Health & Disability Notes PDF
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These notes outline different perspectives on health, including medical, holistic, and wellness models. It describes impairment, disability, handicap, quality of life, and rehabilitation. The document also covers the natural history of disease and the impact of chronic illness on individuals, families, and society.
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1 Health & Disability Wednesday, December 05, 2012 10:14 PM Objectives - Discuss different definitions of health, at individual and population levels. - Define core concepts such as impairment, disability, handicap, quality of life and rehabilitation - Discuss the concepts of life course, natural hi...
1 Health & Disability Wednesday, December 05, 2012 10:14 PM Objectives - Discuss different definitions of health, at individual and population levels. - Define core concepts such as impairment, disability, handicap, quality of life and rehabilitation - Discuss the concepts of life course, natural history of disease, with respect to preventive and public health interventions. - Illustrate the impact of a chronic disease on the patient, their family, and the community. - List typical community resources & services available for people with long-term health needs. Definition of Health - 3 models: medical model, holistic model, wellness model - evolution from a biomedical to a wellness model 1) Medical Model (1900s) - views body as machine, to be fixed when broken - health = anatomical integrity and absence of disease - health as state of anatomic, physiologic and psychological integrity with ability to fulfill roles and deal with stress - do not address mental problem, social problem, prevention - individual health = absence of disease - population health = healthy population where all members of the population are healthy 2) Holistic Model (1950's) - health = state of complete physical, mental and social well being - positive health, not merely absence of disease or infirmity - individual health = physical, mental and social well being - population health = sum of the indicators of well being (physical, mental and social) 3) Wellness Model (1980s) - health = resource for everyday life, health gives one capabilities to realize aspiration, satisfy needs and cope - health not a state, but a process and force - individual health = resource for everyday life - population health = success of population to adapt to changes Impairment vs. Disability vs. Handicap Definitions - standard definition = WHO ICF (International Classification of Functioning) - impairment, disability and handicap are all consequences of disease, but at different levels Impairment ---> disability (aka activity) ---> handicap (aka participation) - impairment = loss of psychological, physiological or anatomical structure or function - reduction of physical or mental capacities - disability = restriction in one's ability to perform a function considered part of normal everyday life - handicap = social disadvantage that may arise from disability - failure to fulfill a normal social role (family, occupation etc) - example: impairment of vision ---> disability in seeing ---> handicap in orientation - rehabilitation = minimizing disability and handicap for a given level of impairment - physical, emotional or supportive help - aim to restore or improve one's health, function, and quality of life Disease vs. Illness vs. Sickness definition - disease = impairment, the biologically defined underlying pathology - what the doctor diagnoses and treats - illness = disability, the patient's subjective experience of symptoms, including her feelings SIM Page 436 - sickness = handicap, - socially defined condition Quality of Life - quality of life is a subjective perception of current ability to function, compared to the person's sense of ideal - positive, qualitative and subjective perspective on health - health = capacity to function and live, according to an individual's subjective standards - extend disease to include disability and measure how well a patient can function activities of daily living, as perceived by the patient - can include person's feelings, satisfaction, work and home life Natural History & Clinical Course - natural history of disease = the way the disease unfolds if left untreated - clinical course = typical evolution of condition when being managed clinically - life course of disease = etiology of a disease from its childhood origins - natural history = onset -> preclinical phase -> symptom appear -> clinical phase -> outcome - clinical course = onset -> preclinical phase -> symptom appear -> clinical phase -> diagnosis -> therapy -> impact Impact of Disease on Patient, Family and Community - patient: impairment, disability, handicap, guilt of being burden - family: caregiver stress, coping, financial burden, spirituality - community: economic, population health, communicable factors Community Resources & Services for Long Term Health Needs - public home care services - in Ontario, given to people of all ages if they meet criteria - can be acute or long term or placement - acute: short term, with goal of rehabilitation and discharge from program - long term: long term, goal of prevent or slow functional decline or delay institutional admission - assistance to patient requiring functional support, cognitive