"What do you Mean I Cannot Consent For My Grandmother's Medical Procedure?": Key Issues With State Default Surrogate Decision Making Laws

When a patient is unable to make medical decisions, a health care surrogate must be designated to make decisions on the patient's behalf. Studies show that fewer than 20% of patients have completed health care representative forms to legally designate a surrogate. Without a prior designation, surrogates are determined via state statute. Currently, there is no up-to-date comprehensive evaluation of state surrogate legislation. A survey of state legislative codes was conducted to determine: 1) whether the state has a default surrogate statute; 2) who is included as an acceptable legal surrogate; and 3) whether there is a hierarchy to determine a final decision-maker. Currently, 36 states have enacted some form of surrogate statute. There is little consistency between states regarding who may serve as a surrogate decision- maker. The key challenges with state laws include: 1) a narrow list of persons who qualify as allowable legal surrogates; and 2) a lack of a hierarchy to determine a final decision-maker. The results of this survey show that state surrogate decision making laws have many flaws which could affect patient care. The narrow construction of state laws can leave patients in situations where they either have no qualified surrogate under the law, or where they have multiple surrogates with competing interests who may be unable to reach consensus on the patient's medical care. State laws need to be changed so that they accurately reflect the realities of clinical practice and expanded to allow a broader spectrum of potential surrogates

Evidence for behavioural interventions addressing condom use fit and feel issues to improve condom use : A Systematic Review

© CSIRO 2019. Open Access Article (CC BY-NC-ND)Continuing high rates of sexually transmissible infections (STIs) in many countries highlight the need to identify effective behavioural interventions. Consistent and correct use of male condoms is a key strategy for the prevention of STIs. However, some men report problems with condom fit (e.g. the size and shape of the condom) and feel (e.g. tightness, irritation, sensitivity), which inhibits their use. We conducted a systematic review to identify existing interventions addressing condom use fit and feel problems. We searched electronic databases for peer-reviewed articles and searched reference lists of retrieved studies. Five studies met the inclusion criteria. These were generally small-scale pilot studies evaluating behavioural interventions to promote safer sex with men aged under 30 years, addressing, among other things, barriers to condom use relating to fit and feel. There were significant increases in the reported use of condoms, including condom use with no errors and problems. Improvements in some condom use mediators were reported, such as condom use self-efficacy, knowledge, intentions and condom use experience. There were mixed findings in terms of the ability of interventions to reduce STI acquisition. Behavioural interventions addressing condom fit and feel are promising in terms of effectiveness but require further evaluation.Peer reviewe

Policy perceptions of US state public health and child and family services regarding maternal opioid use and neonatal exposure

Objective To explore how state legislatures and departments of health are responding to the public health and economic issues of increases in opioid use disorder and the impact on pregnant women and infants. Design The design was a non-experimental descriptive study using a mixed methods survey research approach. Setting Electronic and telephone survey of individuals from state departments of health associated with departments of behavioral health and substance use, or child and family services. Participants Fifty-two respondents employed by individual state departments of health and child and family services. Methods Univariate analysis and frequency distribution of ordinal variables was completed. Thematic analysis was used to analyze free text questions and identify themes. Results All states reported recent changes or plans to address the problem of opioid misuse in their state. Many respondents feel their state continues to lack adequate services for treatment. Some states are exploring unique methods for addressing this in a safe and timely fashion, such as moving medication-assisted treatment to primary care and expanding licensure to Primary Care Physicians (PCPs) and nurse practitioners. Conclusions Our findings demonstrate an increased commitment throughout the United States to enhance access to clinically appropriate treatment of substance use disorder particularly during pregnancy, consider unique methods for addressing the problem of opioid dependency, and increase education and primary prevention programs

The effect of a state health care consent law on patient care in hospitals: A survey of physicians

Objective: When a patient cannot make medical decisions for him or herself, and has not appointed a healthcare representative, default state healthcare consent laws determine who is able to make healthcare decisions for the patient. The narrow construction of some state laws leaves many patients in situations where the closest person to the patient does not qualify as a representative under the law, or where the patient has too many representatives and a consensus cannot be reached on the patient’s medical care. Methods: In order to determine how state healthcare consent laws affect patient care in hospitals, a survey of 412 Indiana physicians was conducted. Results: The data shows 53.8% of physicians experienced a delay in patient care because they were unable to identify a legally appropriate health care representative. Almost half (46.01%) of physicians experienced delay of patient care due to the inability to identify a final decision maker when disputes arose between multiple legal representatives. Conclusions: The results of this study have important implications for hospital administrators as a delay in patient care can be costly and unnecessarily utilizes hospital resources. Additionally, the results of this study have important implications for the status of state surrogate decision making laws. Amending state laws to include more potential surrogates, has the potential to minimize delays in patient care and ensure that appropriate surrogates are making medical care decisions for patients without the undue burden of court intervention

Physician understanding and application of surrogate decision-making laws in clinical practice

