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Chapter 4. Medical ethics and deontology in caring for patients
Medical ethics is the science of morality and morality in the activities of medical workers.
The first acquaintance of patients and their relatives with medical workers begins with the registration of clinics, emergency departments of hospitals, nurses and orderlies. This implies the need to improve the general culture of medical institutions and their workers.
Basic deontological principles:
"Do no harm";
“Everything that is applied must be beneficial.”
Personal qualities necessary for a medical worker when caring for a patient:
high professionalism;
caring and attention to the sick;
patience;
politeness and tact;
a high sense of responsibility for the fate of patients;
mastery of your feelings.
Basic principles of relationships between medical professionals:
subordination (the system of subordination of a junior to a senior). The nurse must carry out medical prescriptions strictly, observe the dosage of medications, the time and sequence of their administration.
Negligence and error can be life-threatening for the patient and lead to irreparable consequences. It is unacceptable for a nurse to cancel a doctor’s orders herself or to make them at her own discretion. She should not take on the responsibility of diagnosing and treating a patient without a doctor’s prescription. If there are changes in the patient’s condition that require discontinuation of medications or the prescription of new drugs, the doctor should be informed about this, who will give appropriate instructions. In emergency situations, in the absence of a doctor, orders are given by the nurse of the relevant unit.
Middle and junior medical personnel in other departments of the department must carry them out immediately and unquestioningly;
tactfulness, politeness. It is unacceptable to criticize your colleagues in the presence of patients and visitors. This undermines the authority of the person being criticized and deprives patients of further trust, who may exaggerate the significance of the mistake made.
goodwill, mutual assistance and mutual assistance. If a doctor or nurse feels insufficiently prepared to perform certain therapeutic or diagnostic procedures, they should seek help and advice from more experienced colleagues. At the same time, more trained medical workers should help less experienced colleagues master the techniques of various manipulations. Arrogance and arrogance in relations between medical workers are not acceptable.
Politeness. The patient should be addressed using “you” and by name and patronymic. When talking with a patient, you need to monitor the content of your speech, intonation, facial expressions, and gestures. A benevolent attitude towards the patient should not turn into familiarity.
Patience. Sometimes patients have a negative attitude towards medical prescriptions (diagnostic manipulations and treatment). When dealing with such patients, it is necessary to show patience. It is unacceptable to argue with them. It is necessary to convince them of the need to carry out the prescribed procedures and perform them as sparingly as possible.
A caring attitude towards the patient helps to restore proper contact with him.
The response of medical personnel to the patient’s call should be immediate with the prompt fulfillment of his reasonable request.
In critical situations (profuse bleeding, cardiac arrest, etc.), panic and confusion should not be allowed. Actions must be clear, targeted, without fuss.
It is unacceptable for medical personnel to shout at the entire department when addressing each other at a great distance. It is necessary to come to a distance where a quiet conversation is possible.
Maintain silence in the department, especially at night. A gentle regimen is a prerequisite for successful treatment. No medicine will help a patient if he cannot fall asleep due to loud conversations, the clicking of heels, or the creaking of a gurney.
Monitoring patients' compliance with the hospital regime.
In individual patients, due to examinations, operations, and dressings, this order may change, but the general scheme of the order remains. The individual behavior regimen of each patient is established by the attending physician, the observance of which is monitored by the ward nurse. Often, individual patients, most often those who are recovering, violate the treatment regimen: they smoke in the wards, drink alcohol, are rude, and behave aggressively. In such cases, medical personnel must resolutely suppress violations of discipline and be strict (but not rude!). Sometimes it is enough to explain to the patient that his behavior harms not only him, but also others.
Give the patient confidence in recovery.
The greatest difficulties are caring for seriously ill patients with extensive purulent-putrefactive wounds, gastric and intestinal fistulas, bedsores, and paralysis. Such patients require the use of special methods of care, frequent changes of bed and underwear, feeding and fulfillment of physiological needs in bed, etc. All this must be performed skillfully, without causing additional pain to the patient. At the same time, medical personnel should not show disgust or show that they are uncomfortable with performing a particular procedure.
Sensitivity, warmth, friendliness.
Only with sincere sympathy for the patient and understanding of his situation is the patient’s trust possible. Indifferent, unbalanced people who are incapable of compassion should not be allowed to work in medical institutions, especially in surgical departments.
Callousness, a formal attitude to work, self-confidence, arrogance, arrogance and rudeness are unacceptable qualities for medical personnel.
Proper appearance.
It is also equally important that the high professional level and high moral qualities of medical workers are combined with their proper appearance. Untidy clothes, a dirty robe, and excessive use of cosmetics make the patient doubt the professionalism of the health worker. And these doubts are often justified. Maintaining medical confidentiality is the professional responsibility of all medical workers. Everything that is included in
All information that a nurse gives to patients must be agreed with the doctor. If the information received from the nurse differs from the information given by the doctor, this will raise doubts about the reliability of his reports and distrust of him.
Patients often enter into a conversation about their illness with junior medical staff, receiving from them unnecessary, sometimes harmful information regarding unfavorable outcomes for a similar disease in patients who were previously in the department.
The nurse should discourage such conversations.
The Hippocratic Oath says: “Whatever I see or hear when communicating with people during the exercise of my profession or even outside it, I will keep silent about what should not be disclosed, considering silence in this case as my duty.”
A medical worker is exempt from maintaining medical confidentiality in case of diseases that threaten the health of other people (information about infectious and sexually transmitted diseases, HIV infection, AIDS, poisoning, etc.).
Medical documents with research results should be inaccessible to the patient.
Their incorrect interpretation by the patient can lead to fear of a particular disease (“phobia”) - fear of cancer (cancerophobia), heart disease (cardiophobia), etc. An inept conversation, especially with a suspicious patient, can cause a painful condition or disease in him , which is called iatrogenic disease (from the Greek jatros - doctor, genes - generated).
You must constantly strive to improve your skills.
Relationships between medical workers and relatives and loved ones of patients Medical personnel constantly have to communicate with relatives and close friends of the patient. When concealing from the patient the presence of an incurable disease or a deterioration in his condition, this must be communicated to the patient’s close relatives in a form understandable to them. It should be remembered that among them there may be patients for whom this information may cause a deterioration in their condition. This conversation with relatives is conducted only by the attending physician or the head of the department. You need to be especially careful when giving information over the phone; it is better not to provide any serious, especially sad, information at all; it is better to ask a relative to come to the hospital and talk to the doctor in person.
