many near-miss events on call (31.5% vs 55%; p=0.0341) and were twice as likely to respond that they were confident or very confident in their patient handovers compared to traditional practices (93% vs 49%; p=0.01). Conclusion Standardisation of information transmitted during patient handovers through the use of a structured, web-based application led to consistent transfer of vital patient information and was associated with improved resident confidence and fewer perceived near-miss events on call.
Journal Article
Effect of the 1-h bundle on mortality in patients with suspected sepsis in the emergency department: a stepped wedge cluster randomized clinical trial
PurposeThe efficacy of the 1-h bundle for emergency department (ED) patients with suspected sepsis, which includes lactate measurement, blood culture, broad-spectrum antibiotics administration, administration of 30 mL/kg crystalloid fluid for hypotension or lactate ≥ 4 mmol/L, remains controversial.MethodsWe carried out a pragmatic stepped-wedge cluster-randomized trial in 23 EDs in France and Spain. Adult patients with Sepsis-3 criteria or a quick sequential organ failure assessment (SOFA) score ≥ 2 or a lactate > 2 mmol/L were eligible. The intervention was the implementation of the 1-h sepsis bundle. The primary outcome was in-hospital mortality truncated at 28 days. Secondary outcomes included volume of fluid resuscitation at 24 h, acute heart failure at 24 h, SOFA score at 72 h, intensive care unit (ICU) length of stay, number of days on mechanical ventilation or renal replacement therapy, vasopressor free days, unnecessary antibiotic administration, and mortality at 28 days. 1148 patients were planned to be analysed; the study period ended after 873 patients were included.Results872 patients (mean age 66, 42% female) were analyzed: 387 (44.4%) in the intervention group and 485 (55.6%) in the control group. Median SOFA score was 3 [1–5]. Median time to antibiotic administration was 40 min in the intervention group vs 113 min in the control group (difference − 73 [95% confidence interval (CI) − 93 to − 53]). There was a significantly higher rate, volume, and shorter time to fluid resuscitation within 3 h in the intervention group. There were 47 (12.1%) in-hospital deaths in the intervention group compared to 61 (12.6%) in the control group (difference in percentage − 0.4 [95% CI − 5.1 to 4.2], adjusted relative risk (aRR) 0.81 [95% CI 0.48 to 1.39]). There were no differences between groups for other secondary endpoints.ConclusionsAmong patients with suspected sepsis in the ED, the implementation of the 1-h sepsis bundle was not associated with significant difference in in-hospital mortality. However, this study may be underpowered to report a statistically significant difference between groups.
Journal Article