OBLIGATIONS AND DUTIES OF PHYSICIANS
Some of the following obligations and duties are contained in the laws and moral codes of the art of medicine; while others arise from current legal requirements given the evolution of our society, among them are professional secrecy, provide adequate technical information to the patient, voluntary informed consent, the obligation of knowledge, diligence and by the physician, continuity in treatment, assistance and advice, certification of disease and treatment as well as birth and death. (141)
Each and every one of the actors involved in the medical act, are individually responsible for the universality of the damage, with power of the judge, or except to attribute to each of the health workers to a greater or lesser degree and establish the percentage of responsibility for the harmful event. (142)
Eventually a doctor can acting against the wishes of a patient, for example, to save his life, can reach face disciplinary and criminal courts because of the principle of autonomy is nothing more than the moral right to govern; and this can lend itself to such conflicts of professional and ethical naturally. (143)
DISRUPTIVE COMPONENTS OF MEDICAL PRACTICE
Negativity accepting therapeutic maneuvers.
Among the conflicts that often arise during the practice of medicine, there are those of religious type, a common example are called "Jehovah's Witnesses", a fundamentalist Christian group that refuses to accept the transfusion of blood products yet when the patient's life is at risk, and the decision involving children or patients whose health is critical and although currently there are resources in the medical arsenal such as erythropoietin and autologous colloids.
There are real emergencies that threaten the patient's life for example: septicemia complicated with disseminated intravascular coagulation, hypovolemic shock, where it is urgent blood transfusion to the patient; and although such decisions involving the indication of a blood derivative, is a starting point for complaints from this religious group, medical staff should not forget that the Constitution of the Bolivarian Republic of Venezuela provides protection to life as an inalienable legal right, so that the doctor would be covered in the event of having to make an emergency decision at a particular time, if a patient is brought to a room Emergency unconscious by hypovolemic shock. Similarly, the Venezuelan Organic Law for the Protection of Children and Adolescents (LOPNA) notes that prevails before the autonomy of legal personality and the physician must act accordingly. (144)
THE AGGRESSIVE PATIENT
In Latin America, one of the issues becomes more important is violence in its different forms and manifestations, which has individual and collective impact. According to the literature, one of the employment sectors most at risk from exposure to aggression is the health sector because health centers are places where great activity and emotions related to life, illness and death is handled; this entails close interaction between health personnel, family and patients, sometimes trigger conflict and violence. (145)
In the psychological context, violence is a form of inadequate response that arises as a secondary reaction to different emotions no defense mechanisms appropriate to the particular situation of frustration, loss of a loved one, anxiety and fear of being despised. It constitutes a maladaptive response type and level can range from a verbal response as insults and recriminations are to physical attack and this depends on several factors. (146)
1. Personal factors
Age.
Being young is a risk factor for violence, and that the younger you are fewer defense mechanisms to conflict situations in the same way, a young doctor has less experience in dealing with such difficult situations and likewise the younger the patient, can be adolescent of adequate defense mechanisms to deal with conflicts.
Sex.
There is a slight bias of male aggression on women and is linked with life experiences in childhood (especially in case of history of abuse during childhood), degree of prior successful life experiences, the immediacy of reactions, appearance physical.
Relationship with the environment. There are factors that encourage aggression as the work alone, without other professionals who can give notice to the authority of the state of aggressiveness, work with the public and stressed or loaded contact with a high level of anxiety individuals. The sense of danger perceived by the victim, the psychological situation of the actors of the doctor-patient relationship, and expected and feared consequences; and the perception of acquired rights.
Institutional factors. Institutional climate of the unique physical characteristics of the hospital where no comfort is given and an environment appropriate and organized waits, delayed patient care in turn generate more stress on it, and he sees no response to your request for service health, and cultural and political aspects of the enclosure and its projection to society.
The personality of the patient and physician at risk for aggression (temperament) among which mention the most important passive aggressive personality, paranoid, compulsive, histrionic, borderline or borderline, antisocial personality, attitudes and expectations.
The clinical situation there is greater risk in emergency services and institutions that foster a prize to the aggressiveness of the public (patients and families) and staff accordingly.
