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HLTC22H3
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Anna Walsh

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2. Kelner, M. J., & Bourgeault, I. L. (1993). Patient control over dying: Responses of health care
professionals. Social Science and Medicine, 36(6), 757-765.
Abstract
- Patients are demanding more control over their decisions as to where and when they should die
- Results show that the patient control over dying is a challenge to the clinical judgement of
health care professionals.
- It is said that in the decision making process the practitioners and patients will be pressured to
concede their autonomy and enter a partnership
Introduction
- Today patient demand their power over where they want to dye and their destinies
- Charmaz claims that this emphasis on }v}o}(}voÆ]v^Àu]v o](X_
- The rapid movement of technology has affected pe}o[v}(}v}oX&}Æuoµ
of new technologies we are now able to treat severe illnesses, without patients consent.
- One of the most striking manifestations of patients desire for control is termed revolt of client
by Haugg and Susman it is challenge professed to the medical association in particular by a
number of scholars including Lavin and Haugg in U.S , Coburn , Torrance and Kaufert in Canada.
It was done in U.S in 1980 Haugg and Lavin conclude that patient consumerism is increasingly
becoming the accepted stance. The authority of medical profession to make decisions for others
on the basis of specialized knowledge is being challenged by a more educated and more
egalitarian society.
- The growing sophistication of the public and the strong influence of the media in popularizing
and disseminating medical information have made patients more demanding and more willing
to question who should control decisions about their health care.
- In Canada especially medicine has also surrendered some of its control over the provision of
health care.
- Public health insurance programs introduced in late 1950s and 1960s served to transfer financial
}v}o}(u]oÀ]}P}ÀvuvUÁ]Zµµvo]u]]}v}vZ}(]}v[
ability to govern its income levels, the number of hospital beds available and the allocation of
medical technology
- At the clinical level, public pressure in decision making about health care also has an impact on
medical dominance.
- For example: in Ontario a court decision ÁuZZÇ]]vv[P]Ào}}v(µ]}v
}vǵv}v]}µ]vÁZ}Ç]v]]vPZZÇ:Z}ÀZ[Á]vµ
they reject it under any circumstance.
- Haug and Levin found that physicians seemed reluctant to accommodate to patients
preferences in treatment. They found that many physicans, especially those who were older,
www.notesolution.com
would assert the dominance of their expertise when faced with patient challenges, or resort to
persuasion on the basis of their esoteric knowledge .
- It shows that there is allot of attention going to patients do get the right to say when they want
to die, or stop the treatment, but the issues are not resolved.
- The explosives in the biomedical technology since the 1920s has increasingly made dying a
matter that requires allot of decisions.
- Now there is a treatment for almost any illness, but the type of life that they would get after this
treatment is probably not the life they want
- The causes of death have changed, the communicable diseases have decl ined and chronic
disease are now predominant. Chronic illnesses such as heart diseases and cancer, tend to occur
later on in life and are usually progressive for some years before the patient dies. Those facing
death are more likely to be older, with the exception of AIDS and to suffer from illnesses for
which therapeutic interventions are available.
- Many die in hospitals, estimate is that 80% of the deaths in U.S take place in hospitals and long
term care institutions. This shows that terminally ill have little privacy and often little choice
regarding the circumstances of their dying.
- Death can become beureaucraticized as described by Blauner.
- Studies show that most patients want to have an influence on decisions concerning their
circumstances of their dying.
- This is why many health care professionals are confronted with new dilemmas in trying to
}uu}]v[Á]Zfor self-determination during dying process and are responding
in a variety of ways to this challenge.
- Many patients are worried about the loss of control regarding their dying and their fears can
cause conflicts between health care professionals and patients or their families.
- There is allot of money going into the medical system, and new technologies that enhance the
capacity of }v[s life, but the need to curtail spending on health care has prompted questions
about the wisdom of keeping patients alive when they no longer wish to have their lives
prolonged.
Purpose
- It is the first article ever to be examined about the responses of physicians and nurses to
]v[ desire of control over their dying process.
- The goal was to identify key factors that influence the knowledge, attitudes and behaviour of
health care professionals concerning this issue.
- Its focuses on 1) the reactions of physicians and nurses in a major teaching hospital to the
general principle of patient control over dying. 2) The main factors that affect their adherence to
this principle in practice and 3) who they believe should have the final authority for deciding
whether to prolong the lives of terminally ill patients.
- In the study the concept of patient control includes the notion of patient autonomy,
empowerment and self-determination which means that patients have a choice concerning the
nature and goals of the treatments they receive from health care professionals. It basically
www.notesolution.com
means that patients can choose whether they wish to be aggressively treated in order to
prolong their lives, or wish to terminate life-sustaining therapies and allow their lives to end
sooner than they might otherwise do.