Often relatives ask for help in caring for the sick. Close relatives may be allowed to visit a seriously ill person, but they should not be allowed to perform any procedures.
Deontological aspects of teaching students
From a dental point of view, it is unacceptable to immediately train patients to perform complex manipulations, poor mastery of which can lead to serious complications: injections, enemas, gastric lavage, bladder catheterization, etc. First, these skills must be mastered on a simulator and only then applied in clinical practice.
Medical ethics is a section of the philosophical discipline of ethics, the object of study of which is the moral and moral aspects of medicine. Deontology (from the Greek dEpn - due) is the doctrine of problems of morality and morality, a section of ethics. The term was introduced by Bentham to designate the theory of morality as the science of morality.
Subsequently, science narrowed down to characterizing the problems of human debt, considering debt as an internal experience of coercion determined by ethical values. In even more in the narrow sense deontology was designated as a science that specifically studies medical ethics, the rules and norms of interaction between a doctor and colleagues and patients.
The main issues of medical deontology are euthanasia, as well as the inevitable death of the patient. The goal of deontology is to preserve morality and combat stress factors in medicine in general.
There is also legal deontology, which is a science that studies issues of morality and ethics in the field of jurisprudence.
Deontology includes:
- 1. Issues of maintaining medical confidentiality
- 2. Measures of responsibility for the life and health of patients
- 3. Relationship problems in the medical community
- 4. Problems in relationships with patients and their relatives
Medical deontology is a set of ethical standards health workers fulfill their professional responsibilities. Those. Deontology primarily provides for norms of relationships with the patient. Medical ethics provides more wide circle problems - relationships with the patient, health workers among themselves, with the patient’s relatives, healthy people. These two directions are dialectically related.
Understanding of medical ethics, morality and deontology
At the beginning of the 19th century, the English philosopher Bentham used the term “deontology” to define the science of human behavior in any profession. Each profession has its own deontological norms. Deontology comes from two Greek roots: deon - due, logos - teaching. Thus, surgical deontology is a doctrine of what should be done, it is the rules of conduct for doctors and medical personnel, it is the duty of medical workers to patients. For the first time, the basic deontological principle was formulated by Hippocrates: “We must pay attention so that everything that is used is beneficial.”
The word "morality" comes from the Latin "toges" and means "character", "custom". Morality is one of the forms of social consciousness, which is a set of norms and rules of behavior characteristic of people of a given society (class). Compliance with moral standards is ensured by the power of social influence, traditions and personal conviction of a person. The term “ethics” is used when they mean a theory of morality, a scientific justification for a particular moral system, a particular understanding of good and evil, duty, conscience and honor, justice, the meaning of life, etc. However, in a number of cases In cases, ethics, just like morality, means a system of norms of moral behavior. Consequently, ethics and morality are categories that determine the principles of human behavior in society. Morality as a form of social consciousness and ethics as a theory of morality change in the process of development of society and reflect its class relations and interests.
Despite the difference in class morality characteristic of each type of human society, medical ethics at all times pursues universal, non-class principles medical profession, defined by its humane essence - the desire to alleviate suffering and help a sick person. If this primary obligatory basis of healing is absent, one cannot talk about observing moral standards at all. An example of this is the activities of doctors and scientists in Nazi Germany and Japan, who during the Great Patriotic War made many discoveries that humanity still uses to this day. But they used living people as experimental material, and as a result, by decisions of international courts, their names were consigned to oblivion both as doctors and as scientists - “Nuremberg Code”, 1947; International Court in Khabarovsk, 1948.
There are different views on the essence of medical ethics. Some scientists include in it the relationship between doctor and patient, doctor and society, the doctor’s performance of professional and civic duty, others consider it as a theory of medical morality, as a section of the science of moral principles in the activity of a doctor, the moral value of the behavior and actions of a doctor in relation to patients. According to S.S. Gurvich and A.I. Smolnyakov (1976), medical ethics is “a system of principles and scientific concepts about norms and assessments for regulating a doctor’s behavior, coordinating his actions and the methods of treatment he chooses with the interests of the patient and the requirements of society.”
The given definitions, despite their apparent differences, do not so much differ from each other as complement the general ideas about medical ethics. Defining the concept of medical ethics as one of the varieties of professional ethics, philosopher G.I. Tsaregorodtsev believes that it is “a set of principles of regulation and norms of behavior of physicians, determined by the characteristics of their practical activities, position and role in society.
According to modern ideas, medical ethics includes the following aspects:
- Ш scientific - section medical science, studying the ethical and moral aspects of the activities of medical workers;
- Ш practical - an area of medical practice, the objectives of which are the formation and application of ethical norms and rules in professional medical practice.
Medical ethics studies and determines solutions to various problems of interpersonal relationships in three main areas:
- Ш medical worker - patient,
- Ш medical worker - relatives of the patient,
- Ш medical worker - medical worker.
The four universal ethical principles include: beneficence, autonomy, justice and completeness medical care.
The principle of mercy says: “I will do good to the patient, or at least not harm him.” Mercy implies a sensitive and attentive attitude towards the patient, the choice of treatment methods proportional to the severity of the condition, the patient’s willingness and ability to cope with the prescribed medical intervention. The main thing is that any action medical worker was aimed at the benefit of a specific patient!
The principle of autonomy requires respect for the individuality of each patient and his decisions. Each person can only be considered as an end, but not as a means to achieve it. The principle of autonomy relates to such aspects of medical care as confidentiality, respect for the patient's culture, religion, political and other beliefs, informed consent to medical intervention and joint planning and implementation of the plan of care, as well as independent decision-making by the patient or decision-making by a legal representative of this patient.
The principle of justice without causing harm requires equal treatment of medical workers and provision of equivalent care to all patients, regardless of their status, position, profession or other external circumstances. This principle also determines that whatever assistance a medical professional provides to a patient, his actions must not cause harm to either the patient or others. When faced with a situation of conflict between a patient and his loved ones or other medical workers, guided by this principle, we must be on the patient’s side.
The principle of completeness of medical care implies professional provision of medical care and a professional attitude towards the patient, the use of the entire available arsenal of healthcare to conduct high-quality diagnostics and treatment, implement preventive measures and provide palliative care. This principle requires absolute compliance with all laws related to health care, as well as all provisions of the code of ethics.