Target recognition physicians should focus on what is really important and rethink the objectives in the doctor-patient relationship. (147)
Proposed new relationship is sometimes necessary to propose to the patient who treats other staff, however this option should be used as a last resort and unfortunately is not always possible.
Control measures and prevention, ranging from proper reception to the patient, avoiding delays, keeping rooms unsaturated expected and even if possible with a quiet and relaxed atmosphere avoiding discussions. If possible, the patient should have an initial contact or greeting with health personnel and can be helpful to train health personnel with tools for self-control and approach so learn to avoid being carried away by negative emotions. Use self-control maneuvers as "counting to ten" or "emotional counterbalance" (which is to impregnate the patient with a balanced emotional climate of peace and avoiding any drop in the climate of aggressiveness time). (148)
Customizing messages should show the patient the importance we give to you in time and also showing interest in helping, as a rule in the initial interview the examiner should always think and prioritize their personal safety, must shed necklaces, earrings, glasses, ties before starting an interview with a potentially aggressive patient and eliminate the patient's view of an object which may come to be used as a weapon (pencils, pens, syringes, scalpels). The doctor must notify the medical team, when they will interview the patient, to put alerts staff to any need for intervention by the security personnel and conduct an assessment never alone with a violent patient.
Violence is a dyadic process, according to this, the behavior and pre-verbal elements of communication examiner may induce or prevent violence, should speak so slowly showing a calm demeanor, showing interest in whatever the patient says, without ignoring or criticize what it communicates. The violent or aggressive patient should never be considered whether it is armed, in these cases, should be given alarm to security personnel or the police. Within a few recommendations to these aggressive patients they are: Never back to a violent individual, keep your hands in view of this individual, avoiding abrupt or sudden movements, please out of reach of the beating of the patient, never try to touch him when aggressiveness. Early signs of violence are talking about a faster way, raise the tone, sarcasm, wandering, refusing to take a seat, jaw clenching. When a patient is very agitated or irritable, it is impossible to reason. Specialists in the field say that "In the midst of aggressive reasoning should be avoided." (149)
THE AUTOPSY REVEALS SECRETS
Unfortunately the autopsy is increasingly obsolete, and even replaced in some countries by the so-called "Virtopsy" (virtual scanning technique) that can "discover" oversights or errors in diagnosis. In the US in the early 70s, only 20% of the bodies were performed autopsies and today it is estimated that only 8.5%. Perhaps it is because the autopsy reveals often medical errors and exposes professionals and hospitals. Moreover, for the bereaved and those close to the deceased people, the idea that the body of a loved one is dissected it is unpleasant and even some religions such as Islam and Judaism reject this procedure postmortem, so, science has come to virtual autopsy and postmortem imaging, as a routine procedure in the US, Australia, UK and Japan. (150)
They have been conducted in patients who died in the emergency area, and autopsies performed on these bodies, diagnoses had not even been suspected, such as malignant tumors, hemorrhagic pancreatitis and in almost half of cases are found there was a discrepancy important from the report of the autopsy and clinical diagnosis. Studies show that in the Private Hospital of Cordoba (Argentina), 53 autopsies were reviewed clinical cases in adults from January 2005 to June 2009 Goldman classification applied to establish clinical-pathological discrepancies between pre and post mortem diagnosis. The most frequent clinical diagnoses were respiratory infections and acute pulmonary thromboembolism. While the findings of autopsies usually found showed respiratory infections and acute myocardial infarction. 17 major discrepancies, and 30 matches were detected, respiratory infections were the main cause of failure followed by acute myocardial infarction, being the first who were the main type of error, so in this study suggests adopting information strategies and education to upgrade the autopsy and traditional clinical practices. (151)
Recent studies have found that about 25% of the diagnoses of causes of death are wrong, and the autopsy which is useful to help correct many of the death certificates. Comparing the results of clinical diagnoses with autopsies in Spain, 52.1% of errors was found in death certificates and autopsy 24% in those hospital certificates based only on clinical criteria. This discrepancy rate between clinical diagnosis and autopsy finding were held constant for over 30 years, although the medicine currently has more advanced features. Of all medical errors, diagnostic errors and costly comprise a substantial fraction. (152)
THE DEFENSIVE MEDICINE
Although mistakes in the medical field are eventually unforeseeable and unavoidable always be latent, and working conditions in which the health care team to unfold, will be a major influence that can serve as a "trigger" of unsafe acts or "risky" in medical practice. In our modern society, the collective unconscious has idea that health problems, whatever be solved and always must have a happy ending, not otherwise agree and when it does, then you have to find someone to blame "the doctor". (153)
Error given a punitive treatment, the doctor guilty, so we tend to avoid communication because any favors. The doctor passes a social media-lynching emitted prejudiced verdicts and lengthy legal proceedings; so that later, in most cases, remains cleared. The doctor is alone, without support from peers and institutional and personal level through a series of psychological disorders impact on his private life, professional and economic.(154)
In Spain, circa 1986 started a boom in medical claims, which created the "Defensive medicine"; however, there are many factors interacting with each other have increased litigiousness. The trend is that in practice defensive medicine will increase, said that, in the US for 2000 the cost of claims ranged in 41,000 million dollars, then in 2008 the cost was 200,000 million per year, representing 10% of total health spending for the nation. Most medical claims are related to the information given to the patient and family and rarely with the effectiveness of medical practice, hence the importance of “Informed Consent “ and the development of good and effective relationship doctor-patient including family members responsible for the case.
