Medicine and law
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This paper reviews the rationale for cardiopulmonary resuscitation (CPR) and a "Do Not Resuscitate" order (DNR). It includes the confusion surrounding consent and related treatments; implications and misunderstandings for care givers, patients and families; efficacy; value; unilateral DNRs; and discomfort on the part of physicians to discuss patients' preferences early in treatment. CPR and DNR challenge accepted definitions of beneficence and force us to consider the immediate as well as the long-term value and benefit to patients and families, the concept of futility, and our view of the good. ⋯ Patients' medical status and prognosis may mitigate the wisdom of attempting to resuscitate. This paper reviews the principles of best interest and substitute judgment, it provides suggestions to frame and facilitate conversations about DNR related to the larger treatment goals and plans among physicians, nurses, patients, and families. Policies and forms developed at institutions are reviewed to identify mechanisms for improving the process and special circumstances such as the operating room.
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That medical and nursing students should learn at least certain subjects together has long been discussed. The implementation of such learning is becoming more important. The reasons are cultural diversity and differing values. ⋯ It is by listening to each other that we learn of our own and others' values. The international scene is so accessible now that international joint learning is becoming imperative, otherwise the person of the patient gets excluded. Because people--and patients--matter, we cannot ignore the need to hear and respond to their values.
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Medical students, overwhelmed by new information, rarely appreciate patients' complaints beyond their biomedical aspects. To encourage students to think more comprehensively about patients, I initiated a biweekly series of seminars in medical humanities at the Duke University School of Medicine. ⋯ The humanities inculcate a tolerance for ambiguity, provide a basis for the reconciliation of competing values, and foster the ability to discern the narrative thread in the setting of illness. The paper highlights the elements of the lecture series and suggests how it helps cultivate a core competency of medical education: learning to engage in the dialogue that grounds the doctor-patient relationship.
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This paper examines briefly the rights and vulnerabilities of children and young people. It brings together themes relative to respect for individuals, maintaining trust and competence to make valid decisions. ⋯ It looks at the criteria for "best interests" judgements. Also, the role of the doctor is considered in regard to the whole family.
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Informed consent for research in psychiatry raises a number of ethical and legal issues. To illustrate some of the ethical problems involved, in particular issues of patient competence and proxy consent, as well as the motives of patients to become research participants, as an example the case of so-called medication-free research in schizophrenia is discussed. ⋯ In case of substituted consent it is shown that proxy decision makers may fail to protect the interests of incompetent patients in research. Finally, researchers ought to be aware that research subjects may be motivated to participate in research because they may mistakenly believe that the research project is designed to benefit them directly.