Meropenem vs Imipenem/Cilastatin in the Treatment of Bacteria Patients

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Models for Physician-Patient Relationship

• The context for shared decision making

• Paternalistic
• Informative
• Interpretive
• Deliberative

Emanuel Emanuel, JAMA 19922672221-26
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Paternalistic Physician as guardian

• Physicians role to promote patients well-being
  independent of patients preferences.
• Patients role assent to the physicians
  recommendations

4
InformativePhysician as technical expert

• Physicians role to provide relevant factual
  information
• Patients role make the decision based on
  information presented by physician

5
InterpretivePhysician as counselor/advisor

• Physicians role to provide relevant factual
  information AND elucidate and interpret patient
  values
• Patients role make medical care decisions with
  assistance from physician.

6
DeliberativePhysician as friend/teacher

• Physicians role advising the patient of the
  relevant choices, along with the value dimensions
  of those choices, and helping the patient select
  the choice that most closely matches the
  articulated values
• Patients role make decision in collaboration
  with physician

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Values/Decision
Deber et al. What Role do Patients wish to play
in treatment decision making? Arch Intern Med.
19961561414-1420
Deliberative/ Interpretive
Informative
Paternalism
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Differences in Perspective

• Differences in
• Values
• Time horizons
• Outcomes of importance
• Attitudes toward uncertainty
• Attitudes towards risk

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Influences on Patient Preferences

• Differences in
• Values
• Time horizons
• Outcomes of importance
• Attitudes toward uncertainty
• Attitudes towards risk

• Other dimensions
• Acute vs. chronic illness
• Extremes of age
• Culture
• Finances

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Ethical Principles Behind SDM

• Beneficence
• Respect for Autonomy

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?????????

• ??????
• (the principle of respect for autonomy)
• ?????
• (the principle of nonmaleficence)
• ????
• the principle of beneficence)
• ????
• (the principle of justice)

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• ????????????????????,?????????????????????????????
  ????????
• ??? (competent) ????????????????????????????,?????
  ??????????????

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• ?????????????????????
• ??(truthfulness)???????????,???????????????????
• ??(confidentiality)?????????????????????????????
• ????(Informed consent)???????????,???????????????
  ????

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?????

• ???????????????????,????????????????????
• ???????
• ?????????????????????????????????? (standard of
  due care)? ?
• ???????????????? ?

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????

• ??????????????
• ?? (beneficence) ???????????????,????????????
• ????,???????????????????(perfect
  duty),??????????(general beneficence) ?
• ????????????????,???????????????????,??????????
  (specific beneficence)?

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????

• ???????????????????
• ?????????? (????)
• ??????? (????)
• ????????? (????)

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Elements of Shared Decision MakingPresidents
Commission 1982

• Decision making capacity
• All relevant information regarding
• Medical condition
• Alternative treatments
• Risks, benefits, costs, other consequences
• Uncertainties surrounding the decision
• Voluntary consent to proposed treatment

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?????????

• ??
• ????
• ??

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????????

• ??(assent)
• ??(consent)
• ????(informed consent)
• ????(shared decision-making)
• ????(autonomous authorization)

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??????

• ??(assent)?????????????????? ??????,????????????
  ?????????????
• ??(consent)???????????????????,?????????????????(
  ??????????????),??????????????

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??????

• ????(informed consent)???????????????????????,???
  ???????????????????????
• ????(shared decision-making)?????????????????????
  ????????,????????????????,????????????????????????
  ???????????????????

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??????

• ????(autonomous authorization)????(autonomous
  action)????????(intention)??????????????(understan
  ding)????????????(freedom from undue
  influence)??????????????,?????????????????????,???
  ?????????????

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???????????????????

• ???????????
• ????????(decision-making capacity)???????????????
  ????????????????,?????????????
• ????????????(manipulation)???(coercion)?
• ???????????????????????????
• ??????????(voluntary)????????????

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???????????????????????????????