The moral responsibility of a medical worker implies compliance with all principles of medical ethics.
ETHICAL, MORAL, PROFESSIONAL STANDARDS OF CONDUCT
The duty of a medical worker provides for the qualified and selfless performance by each medical worker of his professional duties, provided for by the norms of moral, ethical and legal regulation medical activity, in other words, the duty of a health worker:
- · moral - provision of medical care regardless of social status, religion, etc.
- · professional - never, under any circumstances, perform actions harmful to the physical and mental state of people.
Rules of conduct for medical workers in the team of a medical institution.
External culture of behavior:
- · appearance (clothes, cosmetics, hairstyle, shoes),
- · observance of external decency: the tone in which they speak, do not use swear words, rude words.
- · Internal culture of behavior:
- · attitude towards work,
- maintaining discipline,
- · friendliness, observance of subordination.
The main qualities of the internal culture of behavior:
- · modesty,
- · justice,
- · honesty,
- · kindness.
- · The basic principles of nursing ethics and deontology are set out in the Oath of F. Nightingale, the Code of Ethics of the International Council of Nurses and the Code of Ethics of Russian Nurses:
- 1. Humanity and mercy, love and care.
- 2. Compassion.
- 3. Goodwill.
- 4. Unselfishness.
- 5. Hard work.
- 6. Courtesy, etc.
Ethical foundations of modern medical legislation:
Ethical framework defines Code of Ethics nurses in each country, including Russia, and are standards of behavior for nurses and a means of self-government for a professional nurse.
Awareness of responsibility for the patient's life requires special sensitivity and attention from the nurse. Sensitivity is not only empathy, deep insight and understanding of the patient’s experiences, but also the ability to be selfless and self-sacrificing. However, sensitivity and kindness should not turn into sentimentality, which deprives the nurse of composure and creative activity in the fight for the health, and often the life of the patient.
Patients often ask nurses about their diagnosis and prognosis. Under no circumstances should you inform a patient that he has an incurable disease, especially a malignant tumor. As for the prognosis, one must always express firm confidence in a favorable outcome. At the same time, one should not assure a seriously ill patient that his illness is “trifling” and he will “be discharged soon,” since patients are often well aware of the nature of their illness and, with overly optimistic answers, lose confidence in the staff. It is better to answer something like this: “Yes, your illness is not easy and it will take a long time to be treated, but in the end everything will be fine!” However, all the information that the nurse gives to the patients must be agreed upon with the doctor.
Patients often enter into conversations with junior medical staff, receiving unnecessary information from them. The nurse must stop such conversations and at the same time constantly educate nurses, technicians, and barmaids, explaining to them the basics of medical deontology, i.e., relationships with patients. In the presence of a patient, one should not use terms that are unclear and frightening to him: “arrhythmia”, “collapse”, “hematoma”, as well as such characteristics as “bloody”, “purulent”, “fetid”, etc. It must be remembered that sometimes patients in a state of narcotic sleep and even superficial coma can hear and perceive conversations in the ward. The patient must be protected in every possible way from mental trauma, which can worsen his condition, and in some cases lead to refusal of treatment or even attempted suicide.
Sometimes patients become impatient, negative towards treatment, and suspicious. Their consciousness may be impaired, hallucinations and delusions may develop. In dealing with such patients, patience and tact are especially necessary. It is unacceptable to argue with them, but we must explain the need for therapeutic measures and try to carry them out in the most gentle way. If the patient is untidy in bed, under no circumstances should you blame him for this or show your disgust and dissatisfaction. No matter how often you have to change bed linen, it should be done in such a way that the patient does not feel guilty.
At the same time, individual patients, as a rule, who are not in serious condition, show indiscipline and violate the treatment regimen: they smoke in the wards, drink alcohol. In such cases, the nurse must resolutely suppress violations of discipline and be strict, but not rude. Sometimes it is enough to explain to the patient that his behavior is harmful not only to him, but also to other patients (however, if a conversation about the dangers of smoking is conducted by a nurse who smells of tobacco, such a conversation is unlikely to be convincing). All cases of improper behavior of the patient must be reported to the doctor, as this may be caused by a deterioration of the patient’s condition and it is necessary to change the treatment tactics.
A nurse must always be self-possessed, friendly, and contribute to the creation of a normal working atmosphere in medical institution. Even if she is upset or alarmed about something, patients should not notice this. Nothing should be reflected in her work, in her tone in conversations with colleagues and patients. Excessive dryness and formality are also undesirable, but frivolous jokes are also unacceptable, and even more so familiarity in relations with patients.
The behavior of a nurse should inspire respect for her, create confidence in patients that she knows everything and can do everything, that they can safely entrust their health and life to her.
The appearance of a nurse is of great importance. Arriving at work, she changes into a clean, ironed robe or into the uniform accepted in this institution, exchanges street shoes for slippers or special shoes that are easy to wear sanitization and not making noise when walking. Covers hair with a cap or scarf. The nurse leaves all work clothes and shoes in a special locker.
A neat, smart employee inspires the patient’s trust; in her presence he feels calmer and more confident. And, on the contrary, untidiness in clothes, a dirty robe, hair sticking out from under a cap or scarf, excessive use of cosmetics, long varnished nails - all this makes the patient doubt professional qualifications nurse, in her ability to work accurately, cleanly and accurately. These doubts are most often justified.
The nurse must strictly follow the doctor’s instructions and strictly observe not only the dosage of the medication and the duration of the procedures, but also the sequence and timing of the manipulations. When prescribing the time or frequency of drug administration, the doctor takes into account the duration of their action and the possibility of combination with other medications. Therefore, negligence or error can be extremely dangerous for the patient and lead to irreversible consequences. For example, a heparin injection not given on time can cause a sharp increase in blood clotting and coronary artery thrombosis. For the same reasons, the nurse should under no circumstances independently cancel the doctor’s orders or do anything at her own discretion.
Modern medical institutions are equipped with new diagnostic and treatment equipment. Nurses must not only know what a particular device is for, but also be able to use it, especially if it is installed in the ward.