Background: Although state surrogate laws are the most common way surrogate decision makers are identified, no studies have been conducted to determine physician understanding of these laws or how these laws are utilized during clinical practice. The purpose of this study is to better understand how surrogate decision-making laws function in practice. Methods: A cross-sectional survey of 412 physicians working in Indiana hospitals was conducted between November 2014 and January 2015 to determine physicians' knowledge of Indiana's surrogate decision-making law and physicians' approaches to hypothetical cases using the law in clinical practice. Results: Fewer than half of physicians (48%) were able to correctly identify all legally allowable surrogate decision makers. Of those physicians who knew the law, nearly all of them (98%) indicated that they would violate the law during clinical practice by allowing nonlegal surrogates such as grandchildren to make medical decisions. Conclusions: A majority of physicians endorse relying on surrogates who have strong ties to the patient but are not legally allowable in Indiana. It is possible that these decisions reflect sound ethical reasoning even though they are illegal. Due to the narrow construction of some state surrogate decision laws, physicians may be placed in the position where they must either choose to follow medical ethical principles or the law. To alleviate these issues, state surrogate decision laws need to be amended to include a broader list of surrogates, such as extended family and close friends

ATTITUDES AND PERCEPTIONS OF LIVING KIDNEY DONOR EVALUATION

poster abstractIntroduction: Attitudes and perceptions of living kidney donors are im-portant aspects to the organ donation process. Few patient-centered studies exist which focus on broad health outcomes and expectations of living kid-ney donors. This is of practical concern due to the trend of decreasing donor numbers observed in the last decade (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2011). While fol-low-up care is a crucial part of the donation process, few studies address the importance of follow-up care and its implications on the health status of the donor following his/her donation. This study aims to evaluate attitudes and perceptions of living kidney donors regarding their total donation experience. Data collected will shape policy recommendations pertaining to the standard of follow-up care for living kidney donors. Methods: The present study uses an electronic survey tool to evaluate living kidney donors’ satisfaction with their post-donation follow-up care. All living kidney donors are eligible. Recruitment is via social networking sites with active donor members; successfully recruited participants receive an e-mail with the study information sheet and a link to the brief survey. Results: Completed survey responses are coded and analyzed using sta-tistical coding software. Data produced will illustrate any patient reported negative health outcomes across multiple transplant centers, attitudes about donor follow-up care, and policy recommendations

Does attractiveness influence condom use intentions in heterosexual men? An experimental study

Objectives: Judgements of attractiveness have been shown to influence the character of social interactions. The present study sought to better understand the relationship between perceived attractiveness, perceived sexual health status and condom use intentions in a heterosexual male population.Setting: The study employed an electronic questionnaire to collect all data, during face-to-face sessions.Participants: 51 heterosexual, English-speaking men aged between 18 and 69?years.Outcome measures: Men were asked to rate the attractiveness of 20 women on the basis of facial photographs, to estimate the likelihood that each woman had a sexually transmitted infection (STI) and to indicate their willingness to have sex with or without a condom with each woman.Results: The more attractive a woman was judged to be on average, the more likely participants would be willing to have sex with her (p<0.0001) and the less likely they were to intend to use a condom during sex (p<0.0001). Multivariate analysis revealed that higher condom use intentions towards a particular woman were associated with lower ratings of her attractiveness (p<0.0005), higher ratings of her STI likelihood (p<0.0001), the participant being in an exclusive relationship (p=0.002), having a less satisfactory sex life (p=0.015), lower age (p=0.001), higher number of sexual partners (p=0.001), higher age at first intercourse (p=0.002), higher rates of condomless sex in the last 12?months (p<0.043) and lower confidence in their ability to assess whether or not a woman had an STI (p=0.001). The more attractive a participant judged himself to be, the more he believed that other men like him would engage in condomless sex (p=0.001) and the less likely he was to intend to use a condom himself (p=0.02).Conclusions: Male perceptions of attractiveness influence their condom use intentions; such risk biases could profitably be discussed during sex education sessions and in condom use promotion interventions

Patient-Centered Medicine and Prevention of Munchausen Syndrome by Proxy

Munchausen syndrome by proxy (MSbP) is known by many names and is considered the deadliest form of child abuse. Although the condition was named in 1976 and there is now a substantial body of scientific literature about this type of abuse, to date, patient‐centered approaches to early identification, intervention, and prevention have been absent from this literature. The purpose of this chapter is to recommend patient‐centered approaches to identifying MSbP in the clinical setting to facilitate prevention and early intervention. It also recommends patient‐centered practices that can be implemented to reduce the MSbP‐related morbidity and mortality contributed by the healthcare system. The evolving nomenclature and definition of MSbP abuse has been an obstacle to achieving scientific consensus on the topic. Yet, the body of scientific literature on the subject is large. This literature is reviewed to enumerate the healthcare system\u27s contribution to MSbP abuse. The Haddon matrix, a public health framework, is applied to MSbP abuse in order to guide the development of recommendations of patient‐centered approaches that should be implemented to reduce the healthcare system\u27s contribution to the morbidity and mortality that MSbP victims face