An elderly man presents with his wife to the practice. They are new in town, having moved in order to be closer to thier daughter. He has significant dementia, is on Namenda, and is extremely well cared for by his wife. She is very bright and says that she can't really see that the Namenda has done much good. He's a delightful man. He smiles, drums on his knees and whistles the entire time he is in the exam room. He doesn't care if you are talking to him or about him. He's kind of funny, and its awkward, but pleasant to be in the room with him and his wife. I ask her how extensive his work up for dementia had been by their previous physician and she's not entirely sure. I ask if it would be okay if I ran a few tests. She agrees.
His B-12 level comes back at 160, which is extremely low. He is not on a vitamin supplement and she does not recall this issue being discussed. It is clearly too late to reverse his dementia, but I advise them to begin monthly B-12 injections along with a mulitivitamin.
Here's the question: is there any value in reporting this finding to their previous physician? She had spoken of him in glowing terms when I first met her and sounds as if he had been caring and gentle with them. Should he be told or "reminded" of the role of Vitamin B-12 deficiency in dementia, or will this information make him feel bad? These are not litiginous people, by the way.
Does a physician have an obligation to let another physician know of a missed diagnosis? A wrong diagnosis?
My experience is that we just pick up and go on and are often "too busy" to share this type of information. Any thoughts?
Monday, March 26, 2007
Terminology
Autonomy
Patients have the right to choose actions consistent with their values, goals, and life plan, even if their choices are not in agreement with the wishes of family members or the recommendation of the physician. Choices should be free from interference and control by others.
Beneficence
Beneficence refers to acting in the best interests of the patients. This concept often is confused with nonmaleficence, or "do no harm." Doing what is best for the patient often involves serious risks.
Confidentiality
Respecting a patient's privacy and maintaining confidentiality allows people to seek treatment and discuss their problems frankly.
Futility
The term futility may be used in several situations, including the following: The intervention has no pathophysiologic rationale. Maximal treatment is failing. The intervention has already failed. The intervention will not achieve the goals of care.
Informed consent
Informed consent is the process by which a patient receives all pertinent information necessary to make a rational autonomous choice. Disclosure standards, comprehension, voluntary action (free of control of others), competence, and consent are the 5 elements of informed consent.
Justice
Justice refers to fairness in the allocation of healthcare resources.
Veracity
Veracity is truth telling and honesty; recognize that it is not uncommon for healthcare providers to misrepresent a situation without technically lying.
Patients have the right to choose actions consistent with their values, goals, and life plan, even if their choices are not in agreement with the wishes of family members or the recommendation of the physician. Choices should be free from interference and control by others.
Beneficence
Beneficence refers to acting in the best interests of the patients. This concept often is confused with nonmaleficence, or "do no harm." Doing what is best for the patient often involves serious risks.
Confidentiality
Respecting a patient's privacy and maintaining confidentiality allows people to seek treatment and discuss their problems frankly.
Futility
The term futility may be used in several situations, including the following: The intervention has no pathophysiologic rationale. Maximal treatment is failing. The intervention has already failed. The intervention will not achieve the goals of care.
Informed consent
Informed consent is the process by which a patient receives all pertinent information necessary to make a rational autonomous choice. Disclosure standards, comprehension, voluntary action (free of control of others), competence, and consent are the 5 elements of informed consent.
Justice
Justice refers to fairness in the allocation of healthcare resources.
Veracity
Veracity is truth telling and honesty; recognize that it is not uncommon for healthcare providers to misrepresent a situation without technically lying.
Sunday, March 25, 2007
Medical Ethics
Attended a conference on Medical Ethics from a Jewish perspective. The discussion was flawed from the outset. No one had the courage to ask the hard question, namely, is there still a place for religion or personal religious belief in the practice of medicine? If we accept that medicine is a scientific discipline, shouldn't our goal be that of striving towards more precise science? And if so, how can we allow religion to dictate critical issues including birth, abortion, end of life, terminal care, palliative care, etc?
I don't intend to sound crass. And I am not against religion. But assume that you are an ethical Jewish doctor who believes strongly that life is for the living. You are treating a terminally ill patient who has no known scientific chance for any quality of life. You would consider it a favor and an honor to help that person die with dignity. If you were someone from a traditional Christian background you may be torn between "allowing God's Will" to intervene and helping that person move to a "better place", e.g. heaven. If you were involved with a Guru and practiced an eastern religion, you would be thinking that the "life force" is only temporarily in the body you are treating, and is perhaps only one stepping stone along the great path. The concept of reincarnation might be guiding your judgement.
Do you see how naive and/or presumptious it is to bring one's religious attitudes into a scientific arena? It is time we had the courage to park the mysticism at the door and attend to the illness and the patient with as full scientific objectivity as we are capapble of.
Newton stopped in his analyses because he was stumped in his mathematics, and so ascribed that which he did not know to "God". In fact, he spent a significant amount of his time trying to "figure God out". Subsequent scientists and mathemeticians were able to advance his ideas, once new concepts were understood, and "God" no longer was necessary to explain the missing phenomena.
We medical scientists must accept that just because there remain unknowns it is NOT "in God's hands". We must have the courage to practice our science and the strength, even if we are "of faith" to leave that faith at the door, and act as men and women of reason, when dealing with life and death.
I don't intend to sound crass. And I am not against religion. But assume that you are an ethical Jewish doctor who believes strongly that life is for the living. You are treating a terminally ill patient who has no known scientific chance for any quality of life. You would consider it a favor and an honor to help that person die with dignity. If you were someone from a traditional Christian background you may be torn between "allowing God's Will" to intervene and helping that person move to a "better place", e.g. heaven. If you were involved with a Guru and practiced an eastern religion, you would be thinking that the "life force" is only temporarily in the body you are treating, and is perhaps only one stepping stone along the great path. The concept of reincarnation might be guiding your judgement.
Do you see how naive and/or presumptious it is to bring one's religious attitudes into a scientific arena? It is time we had the courage to park the mysticism at the door and attend to the illness and the patient with as full scientific objectivity as we are capapble of.
Newton stopped in his analyses because he was stumped in his mathematics, and so ascribed that which he did not know to "God". In fact, he spent a significant amount of his time trying to "figure God out". Subsequent scientists and mathemeticians were able to advance his ideas, once new concepts were understood, and "God" no longer was necessary to explain the missing phenomena.
We medical scientists must accept that just because there remain unknowns it is NOT "in God's hands". We must have the courage to practice our science and the strength, even if we are "of faith" to leave that faith at the door, and act as men and women of reason, when dealing with life and death.
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