When performing complex manipulations, a nurse, if she does not feel sufficiently prepared for this or doubts something, should not hesitate to ask for help and advice from more experienced colleagues or doctors. In the same way, a nurse who is proficient in the technique of a particular manipulation is obliged to help her less experienced comrades master this technique. Self-confidence, arrogance and arrogance are unacceptable when it comes to human health and life!
Sometimes the patient’s condition may undergo a sharp deterioration, but panic or confusion should not be allowed. All actions of the nurse must be extremely clear, collected and confident. Whatever happens (profuse bleeding, sudden disturbance of heart rhythm, acute swelling of the larynx), the patient must not see frightened eyes or hear a trembling voice. It is also unacceptable to shout loudly throughout the entire department: “Hurry, the patient is in cardiac arrest!” The more alarming the situation, the quieter the voices should sound. Firstly, the patient himself, if his consciousness is preserved, reacts poorly to screaming; secondly, it sharply disturbs the peace of other patients, who can be seriously harmed by anxiety; thirdly, shouts, continuous hasting and often nervous altercations exclude the possibility of providing the patient with timely and qualified assistance.
In the event of emergency situations, orders are given by the head of the department or the most experienced doctor, and before the doctor arrives, by the nurse who works in the given ward or office. The instructions of these persons must be carried out immediately and unquestioningly.
Silence in the department must be maintained at all times, especially at night. Gentle mode is prerequisite successful treatment, and no medicine will help the patient if he cannot sleep due to... loud conversations and the clicking of heels in the corridor.
In addition to contacts with patients, nurses often have to come into contact with their relatives and loved ones. In this case, many factors also need to be taken into account. Medical workers, hiding from the patient the presence of an incurable disease or a deterioration in his condition, must inform his relatives about this in a clear and accessible form. But among them there may be sick people, in conversation with whom great caution and tact should be exercised. It is also impossible to inform even the closest relatives, and even more so the patient’s colleagues, about some mutilating operations being performed on him, especially if we are talking about a woman. Before talking to visitors, you should consult a doctor, and sometimes ask the patient what you can tell them about and what it is better to keep silent about.
You need to be especially careful when giving information over the phone; it is better not to provide any serious, especially sad information at all, but to ask to come to the hospital and talk to the doctor in person. When answering the phone, the nurse should first of all name the department, her position and last name. For example: “The fourth therapeutic department, nurse Petrova.” Answers like “Yes!”, “I’m listening!” etc. speak about the low culture of medical personnel.
Very often, visitors ask permission to help care for seriously ill patients. Even if the doctor allowed relatives to stay in the room for some time, they should not be allowed to perform any care procedures. Relatives should not be allowed to feed seriously ill patients. Practice shows that no amount of care from loved ones can replace the observation and care of qualified medical personnel for a seriously ill patient.
It would seem that words such as “doctor”, “paramedic” or, unfortunately, the forgotten phrase “sister of mercy”, on the one hand, and the concept of “deontology”, on the other, should, if not be synonymous, then be in an inseparable logical communications. It would seem... In reality, everything is not so simple.
In addition to purely medical errors (therapeutic and diagnostic, tactical, etc.), it is customary to note deontological errors. They mean a violation of the rules of relationships between a doctor and a patient, as well as between doctors of the same or related medical institutions (unfortunately, this also happens!), as well as general ethical standards.
The control room is the place where the first meeting, albeit in absentia, between the caller and the ambulance takes place. And how it happens depends on whether the call will be accepted; if it is accepted, what priority will it receive, what psychological situation will the team meet with the patient. After Professor V.M. began studying the work of this ambulance unit. Tavrovsky, it turned out that the main thing a person thinks about when calling an ambulance is that they will not refuse to accept the call. Therefore, to the dispatcher’s question: “What happened?” instead of a specific answer, a lot of unnecessary information was dumped: about past and present merits, about participation in wars, about being attached to some “prestigious” hospital, etc. It is impossible to interrupt this “turbulent flow”, it will be regarded as disrespect to "merits". And although time was wasted, I had to put up with it. Only after this could the dispatcher proceed to “extracting” the necessary information. And in response to the question asked, hear: “What are you interrogating, come quickly, you will see for yourself!” But it is still unknown whether it is necessary to come, especially “as soon as possible”, whether an ambulance is needed. Sometimes the dispatcher would engage in moralizing, which is generally unacceptable: “Where were you before, why are you just calling now?”
Proposing a new system for the control room, V.M. Tavrovsky recommended a completely different dialogue algorithm. The dispatcher must take the initiative “into his own hands,” and this can be done by making it clear to the caller that there are no problems with receiving the call. It is clear that when called to the street or to an apartment, the information about the patient cannot be the same. After the message about accepting the call, a recommendation is given, for example: “Sit (lay down) the patient, give nitroglycerin, if there is no effect, repeat after 3-5 minutes.” Now the waiting time will not be so painful. If the dispatcher is not sure about the need for an ambulance to arrive, he switches the caller to a senior doctor, who not only refuses to allow the team to leave, but gives advice on managing the patient and recommends where to go.
So, if the call was accepted, the team went to the patient. Having arrived at the place, a medical worker should under no circumstances start a conversation with dissatisfaction: why didn’t we meet you, why did you call, we were driving across the whole city, you are not in our area, the 9th floor, and the elevator is not working, etc. All this “verbal garbage” will immediately create a barrier and interfere with the main task: making a correct diagnosis and providing adequate assistance in accordance with it.
Particular attention should be paid to the situation when assistance has to be provided on the street, at an enterprise (workplace), in other similar points (shop, salon) public transport, underground passage) - in a word, wherever a person is, he may need emergency medical care. The best thing that can be advised in this situation is not to pay attention to others and confidently do your job. Do not enter into discussions, do not respond to remarks. This distracts from work, even if the comments seem offensive. Rise above it. It is necessary to bring the patient’s condition to transportable as quickly as possible, take him into the car and leave this place (if we are talking about the street). After this, everyone around you will lose all interest.
Question about hospitalization of a patient from public place The decision is clear - you can’t leave him on the street. But if you don't yet know where you need to be hospitalized, you can drive around the corner, stop, finish the examination if you haven't done it before, and contact the hospitalization office.
For the patient and his relatives, hospitalization is, if not a tragedy, then in any case a disaster, especially if we are talking about a young person who is suspected (or diagnosed) with acute coronary syndrome (ACS). After all, just yesterday the patient led an active lifestyle, but today he is forced to lie down, reducing his activity to a minimum.
