Hospital progress最新文献

Deciding to Forego Life-Sustaining Treatment, a report of the President's Commission for the study of Ethical Problems in Medicine and Biomedical and Behavioral Research, examines four common medical-ethical distinctions. The report highlights the 1980 Declaration on Euthanasia and closely follows Catholic moral teaching on the following. Death by action versus omitting to act. The commission rejects the idea that a physician who fails to act should not be held responsible for a patient's death. Failing to resuscitate, for example, or to take other steps to prolong life, are just as much causes of death as a lethal injection. The health profession's traditional duty to act on the patient's behalf precludes any distinction between acts and omissions. Withdrawing versus withholding treatment. Acknowledging that initiating treatment may create an obligation to continue treatment, the commission suggests that distinguishing between withholding and withdrawing could encourage undertreatment and overtreatment. Fear of being unable to withdraw unsuccessful treatment could lead to physicians' failing to treat patients who might benefit from the therapy. Ordinary versus extraordinary means. The commission upholds this distinction. It suggests, however, that the phrase "proportionate versus disproportionate" better describes the moral issue involved in selecting treatments that, in relation to their expected benefits, impose no excessive burden on the patient or family. Regarding intended versus unintended consequences, the commission departs from Catholic tradition. It fails to acknowledge the significance of physicians' intentions. What matters instead, according to the commission, is whether physicians act within their authority as defined by society. Thus, the commission suggests, the use of pain medications that may cause death can be socially and legally acceptable.

Columbus-Cuneo-Cabrini Medical Center prepared extensively for the Medicare prospective payment system (PPS), which went into effect there Jan. 1, 1984. Administrators believe the planning effected a smooth transition from the retrospective reimbursement system. Preparation took two froms: educational sessions for all staff and trustees and establishment of a Prospective Payment System Implementation Task Force to develop ways to deal with new problems. All staff and trustees attended educational sessions, which were tailored to address each group's specific concerns. The sessions compared the old and new systems and emphasized PPS's effects on the institution over three years. The financial staff also provided weekly written updates to administrators and physicians on financial issues, including PPS, regulations, and reimbursement. The medical center's task force consisted of eight "in-house experts" on PPS. Because they had to act quickly, they operated under unique ground rules: Communicate with each other. Ignore the chain of command. Believe any problem can be resolved. Believe conflict is good. As chairman, the vice-president of finance had the task of estimating PPS's impact on the institution. The medical records director was responsible for the case-mix management system. The utilization review director ranked physicians and DRGs according to their profitability. The data processing director was responsible for installation of the DRG information system. The controller, reimbursement director, and cost accounting manager developed ways to maintain accurate financial records. The director of patient care services developed and scheduled PPS education programs. As a result of the preparation, the medical center staff realizes the importance of cost control if the institution is to remain viable.

In developing inpatient and home hospice services in a subacute care setting, Villa Mercy chose to forego traditional hospice models in favor of a strong medical model. It confronted six basic issues in its pioneering effects. 1. Goal formulation. Villa Mercy provides for inpatient admissions whenever appropriate, but also aims to enable patients to stay at home as long as possible and to educate health professionals and the community on hospice care and the dying process. 2. Medical model functions. A hospice core team--composed of a hospice medical director, a chaplain, a social worker, a pharmacist, and registered nurses--meets weekly and assesses each patient's progress. Each core team member follows a specific role in meeting the patient's physical, psychological, social, and spiritual needs. 3. Pain and symptom management. Specific guidelines are followed in observing and listening to the patient, administering pain medication and controlling dose increases, working with patients who are in chemotherapy or drug therapy, and dealing with symptoms caused by the drug regimen. 4. Inpatient versus home care issues. the staffs of both components must coordinate their efforts and feel comfortable with moving patients from one component to the other. 5. Reimbursement channels. Title 18, Blue Cross, and other commercial third party payers have provided coverage at Villa Mercy. Tightening Health Care Financing Administration (HCFA) regulations, however, will make funding more difficult for providers operating under HCFA guidelines. 6. Volunteers. Volunteers are an essential part of the facility's hospice services and receive 20 hours of intensive classwork over a 10-week period before working with a patient and family.

The identification and treatment of older alcoholics often are complicated by negative stereotypes and inaccurate information about the aging process. these misconceptions may result from incomplete statistical data, lack of attention to the subjects of alcoholism and aging in medical and gerontological journals, disagreement concerning the disease's origin and treatment, and conflict over whether to differentiate between alcoholism and alcohol abuse. In recent professional literature, however, some of these concerns are being addressed. A wider dissemination of information is essential for health professionals as well as for alcoholics and their families. Both groups must understand the changes associated with aging so that existing programs for alcoholism treatment can be adapted to serve the elderly. Results of an informed, enlightened attitude toward older alcoholics would be: Awareness that alcoholism--at any age--is a treatable disease; Increased attention to the special communication and mobility needs of the elderly; Availability of printed and audiovisual materials about aging and alcoholism in locations where older adults gather; and The training of family members and health care workers in alcoholism identification and intervention.

Recognizing the registered nurse's (RN's) important role in providing spiritual care, the Catholic Health Association of Wisconsin has created a program to prepare nurses to identify and respond to patients' spiritual needs. The program features instruction in theological and ethical issues and a three-month practicum, during which nurses evaluate their abilities to incorporate an awareness of spirituality into professional practice. A patient questionnnaire enables an objective measurement of the program's effect on nurses' care-giving skills. The program's ultimate goal is to formalize the RN's role as a member of the spiritual care team in the Catholic health care facility. The program represents not only an opportunity to contribute to the RN's professional growth but also to advance the Catholic health care mission.

As pressure mounts to contain Medicaid long term care spending, short-range "quick fixes" must be avoided. Three such false solutions in particular have shortcomings that may actually exacerbate long term care's financial dilemma because they are based on inadequate definitions of the problem. Two of these proposals--legislation to broaden family responsibility toward institutionalized elders on Medicaid and expanded state power to put liens on such elders' real property--err by trying to mandate "caring" and are predicated on a misunderstanding of the "spend-down" problem. The other proposal--to provide tax incentives to family members who care for elders--requires a large administrative apparatus, assumes an elasticity of supply that may not exist, and could disrupt the "gift relationship" on which family exchanges are often based. What is needed is a strategy with short term, intermediate, and long term objectives that move toward an insurance approach. The short term plan should lay the groundwork for intermediate strategy and control costs by changing rate-setting methods and putting limits on facility construction. The intermediate plan should change the problem's definition from one of merely controlling Medicaid long term care expenditures to one of efficiently managing state resources for the elderly through the development of state financing and local delivery systems that target older persons in greatest need. An effective means of doing this is through the creation of social/HMOs, which have five key features: integration of service responsibility and authority; flexibility in organizational design; balanced clientele; pooled prepaid funding; and financial risk for the provider organization. Finally, the long term strategy should transfer much of the long term care financial burden from individuals and state Medicaid agencies to insurance mechanisms. Many individuals would thus avoid impoverishment caused by health care spending and Medicaid would greatly reduce its caseload. Insurance coverage is an appropriate funding mechanism, moreover, in that relatively few persons will ever incur high costs.