Methods
- A purposive sample was used as a basis for establishing patterns of knowledge, attitudes and
behaviour.
- It was a study done from 4 clinical specialities, and 5 physicians and 5 nurses from each of family
and community medicine, oncology, intensive care and geriatric care.
- These were chosen because they represent different type of clinical care and permits
comparative analysis.
- Intensive care- provides few opportunities for considered decision making
- Geriatric care- provides long period in which to deliberate their choices regarding the dying
process
- Oncology- introduces the elements of severe pain and imminent death,
- Family and community medicine- is not typically faced with these pressures
- There was a study done in Toronto Ontario of 20 physians and 20 patients and they tested their
choice of dying, the interviews were taped and summary was written the taped interviews were
transcribed and entered in verbatim into a computer for coding.
- Various qualitative data analysis procedures, such as content analysis and concept saturation,
Áµ}}vP}µZZoZ}(]}vo[}v]v}lÇ}v]vZ
mode of grounded theory as delineated by Glaser and Strauss.
- Some of the data were also analyzed with descriptive statistics including frequency and cross
tabulations.
- The properties and the concepts resulting from this analysis however should be regarded as
transferable, in the sense that it is likely that other health care professionals in other hospitals in
North America, will also identify similar concepts.
Findings
- The 20 physians and nurses were characterized by age and years of practice , although only
nurses appear in the younger category who were catholic or protestant with only one agnostic
- Whereas the physicians included some Jewish respondents as well as several who describe
themselves as agnostic or atheist.
- To be religious was to be a person whose actions were regarded by religious/moral principles.
- While the nurse sample is completely female the physician sample is 35% female which is higher
than the proportion of women currently practicing in Canada.
The principle of Patient control
- At the beginning of the interviews the phsycians and nurses were asked to indicate personal
views on general principle of patient control over the dying process. Most said that it focused on
www.notesolution.com

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Description
2. Kelner, M. J., & Bourgeault, I. L. (1993). Patient control over dying: Responses of health care professionals. Social Science and Medicine, 36(6), 757-765. Abstract - Patientsaredemandingmorecontrolovertheirdecisionsastowhereandwhenthey shoulddie - Resultsshowthatthepatientcontroloverdyingisachallengetotheclinicaljudgementof healthcareprofessionals. - It issaid thatin thedecisionmakingprocessthepractitionersandpatientswillbepressuredto concedetheirautonomyandenterapartnership Introduction - Today patientdemandtheirpoweroverwheretheywanttodyeandtheirdestinies - Charmaz claimsthatthisemphasison }L}o}Z}Lo]ZL ^ZK] Lo]:_ - Therapid movementoftechnologyhasaffectedpe}o[ZZLZ} }L}o:}Ko Z of newtechnologieswearenowabletotreatsevereillnesses,withoutpatientsconsent. - Oneof themoststrikingmanifestationsofpatientsdesireforcontrolistermed revoltofclient by HauggandSusmanit ischallengeprofessedtothemedicalassociationinparticularbya numberofscholarsincludingLavinandHauggin U.S , Coburn, Torrance and KaufertinCanada. It was doneinU.S in1980 Hauggand Lavinconcludethatpatientconsumerismisincreasingly becomingtheacceptedstance.Theauthorityofmedicalprofessiontomakedecisionsforothers on thebasisofspecializedknowledgeisbeingchallengedbyamoreeducatedandmore egalitariansociety. - Thegrowingsophisticationofthepublicandthestronginfluenceofthemediainpopularizing and disseminatingmedicalinformationhavemadepatientsmoredemandingandmorewilling to questionwhoshouldcontroldecisionsabouttheirhealthcare. - In Canadaespeciallymedicinehasalsosurrenderedsomeof itscontrolovertheprovisionof healthcare. - Publichealthinsuranceprogramsintroducedinlate1950s and 1960s servedtotransferfinancial }L}o}K] oZ] Z}2}LKL7]ZZZLo]K]]}LZ}LZ}ZZ]}LZ[Z abilitytogovernitsincomelevels,thenumberofhospitalbedsavailableandtheallocationof medicaltechnology - At theclinicallevel,publicpressureindecisionmakingabouthealthcarealsohasan impacton medicaldominance. - Forexample:inOntarioacourt decisionZKZZZ] ]LZ L[2]o}}LZZ]}LZ }LL }LZ ]}Z]LZZ} ]L] ]L2ZZ:Z}Z[Z]LZZ Z theyrejectitunderany circumstance. - Haug and Levinfoundthatphysiciansseemedreluctanttoaccommodatetopatients preferencesintreatment.Theyfoundthatmanyphysicans,especiallythosewhowereolder, www.notesolution.com
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