SUSCEPTIBILITY TO MEDICAL ERRORS IN INTENSIVE CARE UNIT (ICU).
"The smart man learns from his own mistakes, the wise learn from the mistakes of others." Adasme Arturo Vasquez.
The Institute of Medicine of the United States (IOM) in 1999, published an article entitled: "To err is human", estimating that medical errors were causing between 44,000 to 98,000 deaths per year and determined that the Intensive Care Unit (ICU ) represented a substantial part in terms of challenges in patient safety. The work within the ICU, is a special feature highly complex and usually requires urgent high-risk decisions in a short time, including treating individuals whose personal details and anamnestic are unknown or poorly provided by individuals or families, in addition to this, patient must be addressed by doctors at various levels of training in critical care or are interconsulted specialists. The error in the medical indications, is associated with a high proportion of incidents and adverse events, the drugs most often associated with errors in ICU are cardiovascular drugs (24%), anticoagulants (20%) and antibiotics (13%), and usually they occur during procedures or administration of treatment (74.8%), especially by the medical order or interpretation thereof. In general, within the critical care units, drug specifically relate to error are: inotropic, narcotics, sedatives, analgesics, magnesium, anticoagulants and antibiotics.
ICU personnel should recognize their limitations in dealing with certain diseases or complications that are not properly prepared, and the physician must advise the patient of it, their families or representatives to present options; interconsultation as other specialists to strengthen the diagnosis and behavior. To specific complications can be timely patient transfer to a specialized center or with better resources. The principles of ethics, autonomy, beneficence and justice must be key elements that underpin clinical making many of its decisions in ICUs. (155)
MISTAKES IN CRITICALLY ILL ADULTS
In industrialized countries, in order to optimize the quality of health service delivery and minimize the possibility of errors, especially in the treatment of critically ill adult patients, a review of the scientific literature was conducted between the years 1985 - 2008 , mistakes made by nurses of Intensive Care Units (ICU) reported on the leaves of patient records, where it was evident that they were bound by medical indications with a variety of drugs at different doses is considered a same patient, which was a factor error added to misguided treatments. In the ICU great clinical skills it is needed, and a correct and meticulous way of working because of the complexity operating within these structures health, since it works with patients prognosis and highly susceptible to serious consequences when committed mistakes. (156)
Errors in medical indications, especially in treatment, were defined as preventable prescription or improper use of a drug that has caused damage. Generally ICU nurse can make mistakes during drug delivery, as well as error in the calculation and preparation of doses, antibiotics most frequently involved are amikacin, vancomycin, metronidazole and ciprofloxacin.
As cardiovascular drugs related mistakes are indicated: digoxin, epinephrine and also electrolytes such as potassium and magnesium. Among the factors frequently involved distractions nurses are identified, deficiency in communication nurse versus doctor. It is worth noting they also constitute errors, lack of stability and bioavailability of various drugs, which can cause drug overdose often, opioids can cause severe respiratory depression in spontaneously breathing patients and not significantly affect a patient under mechanical ventilation. (157)
why the doctors are wrong? Page 4
