Qualified Nursing On Treating Incurable Patients Essay


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Meanwhile, modern medicine too often behaves as if caring for such
human needs is beyond its purpose. Medical education stresses pathophysiologic process to the exclusion of the social, personal, and even
functional dimensions of health and illness. Residency training teaches
diagnosis by biotechnological methods, rendering interpersonal skills and
human performance measures anachronistic. Medical financing has followed suit: it so favors the biotechnological aspects of care that its implicit
message to professionals is, “Deal with your patients’ concerns on your
own time.”
This disjuncture between the patient’s realities and the pursuits of
modern medicine is moving toward a new alignment. This essay examines
forces for change that are recognizable, formidable, and hard at work.
Change will come because millions more aging American families will
experience serious illness and insist on it, because researchers are facilitating it, and because medical practitioners and organization leaders are
beginning to see the rewards of providing it. But the driving force for
change is competition in medical care delivery.
Competition is leading to a redefinition of business purpose and quality
Thomas W. Moloney is senior vice-president and Barbara Paul is associate director for research at
The Commonwealth Fund in New York City. This essay stems from a report to the foundation’s
board of trustees.
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in industries from automobiles to banking to airlines. Businesses that are
winning the loyalty of customers these days define quality as meeting the
needs of the customer, a concern that includes but is well beyond
manufacturing a reliable product. Companies losing customers are those
driven by the traditional producer’s preoccupation with product improvement while ignoring service enhancement. Back in favor is Peter
Drucker’s thirty-year-old conclusion that the only valid business purpose
is to create satisfied customers. The buyer’s pursuit of better services has
been so influential that Business Week has labeled the 1990s the “Decade
of the Customer.”2
Changes in customers’ expectations are moving into medical care
services, as patients begin to take matters more into their own hands.
Patients may well mobilize an expanded definition of quality in medical
care, one calling on practitioners to attend to the full range of problems
that patients present.
Why Change Is Inevitable
Substantial change will take place in consumers’ expectations and
interactions with the medical community for the following reasons.
With the growing burden of chronic care in an aging society, families
are increasingly seeking practitioners skilled in addressing functional loss,
pain, and anxiety.Qualified Nursing On Treating Incurable Patients Essay
“Baby Boomers” want far more information, involvement, control, and
choice regarding the services they buy, including medical care, than do
previous generations. The first real changes in hospital care have come
in the services they have used first: far greater family accessibility and
participation in birthing and pediatric units. The pressures of this most
educated, consumer-oriented generation will soon be felt in internal
medicine and geriatrics as they age and also begin to manage care on
behalf of their parents.
Vast improvements in information-processing technology are making
it feasible to publish patients’ ratings of competing health care providers.
J.D. Power changed the nature of the automobile marketplace by making
consumer ratings of new cars widely available to the public. New surveys
show that patients look forward to using their neighbors’ ratings in
deciding where to seek care in the future.3
Can the day be far ahead when
employers, insurers, or consumer groups publish surveys of patients’
experiences with competing medical plans, hospitals, or group practices?
A beginning effort in Pennsylvania was reported in The Wall Street
Journal: “[F]or the first time, consumers… can compare hospitals on price
and performance, much as people compare mileage ratings, service recDownloaded from HealthAffairs.org on March 26, 2020.
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270 HEALTH AFFAIRS | Winter 1991
ords, and sticker prices when they shop for cars. The implications for the
nation’s medical care system are huge.”4
Many patients are now actively involved in choosing their own medical
services, often selecting a health plan or hospital first, then choosing a
doctor from among those affiliated. Loyalty to a single provider is not
common; many patients report they have switched hospitals or doctors Qualified Nursing On Treating Incurable Patients Essay
recently or are considering doing so.5
Finally, patients are choosing providers on factors other than technical
expertise, given the high quality level of equipment and personnel now
readily available throughout the country and the difficulty in distinguishing among practitioners’ ability to provide complex technical care.6
Patients are far more likely to focus on differences in providers’ willingness
to address the range of problems that accompany serious illness than on
differences in technical skills.
The Potential
The groundwork for a major evolution in American medical care is
being laid as researchers and practitioners respond to patients’ mounting
insistence on a more responsive system. A new era of consumerism on
the part of patients could bring profound benefits over time.