• 1.???????(professional practice standard)?
  ?????????????????????????
• 2.??????(reasonable person standard)?????????????
  ???????????????????????
• 3.?????(subjective standard)?????????????????????
  ?????????

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Informed Decision Making in Office
VisitsBraddock et al. 1997

• Elements
• Discuss patients role
• Describe issue/problem
• Delineate alternatives
• Discuss pros cons of alternatives
• Relay inherent uncertainties
• Assess understanding
• Ascertain patient's preference

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Types of Decision Making
Medical Opinion Consensus Wide
support Controversy

• Impact on patient
• Minimal
• Moderate
• Extensive

Nature of Outcome Clear, singular Multiple,
finite Uncertain, Various

• Basic
• Intermediate
• Complex

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Types of Decision Making

• Example
• Routine lab test
• New Medication
• Surgery

• Basic
• Intermediate
• Complex

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???????
???? ?????? ????
1.???????????? 2.?????????????? 3.????????????? 4.?????????????? 5.?????????? 6.????????? 7.????????? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ?? ??
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Key Components of Informed Decision Making

• Basic
• Nature of decision
• Patients role OR stated preference
• Intermediate
• Basic PLUS
• Alternatives, pros/cons, understanding
• Complex
• Intermediate PLUS
• Uncertainties

• Relevant to virtually all clinical decisions
• Includes explicit discussion of patients role
• Extent of discussion driven by decision
  complexity

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Examples of Informed Decision Making

• CBC order
• (Basic)
• Medication dose change
• (Intermediate)
• PSA order
• (Complex)

• Id like to check some blood tests. Heres the
  slip to take to the lab.
• Id like you to increase the dose of atenolol
  youre already taking.
• Id like to check some blood tests. Heres the
  slip to take to the lab.

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Basic Decision

• Id like to check some blood tests. Heres the
  slip to take to the lab.
• I think we should check your blood count to see
  if that is causing your fatigue. Does that seem
  reasonable?

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Basic Decision

• Id like to check some blood tests. Heres the
  slip to take to the lab.
• I think we should check your blood count to see
  if that is causing your fatigue 2. Does that
  seem reasonable 7?

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Intermediate Decision

• Id like you to increase the dose of atenolol
  youre already taking.
• We need to control your blood pressure better.
  We could increase the dose of your atenolol or
  add a medication like a water pill. The higher
  dose of atenolol might make you feel fatigued but
  the water pill might make you urinate a lot.
  Does that make sense to you? Id suggest
  increasing the atenolol what are your thoughts?

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Intermediate Decision

• Id like you to increase the dose of atenolol
  youre already taking.
• We need to control your blood pressure better
  2. We could increase the dose of your atenolol
  or add a medication like a water pill 3. The
  higher dose of atenolol might make you feel
  fatigued but the water pill might make you
  urinate a lot 4. Does that make sense to you
  6? Id suggest increasing the atenolol what
  are your thoughts 7?

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Complex Decision

• Id like to check some blood tests. Heres the
  slip to take to the lab.
• At your age, we should start thinking about
  screening for prostate cancer 2. Youve
  probably heard about the PSA test. This blood
  test can detect very small prostate cancer but it
  can also be abnormal if your prostate is
  enlarged, even if theres no cancer 4,5.
  Unfortunately, were not certain that finding
  prostate cancer early will help you live any
  longer 5. We could do the test or not 3.
  Every man has different opinions, as do experts,
  so I would like your views in this decision 1.
  Do you have any questions about the test 6?
  Whats your thinking, then, about a PSA test
  7?

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??????Decision-Making Capacity Assessment

• ????
• ??????
• ?????
• ????????????
• ??(?????????)

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?????STANDARD???????? ?????STANDARD????????
Situation ?????????
Treatment ??????????
Alternative ??????????
No Treatment ??????????
Decision ????????????
Appreciate ??????????????
Rational ??????????
Durable ?????????,?????
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?????????

• ??
• ????
• ??

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????

• ??(assent)
• ??(consent)
• ????(informed consent)
• ????(shared decision-making)
• ????(autonomous authorization)