impairment, palliative care - placement service: referring patient to long term care facilities - community care access center (CCAC) - run by government funded by LIHNs to assess needs of elderly and coordinate home care and long term care (retirement homes) - link to public home care services in Ontario - private home care - private agencies that provide home care for elderly or chronic care patients - paid out of pocket by patients - community health care center - not for profit organization delivering primary care to individuals / families - run by primary care team: physicians, nurses, social workers, community health workers, health promotion SIM Page 437 - not for profit organization delivering primary care to individuals / families - run by primary care team: physicians, nurses, social workers, community health workers, health promotion specialists - family health networks - team of family doctors, nurse practitioners, social workers to care for patient - paid by capitation (paid by number of patients, not service) - community resource center - no doctor, but provide community programs (meals on wheels, alcoholics anonymous) SIM Page 438 2a Child Motor Development Thursday, December 06, 2012 8:42 PM Objectives - Describe the normal stages of physical growth and development of children. - Describe stages of normal development of gross and fine motor skills. - Describe the Rourke well-baby chart and well baby visits. Realms of Development - motor development (gross and fine motor) - gross motor: big muscles (limbs, torso, neck) - fine motor (hands) - speech and language (expressivity, receptive, pronunciation) - social / adaptive / self help skills (how one looks after themselves and how one interact with other people) Principles of Normal Development - variation (age range) in skill acquisition - development progresses: - cephalocaudal (head to toe) - proximal to distal - gross to fine motor skill - newborn primitive reflexes are replaced by postural reflexes as part of normal developmental sequence Primitive Reflex - involuntary reflexes have protective role and indicate immature cortical functioning - present at birth and disappear by 4-6 months of age - symmetrical flexions / extensions - include moro, ATNR (asymmetric tonic neck reflex), palmar/plantar grasp, rooting reflex, placing / stepping reflex moro - spontaneous reaction to loud noise - sudden symmetric abduction and extension of arms, followed by slower adduction - extension of trunk - if persist post 4-6 months, indicate congenital MSK or nerve injury ATNR - limb movements influenced by head position - fencing position: if head is directed to one side, arm on same side extends toward same side and opposite arm flexes - protect against rolling Equilibrium & Postural Reflexes - maturation of cortical functioning replace primitive reflex with reflexes for posture and balance - appear at 4-6 months and persist voluntarily - include: head righting, lateral & frontal propping, parachute reflex head righting - keep head in vertical position despite tilting Propping SIM Page 439 Propping - extend arm to brace against the direction of falling - frontal propping = extend arm forward to prevent falling forward - lateral propping = abduct arm to prevent falling sideways - backward propping = extend arm backward to prevent falling backward - development: frontal propping -> lateral propping -> backward propping parachute reflex - is body is held upside down, hands and leg are outstretched - demonstrate normal sensation and CNS motor response Gross Motor Development head and trunk control - head and trunk control develop in cephalocaudal direction (head to toe) - head control begins in sitting, then in sitting and prone position - trunk control develops slowly from upper to lower until child is able to sit unsupported locomotion - prone (lying on front) to supine (lying on back) rolling by 3-4 months - supine to prone rolling by 5-6 months - early commando crawling (using only arms) by 5-6 months - 4 point crawling (use hands and feet) by 6-9 months - supported standing and cruising (shifting feet while being supported) by 9-10 months - walking independently by 12-18 months normal milestone - sits alone momentarily by 4-8 months - rolls back to prone in 4-10 months - sits steady by 5-9 months - gets to sitting by 6-11 months - pulls to stand by 6- 12 months - stands alone by 9-16 months - independent steps by 9-17 months development post walking - continuous improvement in balance & coordination - running -> jumping on 2 feet -> throw ball overhand (2 years) -> balancing on 1 foot (3 years) -> ride tricycle (3 years) -> hopping (4 years) -> skipping -> catch ball (5 years) 18 months (1.5 years) - walk fast without falling - squats to pick up toy - running stiffly - walking up stairs with one hand held - seating self in small chair - climbing into adult chair - hurling a ball 24 months (2 years) - running without falling - squats and rises easily - walking up and down stairs alone - kick a large ball - throw small ball overhand and forward 36 months (3 years) - walking up stairs by alternating feet SIM Page 440 36 months (3 years) - walking up stairs by alternating feet - walking well on toes and backward - ride tricycle - hopping - throw ball overhand and catches large ball 48 months (4 years) - walks and runs up and down stairs like adults - climb ladders / trees - stand, walk