Sunday, 22 April 2012

Principles of Care

Guiding Principles :

 Ethical decisions are often called for in medical practice, at both the "micro" level of the individua patient-clinician relationship and at the "macro" level of the allocation of resources. Ethical principles that guide the successful approach to diagnosis and treatment are honesty, beneficence, justice, avoidance of conflict of interest and the pledge to do no harm. Increasingly, Western medicine involves patients in important decisions about medical care, including how far to proceed with treatment of patients who have terminal illnesses. The clinician's role does not end with diagnosis and treatment. The importance of the empathic clinician in helping patients and their families bear the burden of serious illness and death cannot be overemphasized. "to cure sometimes, to relieve often, and to comfort always" is a French saying as apt today as it was five centuries ago-- as is French Peabody's admontion:"The secret of the care of the patient is in caring for the patient."


Table: 1-1

Patient Adherence

Patient Adherence :

For many illnesses, treatment depends on difficult fundamental behavioral changes, including alterations in diet,taking up exercise, giving up smoking, cutting down drinking, and adhering to medication regimens that are often complex. Adherence is a problem in every practice; up to 50% of patients fail to achieve full adherence, and one-third never take their medicines.Many patients with medical problems, even those with access to care prematurely. Adherence rates for short-term therapies and are inversely correlated with the number of interventions, their complexity and cost, and the patient's perception of overmedication.
  As and example, in HIV-infected patients,adherence to antiretrovira therapy is a crucial determinant of treatmet success. Studies have unequivocally demonstrated a close relationship between patient adherence and plasma HIV RNA levels,SD4 cell counts, and morality.Adherence levels of >95% are needed to maintain virologic suppression. However, studies show that over 60% of patients are <90% adherent and that adherence tends to decrease over time.

  Patient reasons for nonadherence include simple forgetfulness being away from home, being busy and changes in daily routine.Other reasons include psychiatric disorders(depression or substance abuse), uncertainty about the effectiveness of treatment,lack of knowledge about the consequences of poor adherence, regimen complexity and treatment side effects.

  Patients seem better able to take prescribed medications than to comply with recommendations to change their diet, exercise habits or alcohol intake or to perform various self-care activities(such as monitoring blood glucose levels at home). The effectiveness of interventions to improve medication adherence has been reviewed by Haynes and colleagues. For short-term regimens, adherence to medications can be improved by giving clear instructions. Writing out advice to patients, including changes in medication, may be helpful. Because low functional health literacy is common(almost half of English-speaking US patients are unable to read and understand standard health education materials), other forms of communication--such as illustrated simple text, videotapes or oral instructions----may be more effective. For non English-speaking patients, clinicians and health care delivery systems can work to provide culturally and linguistically appropriate health services.

To help improve adherence to long-term regimens, clinicians can work with patients to reach agreement on the goals for therapy, provide information about the regimens, ensure understanding by using the "teach-back"method, counsel about the importance of adherence and how to organize medication-taking, reinforce self-monitoring, provide more convenient care, prescribe a simple dosage regimen for all medications(preferably one or two doses daily), suggest ways to help in remembering to take doses(time of day, mealtime, alarms) and to keep appointments, and provide ways to simplify dosing(medication boxes). Single-unit doses supplied in foil-backed wrappers can increase adherence but should be avoided for patients who have difficulty opening them. Medication boxes with compartments(eg,Medisets) that are filled weekly are useful. Microelectronic devices can provide feedback to show patients wherther they have taken doses as scheduled or to notify patients whether they have taken doses as scheduled or to notify patients within a day if doses are skipped.Reminders are another effective means of encouraging adherence. The clinician acn also enlist social support from family and friends, recruit and adherence monitor, provide a more convenient care environment and provide rewards and recognition for the patient's efforts to follow the regimen.

   Adherence is also improved when a trusting doctor-patient relationship has been established and when patients actively participate in their care.Clinicians can improve patient adherence by inquiring specifically about the behaviors in question.When asked,many patients admit to incomplete adherence with medication regimens,with advice about giving up cigarettes,or with engaging only in "safer sex" practices.Although difficult,sufficient time must be made available for communication of health messages.

    Medication adherence can be assessed generally with a single question: "In the past month,how often did you take your medication as the doctor prescribed?" Other ways of assessing medication adherence include pill counts and refill records; monitoring serkum, urine, or saliva levels of drugs or metabolites; watching for appointment nonattendance and treatment nonresponse; and assessing predictable drug effects such as weight changes with diuretics or bradycardia from  - blockers. In some conditions, even partial adherence,as with drug treatment of hypertension and diabetes mellitus, improves outcomes compared with nonadherence; in other cases, such a HIV antiretroviral therapy or treatment of tuberculosis, partial adherence may be worse than complete nonadherence.

Approach To Patient

General Approach To Patient:

The medical interview serves several functions.It is used to collect information to assist in diagnosis(the "history" if the present illness),to assess and communicate prognosis,to establish a therapeutic relationship, and to reach agreement with the patient about futher diagnostic procedures and therapeutic options.It also serves as an opportunity to influence patient behavior,such as in motivational adherence.Interviewing techniques that avoid domination by the clinician increase patient involvement in care and patient satisfaction. Effective clinician-patient communication and increased patient involvement can improve health outcomes.