You need to understand the patient's condition. No “horror stories” are needed here. The effect from them will be the opposite of what was expected.
Even if the doctor is confident in the diagnosis of ACS and sees that the patient is afraid of this diagnosis, as a death sentence, you can tell him that there is no heart attack yet, there is only a threat of it, and to prevent it from developing, you need to do this and that. After such a conversation, you can hope that the patient will follow your recommendations both on treatment and on the need for transportation on a stretcher. As a rule, the ambulance has its “ work force“Either there is no, or there is not enough of it: the brigade is mostly women. When deciding on hospitalization, the following dialogue often arises:
- Look for men, we have no one to carry!
- We have no one either. You have a driver, we will pay him!
- He can't leave the car!
A verbal duel, as a rule, leads nowhere. Try to start the conversation differently: “The patient needs to be carried on a stretcher, you see, we have only women, maybe you can help us find someone, we don’t know anyone here.”
This is how the conversation should go, or something like this. No categoricalness, no “stubbornness”, friendly, calm tone. Then you can count on success.
It is important to remember that no reason (narrow corridor, steep stairs, etc.) can be an excuse for violating the hospitalization procedure, especially when a stretcher is needed. Understanding this, a competent doctor or paramedic will always find a way out: a chair, a blanket, etc.
Here is another situation: when transporting on a stretcher from some floor, relatives (surroundings) may be confused as to why the patient is carried “feet first”, since he is still alive? In this case, the doctor or any member of the team should calmly, tactfully explain that this is not “feet forward”, but “feet down”. Because if you carry him head first, then he will end up head down on the stairs, which is unsafe for a seriously ill patient. That is why “feet down” and not feet forward.
But now the patient is placed in the car. He may be alone, perhaps with relatives or colleagues. The patient experiences what happened. Agree that any extraneous conversations will rightly be perceived as disrespect for his condition. Of course, no one demands that team members accompany the patient with mournful faces. However, any talk about things that are not related to “this topic” will rightly be interpreted negatively. As a result, the heroic work done on call, at the patient’s bedside, by you and your colleagues can be neutralized. We need to learn to empathize!
A sick person, due to his illness, has an altered psyche; he is exhausted by prolonged pain, perhaps repeated, and even fruitless, visits to medical offices. " Ambulance"is in a special position. Sometimes they call her without receiving a referral to a hospital from “their” local doctor or without waiting for a doctor from the clinic today... You never know what else! Even a conversation with the dispatcher preceding the arrival of the brigade can make a sick person lose his temper. And all the accumulated negative emotions will be thrown out on the one who is available and from whom you can get the most specific and real help.
But then they “attacked” you with a stream of claims to which you had nothing to do. Should you immediately start “defending yourself” when the patient or relatives are still heated? This energy will involuntarily be transferred to you (the mirror effect), you will get involved in a conflict, and it is possible that you will suffer from it. How to be? There is such a technique. Ask the essence of the complaint (knowing full well that it is not addressed to you) to be stated again, explaining that you did not understand something. (Just don’t interrupt the patient, let him speak. The time spent on this will pay off in preventing a conflict, maybe even a complaint, which will then take much more time and not one, but several people to sort out. Don’t forget to reflect this situation in the call card).
You will notice that there will be fewer emotions. As a last resort, you can ask to repeat once again some part of the entire claim. The conversation will be completely calm. You gave the patient the opportunity to “let off steam.” This is just one way to avoid conflict. There is a popular wisdom: “Of two arguing, the one who is smarter is to blame.” And since you naturally consider yourself smarter, try to make sure that the fire does not break out.
Try to ensure that members of your brigade do not take part in this fight. It will be easier for you. Here is the answer to the question: “Is it possible to be offended by a sick person?” Forgive him! He's sick. And leave your ambitions “for later.”
Providing emergency medical care at the prehospital stage involves medical measures not only on site, but also when transporting patients (injured) to the hospital. These features, in contrast to hospital conditions, require additional attention to moral and legal problems. These are the features.
The extreme nature of the situation requires urgent actions, often performed without proper diagnosis (lack of time).
Patients are sometimes in extremely serious, critical condition, requiring immediate resuscitation.
Psychological contact between a medical worker and a patient can be difficult or absent due to the severity of the condition, inadequate consciousness, pain, convulsions, etc. etc.
Providing assistance is often carried out in the presence of relatives, neighbors or simply curious people.
The conditions for providing assistance may be primitive (room, cramped conditions, insufficient lighting, lack of assistants or their absence at all, etc.).
The nature of the pathology can be very diverse (therapy, trauma, gynecology, pediatrics, etc.).
The listed features of work in emergency medicine create special ethical and legal problems, which can be divided into two main groups:
Due to the specific conditions of emergency care, as well as due to insufficient familiarity of medical workers with this problem, the rights of patients are often violated.
Errors in providing emergency assistance can occur mainly due to the extreme nature of the situation, sometimes due to criminal negligence.
Problems in the relationship between a medical professional and a patient can be built along two lines. One of them is ethical-deontological, when we are talking simply about the relationship between two people, which are regulated by moral and ethical frameworks and norms. The second line is legal. This is stated in the concept of informed voluntary consent (IVC). The most common reasons for violation of the rights of patients when providing emergency care: 1) lack of psychological contact with the patient (victim) and 2) extremeness of the situation. Sometimes the first may depend on the second, and more often both factors act simultaneously, which can lead to their mutual reinforcement. Unfortunately, we have to deal with another factor: 3) the medical worker’s ignorance of the patient’s rights.
When one sage was asked from whom he learned good manners, he answered: “From the ill-mannered. I avoided doing what they were doing." And finally, the wonderful thought of the French encyclopedist Denis Diderot: “It is not enough to do good, you must do it beautifully.”
Medicine is one of the most humane areas of human activity. Every health worker knows this. High level of knowledge, skills, abilities, professional excellence and abilities allows health workers to save people from acute diseases, emergencies and injuries.
Issues of ethics and medical deontology occupy a large place in the work of an ambulance paramedic. Knowledge of them is mandatory for every ambulance worker.
Moral responsibility for the patient, the ability to neglect personal interests in the name of his health, concern for the patient, mental pain, self-sacrifice and heroism are the norm of behavior of doctors and paramedics in our country. The peculiarities of medical deontology are that it cannot be learned, although one can know many “wise thoughts” expressed about the duty of a health worker by our predecessors and contemporaries.
