Focus on critical care最新文献

An adult patient who is conscious and mentally competent has the right to refuse any medical or surgical procedure even when the best medical opinion deems it necessary for life. The doctrine of informed consent is grounded on the premise that a physician's judgment is subservient to the patient's right to self-determination. Some suggestions for the future are offered. It may be beneficial to have a formal doctrine of informed refusal incorporated into the existing system of informed consent thus having patients sign a refusal of treatment form just as they sign a form consenting to treatment. Even if the physician and patient share an ideal relationship that includes mutual respect and participation in decision making, the consent to treatment or refusal of treatment should be documented both on a form and in the physician's own words in the patient record to avoid any discrepancies that may arise later. Items that may eventually be added to the list of requirements for informed consent or refusal include the impact of the treatment or procedure on the patient's job or family situation, impact on quality of life, and the potential long-term cost to the patient or to public or private health care payers.

The role of nutritional support in the management of the critically ill patient has been a topic of much concern and research. Malnutrition experienced by patients with cancer can be related to the nutritional status of the patient before the development of cancer, to the tumor itself, and to cancer therapy. Aggressive treatment may increase the degree of malnutrition, and the combination of the effects of therapy and progressive malnutrition may be a frequent cause of death. The use of intensive nutritional support for some patients may promote weight gain and positive nitrogen balance, increase tolerance of cancer therapy, and improve immune response. The benefits of nutritional support in the patient with cancer may outweigh concerns of nutrition effects on tumor growth. The choice of nutritional support is dependent on the availability of and access to a functioning gastrointestinal tract, comfort and compliance of the patient, the toxicity of drugs, and site of radiation therapy. Extended length of treatment, availability of care givers, and costs are also factors considered in delivering nutrients. Nutrition requirements, nutritional tolerance, and immune status should be monitored by the nurse. The nurse can function as coordinator for treatments and care as well as act as interpreter, teacher, and counselor to coordinate medical and nutritional management of the patient's illness into overall high-quality nursing care.

As health care providers we are not in a position to teach reading. We do, however, have a legal and an ethical obligation to provide patients with self-care instructions they can understand. Because the methods presented for enhancing patient understanding of self-care instructions are relatively new, and because nurses are just beginning to be aware of the need for such interventions, it will be a while before the ideal situation exists. Ideally, each pamphlet or set of instructions would be coded with the reading grade level needed to understand it and each patient's reading level would be recorded in the chart. Under such "perfect" circumstances it would be easy for nurses to provide patients with instructions at the appropriate reading level. For now, any step that nurses take toward making self-care a reality for patients who read poorly is a step in the right direction. People with poor reading skills are less adept at formulating questions than good readers because they lack vocabulary and the ability to analyze written material. Rather than be regarded as stupid, many choose not to verbalize their lack of understanding. This phenomenon puts a large group of patients at risk for health complications related to inadequate understanding of self-care directions.