and run on tiptoes - stand on 1 foot and hops on 1 foot - pick up object bending from waist - increased skill / coordination in throwing, catching and kicking 60 months (5 years) - skips, jumps rope, runs skillfully - tandem gait and tiptoe walks - balance on 1 foot and hops - moves rhythmically to music - bend and touch toes without knees flexed Fine Motor Skills - develop in direction from fine use of - proximal (wrist) to distal (fingers) for upper extremity - ulnar (pinky) to radial (thumb & index finger) - normal development replaces involuntary grasp (that cannot be released voluntarily) to voluntary grasp - loss of palmar (involuntary grasp) at 1 months - hands to midline at 2-3 months - swipes / bats at object around midline at 2-3 months - hands open more often at 2-3 months - voluntary grasp and release of objects at 4-5 months - 4-5 months: fingers and thumb slowly begin to function independently - 5 months: (ulnar) rake for small object - 7 months: radial palmar grasp - 9 months: radial digital grasp - 10 months: inferior pincer grasp (pinch with thumb) - 10-12 months: mature pincer grasp (pinch with superior index finger with thumb) - 12 months (1 year): master tools (cup and spoon) and manipulate objects fine motor planning and control (building blocks, drawing, cutting) - 18 months (1.5 years): manipulate and pile blocks scribbles spontaneously, imitate strokes / dots, hold pencil mid-upper shaft use index finger to point turns several pages of book at a time - 24 months (2 years): build cube tower imitate horizontal stokes, start circular scribble, hold pencil lower shaft turns 1 page of a book at a time - 36 months (3 years): copies circle, hold pencil in preferred hand using first 3 fingers build 9-10 blocks tower copies circle, imitates a cross draws a person's head cuts across paper with scissors - 48 months (4 years): builds 10 cubes holds pencil in adult fashion copies letters, draws person use scissors to cut out pictures SIM Page 441 use scissors to cut out pictures can button and unbutton - 60 months (5 years): good writing / drawing copy square, triangles, letter draw man and house color pictures within lines tie shoe lace / knot in string Feeding 7 months: feed self with fingers 15 months (>1 year): use spoon and cup 30 months (>2 year): spears with fork 60 months (5 years): spreads with knife Rourke Well Baby Visit - important part of primary care during first 2 years of life - include development screening, parental education and immunization - components: 1) growth including height, weight, head circumference 2) nutrition: breast feeding for > 6 months for optimal nutrition 3) education: injury prevention, behavior & family issue, other issues for parents 4) development: note any delay in milestones acquisition 5) physical examination: systematic (entire body) 6) Problem and plans 7) Immunization and investigations (additional screening test) SIM Page 442 2b Epi Research Thursday, December 06, 2012 8:55 PM Objectives - Evaluate research designs and sources of data to describe the health of a population. - Evaluate criteria, statistical measures and research designs for assessing causation. - Discuss criteria, statistical measures and research designs to evaluate a medical intervention. Epidemiology - study of distribution and determinants of health related states and events - aims to identify causes, risk of disease - also application of findings to address health problems Types of Data - data can be categorical /non-parametric (nominal and ordinal) OR continuous / parametric (interval, ratio) - categorical / non parametric data - nominal / categorical data - categories to be counted - cannot be added or multiplied - e.g. sex: male / female - ordinal data - numbers with a meaningful order - not based on equal interval - e.g. staging of cancer - continuous / parametric data - interval data - number with meaningful order and successive numbers are equal in interval - no meaningful zero, so ratio between numbers is not consistent - can be added / subtracted, but not multiplied - e.g. temperature in celsius - ratio data - number with meaningful order and equal interval - meaningful zero, so ratio between numbers is consistent - can be added / subtracted and multiplied - e.g. heart beat Criteria for Causation - no definite way to prove that statistical association are real causal relationships - can only say whether it is likely to be causal - 7 criterion, the more, the increased likelihood toward causal relationship 1) chronological relationship: exposure predate disease - strongest criterion to infer that an observed relationship is causal 2) strength of association: exposed people are much more likely to get disease than unexposed people 3) dose response relationship: more exposure = more severe / longer disease 4) specificity of association: exposure consistently found to be related only to disease - weak criterion, because some causes are associated with many diseases, and are thus not specific - absence of a specificity of association do not undermine a causal interpretation 5) consistency of finding: same association found in other studies / populations 6) coherent / plausible finding: biological a priori rationale for observed association 7) cessation of exposure: removal of exposure lead to cessation of disease Cofounding Confounding factors Mediating factors Independent Vatiable Dependent