You can learn the rules of attitude towards the patient and his relatives. But the most important thing is to understand these rules with your heart and make them your conviction. Modern medical deontology is the doctrine of the duty of a health care worker to the patient. This scientific discipline is a core problem in the education of medical personnel. In the formation of the personality of a qualified health worker, especially an ambulance service specialist, issues of education, professional and political studies, and issues of deontology should occupy one of the main places.
A health worker who correctly, competently, in compliance with all laws of honor, morality and ethics builds his work with colleagues (doctors, nursing and junior medical staff), patients and relatives and complies with all the principles of medical deontology, as a rule, works easily.
The work of an ambulance paramedic takes place in special conditions. First of all, it is necessary to emphasize that this is a heroic specialty, requiring full dedication of spiritual and physical strength, great nervous and emotional stress, since very short periods of time are allotted for recognizing the disease and its treatment. Before highlighting the basic principles of ethics and medical deontology of an ambulance paramedic and their application in everyday practice, it is necessary to characterize the features of the work and the specifics of his work.
"The work of an ambulance paramedic"
V.R. Prokofiev
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Essay
On the topic: “Speech skills in the work of a medical worker”
Plan
1. Communication and its importance in therapeutic activities
2. Features of relationships in therapeutic activities
3. Types of communication
4. Tactics of the medical worker
5. Personality characteristics of a medical worker
6. Paramedic and patient, principles of communication with the patient
7. The role of the paramedic in communication with the patient
List of used literature
I. Communication and its knowledgerelevance in medical activities
Communication -a multifaceted process of developing contacts between people.
Communication plays an important role in people’s lives and activities. Without communication, it is impossible, for example, to develop culture, art, or living standards, because Only through communication is the accumulated experience of past generations transferred to new generations. A pressing issue today is communication between health care workers and patients. Many of us have been to a hospital, clinic, or some other medical facility where each of us interacted with a doctor or nurse. But has anyone ever thought how much this communication influences us, or rather the course of our disease, and how a health care worker can improve our condition? Of course, we can say that everything depends on the medications that the doctor prescribes and the nurse gives us, and the medical procedures are also prescribed by the doctor, but this is not all that is necessary for a complete recovery. The most important thing is the right attitude, which depends on the mental and emotional state of the patient. The patient's condition is greatly influenced by the attitude of the health worker towards him. And if the patient is satisfied, for example, with a conversation with a doctor who listened to him carefully, in a calm atmosphere and gave him appropriate advice, then this is the first step towards recovery. Further in my essay I will try to reveal in more detail the psychology of communication between a medical worker and a patient.
2. Features of relationshipsin medical activities
The psychological characteristics of the patient in the conditions of therapeutic relationships and interaction come into contact with the psychological characteristics of the medical worker. In addition, the persons involved in contact with the patient may be a doctor, psychologist, nurse, or social worker.
In medical activities, a special connection is formed, a special relationship between medical workers and patients, this is the relationship between a doctor and a patient, a nurse and a patient. According to I. Hardy, a “doctor, nurse, patient” connection is formed. Everyday therapeutic activities are connected in many nuances with psychological and emotional factors.
The relationship between doctor and patient is the basis of any therapeutic activity. (I. Hardy).
The purpose of contacts between a medical professional and a patient is medical care provided by one of the participants in communication in relation to the other. Such relationships are conditioned to a certain extent by the conditions in which the therapeutic activity is carried out. Based on the main goal of therapeutic interaction, it can be assumed that the importance of contacts in the health worker-patient interaction system is ambiguous. However, it should not be understood that there is an interest in such interaction only on the part of the patient. A health worker, in theory, is no less interested in helping the patient, because this activity is his profession. The health worker has his own motives and interests to interact with the patient, which allowed him to choose the medical profession.
In order for the process of relationship between a patient and a medical professional to be effective, it is necessary to study the psychological aspects of such interaction. Medical psychology is interested in the motives and values of the doctor, his idea of the ideal patient, as well as certain expectations of the patient himself from the process of diagnosis, treatment, prevention and rehabilitation, and the behavior of a paramedic or nurse.
We can talk about the importance for effective and conflict-free interaction between the patient and health workers of such a concept as communicative competence, i.e. ability to install and maintain necessary contacts with other people. This process involves achieving mutual understanding between communication partners, a better understanding of the situation and the subject of communication. It should be noted that communicative competence is a professionally significant characteristic of a doctor and nurse. However, despite the fact that in a clinical setting the patient is forced to seek help from a doctor, communicative competence is also important for the patient himself.
With good contact with the doctor, the patient recovers more quickly, and the treatment used has a better effect, with far fewer side effects and complications.
One of the foundations of medical practice is the ability of a health worker to understand a sick person.
In the process of treatment, an important role is played by the ability to listen to the patient, which seems necessary for the formation of contact between him and the health worker. The ability to listen to a sick person not only helps to identify and diagnose the disease to which he may be susceptible, but the process of listening itself has a beneficial effect on the psychological contact between the paramedic and the patient.
It is important to note that it is necessary to take into account the characteristics (professionalism) of the disease when contacting the patient. These are, for example, patients with diseases of the cardiovascular system, gastrointestinal tract, respiratory organs, kidneys, etc. And often their painful conditions require long-term treatment, which also affects the relationship between the health worker and the patient. Long-term separation from family and familiar professional activity, as well as anxiety about their health, cause a complex of various psychogenic reactions in patients.
But not only these factors affect the psychological atmosphere and condition of the patient. As a result, psychogeny may complicate the course of the underlying somatic disease, which, in turn, worsens the mental state of patients. And, in addition, in therapeutic departments for examination and treatment there are patients with complaints about the activity of internal organs, often without even suspecting that these somatic disorders psychogenic in nature.
In the internal medicine clinic, specialists deal with somatogenic and psychogenic disorders. In both cases, patients express big number various complaints and are very wary of their condition.