Variable SIM Page 443 Confounding factors Mediating factors Independent Vatiable Dependent Variable Moderating factors - confounder = risk factor for disease and also associated with independent variable - also not in causal pathway - can be adjusted by stratifying population by confounder or matching case and control by confounder - moderating factor = specify under what condition a predictor variable influence a dependent variable - aka effect modifiers - mediating factors = an intervening variable / mechanisms in the causal pathway through which an independent variable is able to influence a dependent variable Research Designs - study designs can be categorized into observational and experimental studies - observational study - researcher observes and collect information, but do not alter the independent variable - can be descriptive or analytic studies - descriptive study do not test a hypothesis and ask general and qualitative questions about demography - analytic study tests a hypothesis to find causal factor and include data collection to test association between an independent variable and an outcome - include cohort study, case control study, ecological study, cross sectional study - experimental study - researcher assign exposure and then observe what happens - experimental study are evaluative studies to test success of a treatment - include quasi-experiments and randomized controlled trials SIM Page 444 Hierarchy of Quality of Evidence From strongest to weakest 1. meta-analyses of clinical trials 2. systematic review or expert consensus statement of RCTs 3. single RCTs 4. quasi-experimental design 5. observational study 6. non-systematic reviews 7. case studies Ecological Study - compare outcome between groups of people that differ in exposure - at group level, not individual - exposure and outcome assessed at same time - advantage - fast, cheap - disadvantage - ecological fallacy: assumption that association found at group level also exist in individual level Cross Sectional Study - descriptive or analytic - sample individuals, not groups (different from ecological study) - participants chosen to form a representative sample of general population - not chosen based on exposure or disease status - can calculate prevalence, but do not measure incidence - prevalence affect the positive predictive value of a diagnostic test - can evaluate new diagnostic procedures (sensitivity and specificity of a diagnostic test) - exposure and outcome measured simultaneously SIM Page 445 - exposure and outcome measured simultaneously - advantage - fast, cheap - can cover whole population - disadvantage - lack of time dimension, cannot show temporality of exposure before outcome Case Control Study - look backwards in time - begin with recruiting participants based on disease status, then determine exposure status - groups to be compared are defined in terms of outcome of interest - common to match cases and controls in terms of cofounders (e.g. match by sex, age) - case control do not calculate incidence nor prevalence Disease No disease Exposed a b Not exposed c d Odds ratio (OR) = ad / bc - people with disease are (OR) times more (if OR>1) or less (is OR1) or less (if RR 1 year of age) - Yellow Fever (>9 months of age) - Typhoid (> 2 years of age) - Cholera (>2 years of age) SIM Page 461 Vaccination Principles - done by family physicians - schedule is by time since birth, not affected by gestational age or birth weight - premature birth is not a contra-indication for vaccination - for starting immunization for adults with no previous immunization, start according to the infant schedule - if there is lag between doses, can just continue from the last dose, ignoring the lag / discontinuation - cannot giver vaccine earlier than the scheduled date - multiple vaccines can be administered at the same visit - rubella vaccination important before pregnancy - tetanus vaccine for anyone with a severe and dirty abrasion (unless tetanus up to date) Adverse Effects of Vaccines - contraindications for routine infant vaccines - suppressed immune system - mainly for live vaccines: MMR, varicella, BCG - anaphylaxis to vaccine (reportable to public health Ontario) - pregnancy (usually only for live vaccines) - vaccine can be given / continued post delivery - Guillain Barre syndrome - proceed with precaution - people with bleeding disorders (subcutaenous vaccination is fine; intra-muscular vaccination is contra-indicated) - recent administration of live vaccine (only if giving another live vaccine) - recent administration of antibodies (only if giving a live vaccine) - not contraindications to routine infant vaccine - premature birth - being "sick" with no or low grade fever - syncope (anxiety and fainting) - cancer - neurologic disorder - breast feeding - antibiotic therapy - child with no exposure to egg Addressing Parental Concerns - physician have responsibility to provide information on availability and cost of all vaccines - non-funded vaccines can be given when paid by patient - vaccines can be immunized earlier than the public date, which would not be publicly funded - no harm in giving many injections at same time Legal Aspect of Immunization - children required to have complete immunization record (MMR, DTaP) in order to enroll in school - vaccination not mandatory, but it is a mandatory choice - people must state they refuse vaccination