Somatogenically caused mental disorders more often occur in anxious and suspicious patients with hypochondriacal fixation on their condition. In their complaints, in addition to those caused by the underlying disease, there are many neurosis-like ones. For example, complaints of weakness, lethargy, fatigue, headache, disturbance of sleep patterns, fear for one’s condition, excessive sweating, palpitations, etc. There are even various affective disorders in the form of periodically occurring anxiety and melancholy of varying degrees of severity. Such disorders are often observed in patients with hypertension, coronary heart disease, and in persons suffering from gastric and duodenal ulcers. And neurosis-like symptoms can often mask the clinical picture of the underlying disease. As a result of this phenomenon, sick people turn to specialists in various fields.
In everyday life, we often hear about “good” or “correct” treatment of a patient. And in contrast to this, unfortunately, we hear about “soulless”, “bad” or “cold attitude towards sick people”. It is important to note that various kinds of complaints and ethical problems that arise indicate a lack of necessary psychological knowledge, as well as the practice of appropriate communication with patients on the part of health workers. Differences in the views of the health worker and the patient. communication paramedic patient treatment
Differences in the perspectives of the health care worker and the patient may be due to their social roles, as well as other factors.
For example, a paramedic is inclined to look, first of all, for objective signs of a disease. He tries to limit the history to further determine the prerequisites for further somatic examination, etc. And for the patient, the center of attention and interests is always his subjective, personal experience of the disease. In this regard, the merchant must consider these subjective sensations as real factors. He should even try to feel or grasp the patient’s experiences, understand and evaluate them, find the causes of anxieties and worries, support their positive aspects, and also use them to more effectively assist the patient in his examination and treatment.
The differences in all the views and points of view of the paramedic (nurse) and the patient are quite natural and predetermined, in this situation, by their different social roles. However, The paramedic (nurse) needs to ensure that these differences do not develop into deeper contradictions. Since these contradictions can jeopardize the relationship between the medical staff and the patient, and thereby complicate the provision of care to the patient, complicating the treatment process.
To overcome differences in views, the health care worker must not only listen with great attention to the patient, but also try to understand him as best as possible. What happens in the soul and thoughts of a sick person? The paramedic must respond to the patient's story with all his knowledge, reason, and the fullness of his personality. The health worker's reaction should resonate with what is heard.
3. Types in generalnia
Highlight the following types communication (Samygin. S.I):
1. "Contact of masks"- This is formal communication. There is no desire to understand and take into account the personality characteristics of the interlocutor. Using familiar masks (politeness, courtesy, modesty, compassion, etc.). A set of facial expressions, gestures, standard phrases that allow you to hide true emotions and attitude towards your interlocutor.
Within the framework of diagnostic and therapeutic interaction, it manifests itself in cases of low interestparamedicor the patient in the results of the interaction. This can happen, for example, during a mandatory preventive examination, in which the patient feels not independent, andparamedic-not havingnecessary data to conduct an objective and comprehensive examination and make an informed conclusion.
2. Primitive communication. They evaluate the other person as a necessary or interfering object; if necessary, they actively come into contact; if it interferes, they push away.
This type of communication can occur within manipulative communicationparamedicand the patient in cases where the purpose of contactingparamedicy becomes the receipt of any dividends. For example, sick leave, certificate, formal expert opinion etc. On the other hand, the formation of a primitive type of communication can occur at willparamedica - in cases where the patient turns out to be a person on whom well-being may dependparamedicA. For example, a manager. In such cases, interest in the contact participant disappears immediately after obtaining the desired result.
3. Formal role communication. Both the content and means of communication are regulated, and instead of knowing the personality of the interlocutor, they make do with knowledge of his social role.
A similar choice of type of communication from the outsideparamedicor may be due to professional overload. For example, the district police officerparamedicat the reception.
4. Business conversation. Communication that takes into account the personality, character, age, and mood of the interlocutor while focusing on the interests of the matter, and not on possible personal differences.
When communicatingparamedicand with the patient this type of interaction becomes unequal.Paramedicconsiders the patient’s problems from the perspective of his own knowledge, and he is inclined to make directive decisions without coordination with the other participant in the communication and the interested party.
Diagnostic and therapeutic interaction does not imply such contact, at least, due to its professional orientation, it does not involve the confession of a health worker.
6. Manipulative communication. Just like primitive communication, it is aimed at extracting benefits from the interlocutor using special techniques. Many people may be familiar with the manipulative technique, more often called “hypochondrization of the patient.”
Its essence is to present a conclusionparamedicabout the patient’s health status in line with a clear exaggeration of the severity of the detected disorders. The purpose of such manipulation may be:
- decrease in the patient's expectations for the success of treatment due to the health worker avoiding responsibility in the event of an unexpected deterioration in the patient's health
- demonstration of the need for additional and more qualified influences on the part of the health worker in order to receive remuneration.
Communication between a health care worker and a patient can, in principle, be called forced communication. One way or another, the main motive for meetings and conversations between a sick person and a health worker is the appearance of health problems in one of the participants in such interaction. On the part of the paramedic and nurse, there is a compulsion to choose the subject of communication, which is determined by his profession, his social role. And if a patient’s visit to a doctor is, as a rule, due to the search for medical help, then the doctor’s interest in the patient is explained by considerations of his professional activity.
The interaction between patient and paramedic is not something set in stone forever. Under the influence of various circumstances, they can change, they can be influenced by a more attentive attitude towards the patient, deeper attention to his problems. At the same time, the very good relationship between the health worker and the patient contributes to greater effectiveness of treatment. And vice versa - positive treatment results improve the interaction between the patient and the healthcare worker.
Currently, many experts believe that it is necessary to gradually remove concepts such as “sick” from the process of communication and vocabulary, replacing them with the concept “patient”, due to the fact that the very concept of “sick” carries a certain psychological load. And it is unacceptable to use appeals to sick people like: “How are you, patient?”, and it is necessary to try everywhere to replace this kind of appeal to the patient with addresses by name, patronymic, especially since the name itself for a person, its pronunciation, is psychologically comfortable.
4. Tactics of the medical worker
Communication with the patient is the most important element of the treatment process.
The art of taking anamnesis is not an easy art. In the language of psychologists, this is a controlled conversation designed to collect anamnestic data, and the conversation should be controlled unnoticed. The patient with whom the conversation is being conducted should not feel this. In the process of collecting an anamnesis, he should have the impression of a relaxed conversation. At the same time, the paramedic needs to assess the seriousness of the complaints, the manner of their presentation, separate the main from the secondary, make sure of the reliability of the testimony without offending the patient with mistrust, help to remember without indoctrination. All this requires a lot tact , especially when it comes to clarifying the state of mind, mental trauma, which plays a large role in the development of the disease.