Information Sources - Public Health Ontario, Ministry of Health, Health Canada SIM Page 462 11 HIV Coping Wednesday, December 05, 2012 5:15 PM Objectives - Describe the concepts of health and illness behaviors, and their relevance for explaining risk factors, health care utilization and adherence to therapy. - Explain the epidemiology of HIV in Canada and the world (prevalence; risk factors; social burden; efficacy of care). Behavior Change by Health Belief Model - probability of change depend on 3 factors 1) do the person feel ready to take action? - perception of threat of disease (susceptibility to the disease or severity of disease) 2) how do the person perceive and evaluate the recommended action? - perceived efficacy of action to prevent disease or reduce disease severity - psychological, financial and other barriers to act 3) cue that motivate change in health behavior - internal cues are from self (e.g. appearance of symptoms) - external cues are from others (e.g. a friend getting sick) Stages of Change for Individual 1) precontemplation: not intending to change behavior - clinician can provide information to motivate change 2) contemplation: have not begun to change behavior, but intends to do so in the future (within next 6 months) - clinician can provide information and motivate patient to make specific preparations SIM Page 463 - clinician can provide information and motivate patient to make specific preparations 3) preparation: have not begun to change behavior, but intends to do so in the near future with a set date (within next 30 days) - clinician can support in practical ways 4) action: begun to change behavior - clinician provide support and monitor change 5) maintenance: individual has practiced new behavior for a period of time (>30 days) - clinician can monitor, encourage and assist in case of relapse Community Level Change - program to implement change in behavior at community level require the 4 E's: 1) education (e.g. health education) 2) environmental support (e.g. changing social norms) 3) economic lever (e.g. taxation) 4) enforcement of regulations and legislations (e.g. laws to prohibit an action) Precede-Proceed Model - precede - proceed model is a guideline for setting up and for evaluating a community health intervention program - tackles underlying determinants and evaluate what has been done - precede = underlying factors that precede and determine a patient's quality of life - proceed = evaluation of implementation (what was done?); process (how was it done?); impact (were intermediated variables changed?); and outcome (what was final result?) PRECEDE-PROCEED Framework Phase 5 Phase 4 Phase 3 Phase 2 Phase 1 Administrative Educational & Behavioral & Epidemiologic Social Policy Ecological Environmental Assessment Assessment Assessment Assessment Assessment HEALTH Predisposing PROMOTION factors Behavior & Health lifestyle Reinforcing Quality Education Health factors of life Policy, Environment Regulation, Enabling Organization factors Phase 7 Phase 8 Phase 9 Phase 6 Process Impact Outcome Implementation Evaluation Evaluation Evaluation - phase 1-5 = precede (assessment of underlying factors) - phase 6-9 = proceed (evaluation of actions) Behavior Modification - techniques for altering behavior: 1) ABC - consider (A) the antecedent of behavior (what sparks it?) (B) the behavior (what is the patient doing?) SIM Page 464 - consider (A) the antecedent of behavior (what sparks it?) (B) the behavior (what is the patient doing?) (C) the consequences (reaction from others and effect on self) - change behavior based on ABCs 2) reinforcement - positive reinforcement of desirable actions - reward (praise, encouragement, actual rewards) immediately following desired behavior - negative reinforcement of undesirable actions - 5 positive : 1 negative ratio 2) extinction - ignoring an undesirable behavior to make it go away - extinction effective if used with positive reinforcement of alternative behavior 3) shaping - reinforcing an existing behavior that closely resembles the desired behavior - then demand to correct to the more desirable behavior - step by step approach 4) intermittent reinforcement - schedule to reward desired behavior in fixed amounts over time Epidemiology of HIV - HIV first case in 1981 - antiviral treatment first used around 1995 Worldwide - 34 million living with HIV and increasing steadily over the last 20 years - about 50% women and 50% men - 2.5 million new HIV cases per year - 2 million HIV deaths per year - most cumulative AIDs death: Africa > southeast Asia > Latin America > North America - highest prevalence in sub-Saharan Africa, eastern Europe and southeast Asia - greatest decrease in new HIV incidence in sub-Saharan Africa, southeast Asia - HIV prevalence negatively correlated with wealth (GDP) grossly in terms of continent - in Africa, seems that richer countries have higher prevalence of HIV Population at risk worldwide - developing world - heterosexual men and women (men = women) - children (from vertical transmission) - developed world - men who have sex with men - people from endemic countries - aboriginals - intravenous drug users - heterosexual men and women Canada - 70,000 living with HIV currently in Canada and increasing dramatically over the last 35 years - 2,500 new HIV cases per year in Canada (750 cases in Ontario), which stayed the same over last 10 years - highest new HIV cases in 1995 at 2,990 - new HIV cases increasing in men who have sex with men and heterosexuals - possibly due to HIV fatigue SIM Page 465 - possibly due to HIV fatigue - new HIV cases decreasing in IV drug users Population at risk in Canada - men (80% HIV prevalent cases) >> female (20%) - 40% of female HIV cases due to IV drug use; 30% of female HIV cases due to heterosexual contact - men who have sex with men (46% HIV prevalent cases, 4% total population) - disproportionally high and increasing in recent years - IV drug user (17% HIV prevalent cases) - heterosexual men and women (27% HIV prevalent cases) - aboriginal (9% HIV prevalent cases, 3% total population ) - disproportionally high, possibly due to aboriginals IV drug use (50% aboriginals HIV cases due to IV drug use) - recent immigrants (16% of HIV prevalent cases), which have 12 times higher risk than Canadian born people - 500 new AIDs cases per year in recent years - AIDs cases decreasing due to medication which slow disease progression - 40% of AIDs cases in 30-39 age group, meaning they were infected in 20s - sharp decline in AIDs deaths from 1996 to now due to medication - medication cost ~$1 million for 1 HIV case over life time in Canada Safe Sex Fatigue and AIDs Optimism - apparent in young age group and men who have sex with men in Canada - overconfidence in efficacy of treatment in HIV lead to decrease in concern over risk of STI, thereby reducing use of safe sex precautions - constant repetition make people immune to advisories on safe sex - result in increase in HIV infection and other STIs (e.g. syphilis and chlamydia) - most dramatic increase in 30-39 year old men STIs in Ottawa - STIs increasing to highest level in Ottawa - increasing cases of Chlamydia in men and women - increasing cases of syphilis mainly in men - increasing cases of gonorrhea in men and women Intervention for HIV - feasibility of vaccine low (virus hijacks immune system and quickly mutates) - to encourage HIV vaccine research by pharmaceutical companies: - private public partnerships - advanced market commitment (government promise to subsidize future purchase of vaccine if vaccines are effective) - microbicides, diaphragms ineffective - circumcision decreases HIV infection risk by 60% - public campaigns encouraging monogamy, increase access to birth control, provision of antiretrovirals to HIV mothers (prevent vertical transmission) are effective - most effective prevention = ABCs (abstinence, be faithful, condom use) Cost of Anti-Retrovirals - lifetime direct cost of treating HIV infected person in US = $100,000 - lifetime direct cost of treating HIV infected newborn = $160,000-$400,000 - estimates are conservative, considering they do not cover the expensive protease inhibitors ($10,000 per person per year) SIM Page 466 SIM Page 467 12 Professionalism Wednesday, December 05, 2012 9:56 PM Objectives - Demonstrate how professionalism values apply to their interactions with their peers and teachers, as well as staff. Link to Professionalism web site. - Interpret the attributes of professionalism with regard to privacy, confidentiality and respect. - Apply professionalism values to examination situations. Professionalism - profession = occupation that provide personal service to clients - core features of profession - body of specialized knowledge and practical skills with cognitive and theoretical basis - produces and evaluate new knowledge - monopoly over practice in field of work (self regulating, sanctioned by government) - strong internal organization (union with members swearing to uphold values) - self regulations (judged by another member of same profession) - public ideology of service to community, placing client's interest before their own - turf battles between professions are common Attributes of a Professional - honesty and integrity: uprightness, honesty, incorruptibility - altruism and respect: unselfish regard for and devotion of welfare of others - put patient's need before one's interest - responsibility and accountability: commitment to maintain integrity of moral and collegial nature of profession and held accountable to one's conduct - compassion and empathy: non-judgmental and non-discriminatory attitudes for wellbeing of patient and their families - dedication and self improvement: strive to develop knowledge, skills and competence, uphold standards of profession Confidentiality - physician should respect patient confidentiality and never release patient personal information without the patient's consent - can be overridden in interest of public health SIM Page 468 - can be overridden in interest of public health - e.g. physicians are legally required to report patients with STIs such as HIV Disclosure - doctor must disclose all relevant information for the patient to make an informed and autonomous choice Informed Consent - consent is required before any type of care (diagnostic, investigational, palliative, therapeutic) - consent must be informed and made by a mentally competent patient Approaching Ethical Decisions 1. describe case with pertinent facts 2. summarize the ethical dilemma (what decision has to be made?) 3. outline alternatives for the dilemma 4. explore each alternative considering patient autonomy, beneficence, justice, context 5. propose resolution (best alternative) 6. review choice (generate a maxim) 7. act SIM Page 469