When questioning a patient, one must always take into account his cultural level, degree of intellectual development, profession and other circumstances. Empty, nothing should be avoided meaningful words, indulgence in the unreasonable whims and demands of some patients. In other words, it is impossible to offer a standard form of conversation between a health worker and a patient. This requires ingenuity and creativity.
Particular attention should be paid to elderly patients and children. The attitude of a paramedic or nurse towards a child, a mature patient and an old man, even with the same illness, should be completely indifferent, which is due to the age characteristics of these patients.
5. Peculiaritiesidentity of the medical worker
It should be noted that a prerequisite for the emergence of positive psychological relationships and trust between health workers and patients is the qualifications, experience and skill of the paramedic and nurse. At the same time, the result of expanding and deepening information in modern medicine is the increased importance of specialization, as well as the creation of various branches of medicine aimed at certain groups of diseases depending on the location, etiology and methods of treatment. It can be noted that specialization carries with it a certain danger of the paramedic’s narrowed view of the patient.
Medical psychology itself can help align these negative sides specialization thanks to a synthetic understanding of the patient’s personality and his body. And qualification is only a tool, the greater or lesser effect of its use depends on other aspects of the paramedic’s personality. We can note Gladky’s definition of the patient’s trust in the paramedic:
"Trust inparamedicy is positive dynamic relation patient toparamedicy, expressing the conditioned expectation from previous experience thatparamedichas the ability, means and desire to help the patient in the best possible way.”
To demonstrate trust in a health care worker, the first impression a patient has when meeting him is important. At the same time, what is important for a person is the actual facial expressions of the medical worker, his gestures, tone of voice, facial expressions arising from the previous situation and not intended for the patient, the use of slang speech patterns, as well as his appearance. For example, if a sick person sees a paramedic who is unkempt and sleepy, he may lose faith in him, often believing that a person who is unable to take care of himself cannot take care of others. Various deviations in behavior and appearance Patients tend to forgive only those health workers whom they already know and trust.
A health worker gains the trust of patients if he, as a person, is harmonious, calm and confident, but not arrogant. Mainly in cases where his behavior is persistent and decisive, accompanied by human participation and delicacy. It should be noted that when making a serious decision, the paramedic must imagine the results of such a decision, its consequences for the health and life of the patient, and increase his sense of responsibility.
Special requirements for a health worker are the need to be patient and self-controlled. He should always provide for various possibilities for the development of the disease and not consider it ingratitude, reluctance to be treated, or even personal insult on the part of the patient if the patient’s condition does not improve. There are situations when it is appropriate to show a sense of humor, however, without a hint of ridicule, irony or cynicism. The principle of “laughing with the sick, but never at the sick” is known to many. However, some patients cannot tolerate humor even with good intentions and understand it as disrespect and humiliation of their dignity.
There are facts where people with unbalanced, insecure and absent-minded manners gradually harmonized their behavior towards others. This was achieved both through one’s own efforts and with the help of other people. However, this requires certain psychological efforts, work on oneself, a certain critical attitude towards oneself, which for a health worker is and should be taken for granted.
Let us note that a health worker is a young specialist, about whom patients know that he has less life experience and less qualifications, and is at a disadvantage when seeking the trust of patients and is at a disadvantage compared to his senior colleagues with work experience. But young specialist It can help to realize that this deficiency is transitory, which can be compensated for by conscientiousness, professional growth and experience.
It should be noted that the personal shortcomings of a health worker may lead the patient to believe that a paramedic or nurse with such qualities will not be conscientious and reliable in the performance of their immediate official duties.
In general, the balanced personality of a health worker is for the patient a complex of harmonious external stimuli, the influence of which takes part in the process of his treatment, recovery and rehabilitation. A health worker can educate and shape his personality, including by directly observing the reaction to his behavior. Let's say, based on conversation, assessment of the patient's facial expressions and gestures. Also indirectly, when he learns about his view of his behavior from his colleagues. And he himself can help his colleagues direct them towards more effective psychological interaction with patients.
6. Paramedicand the patient, principles of communication with the patient
The position and role of the paramedic is acquiring in our time higher value. The patient seeks understanding and support from him. The work of a paramedic involves not only a lot of physical activity, but also a lot of emotional stress. The latter occurs when communicating with patients who are characterized by increased irritability, painful demands, touchiness, etc. It is very important to establish contact with the patient. The paramedic is constantly among the patients, so his clear actions and professional performance, his friendly, warm attitude towards the patient have a psychotherapeutic effect on him. The paramedic must be able to show understanding of the patient's difficulties and problems, but should not strive to solve these problems.
In contact between the paramedic and the patient great importance has the identity of a paramedic. He may love his profession, have excellent technical data and skills, however, if, due to his personal characteristics, he often conflicts with patients, he professional quality do not give the desired effect. The path to true mastery is always long and difficult. Therefore, it is necessary to develop the desired style of work and master the art of having a beneficial effect on patients.
7. Roleparamedic in communication with the patient
The topic I covered in this essay is of great importance for health workers, especially for me, a future paramedic. Therefore, this topic is interesting to me, and when writing the essay, I made certain conclusions for myself that will help me in my future professional activities.
As in everyday life, so in healing activities, there is communication. In both cases it has a certain meaning and psychological characteristics. In medical activities, there are several types of communication between a health worker and a patient. And it depends only on the health worker what type of communication he will have with the patient. But in any case, the paramedic or nurse must follow certain tactics in relation to the patient and, most importantly, the health worker, as a person, must have certain characteristics in all respects in order to earn the patient’s trust in himself. After all, without trust, normal relationships between a health worker and a patient are impossible. Consequently, the personality of the paramedic, the style and methods of his work, the ability to influence and treat patients important element not only the treatment process, but also the psychological communication between the medical worker and the patient.
Bibliography
1. Grando. A.A. Medical ethics and medical deontology. Kyiv, Head Publishing House “Vishcha School”, 1982, 168 pp.
2. Matveev. V.F. Fundamentals of medical psychology, ethics and deontology. Moscow, “Medicine”, 1989, 178 pp.
3. Shkurenko. YES. General and medical psychology. Rostov-on-Don, “Phoenix”, 2002, 352 pp.
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