Patient-centered care could put the medical care system more squarely
in the business of serving the needs of patients with chronic and serious
illness. This could change the nature of medical inquiry, leading to vast
improvements in patient functioning, the reduction of pain, and the relief
of anxieties that accompany illness.
It could expand the business of medical care and the pursuits of its
practitioners. It could lead to a discemibly different role for the generalist
practitioner, one in which the patient’s reports are crucial diagnostic
information and the physician’s counsel is a crucial therapeutic tool. An
expanded concept of the purpose and value of the practitioner/patient
interaction could in turn force the medical payment system to revalue
the time practitioners spend with patients.
It could spawn a generation of patient-interactive technologies, including educational material on treatment options and on self-management
of chronic disease, as well as survey information on patients’ assessments
of competing medical groups, hospitals, and medical care plans. Patientadministered and -monitored treatments should also become commonplace: self-administered pain medication in hospitals is only the start.
It could change how medical care is valued by ushering in a system in
which patients’ values regarding risks and rewards are central to determining the appropriate course of treatment. This would lead to a vast
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change in the type of information collected and analyzed to assess value.
It could limit the use of protocols as standards of appropriate treatment.
It could even alter the scope of medical education and the mix of
applicants. Medical education for general practitioners of tomorrow may
entail far more integration of knowledge from disciplines such as physical
therapy, psychology, and sociology.Qualified Nursing On Treating Incurable Patients Essay
Finally, the sum of these changes could increase public esteem for the
medical care system. The root of today’s discontent with the medical
system is more than financial. It is also deeply personal. Witness the
frustration of a patient writing in a recent “My Turn” column of
Newsweek: “I wanted to be treated as a human being, not just the owner
of a defective breast.”7
Public esteem for any industry is the best predictor
of the level of public investment in it and freedom from regulation over
it. Thus, the nation’s future investment in the medical care system may
depend more on public confidence and trust, built through a better
response to the needs of its patients, than on any other factor.
The Breakthroughs
An enduring principle of biomedical science is that the only relevant
phenomena are those that can be observed, described, and measured in
an objective manner. Phenomena have to be describable with quantifiable precision by independent observers at different times (otherwise,
how can scientists be sure they’re talking about the same thing?).8
the problems that most concern patients often lack such precision. For
instance, how does a scientific practitioner respond to the “severity” of a
patient’s pain, the “extent” of social functioning, or the “degree” of
anxiety? So despite growing pressure from patients, physicians have held
to their narrow ground in the name of science-based medical practice,
even when it puts them in quite vulnerable territory. Witness the
hesitancy expressed about the quantification of kindness in this recent
article: “Any new chemotherapeutic drug that tripled the survival of
patients with incurable cancer would cause great excitement, but we do
not know quite how to handle the fact that kindness, emotional support,
and optimism have quantitative therapeutic activity.”9
Expanding the scope of medical science requires breakthroughs in the
measurement of these “soft” phenomena. Recent research efforts can
claim breakthroughs in a number of areas, including patients’ perceptions
of their own well-being, the effects of patient control over treatment
choices, the role of physician encouragement in the healing process, and
the aspects of hospitalization that help and hinder recovery. We outline
next some of the major research breakthroughs and discuss the potential
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272 HEALTH AFFAIRS | Winter 1991
for greater involvement by foundations in supporting such efforts.
Medical outcomes. The first major breakthrough came recently, the
result of years of tenacious efforts by a team headed by John Ware, of New
England Medical Center, under a project titled the Medical Outcomes
Ware’s team has developed methods for classifying patients’
statements about how well they function and how well they feel, and for
translating those classifications into objective measurements. The study
group developed the first assessment tools to provide valid, reliable
measures of a range of the problems patients care most about, including
their functional status, degree of disability, cognitive functioning, emotional health, and social interaction. For the first time, the patient
becomes both the recorder and the reporter of information that now is
crucial to the diagnosis and treatment processes.
Ware’s innovations could ultimately transform the ways in which
chronic and fatal illnesses are managed. They should expand the boundaries of the scientific approach to the management of chronic and fatal
illnesses, to include how well patients function and how well they feel.
Once Ware’s measures are widely available, remaining a “scientific”
practitioner will entail addressing these broader aspects of the patient’s
experience of illness. Ware’s approach also could change the way in which
medical care is valued. Measuring “quality” will no longer rest exclusively
on traditional physiological and clinical indexes of how various body
organs respond to treatment but will entail determining the effects of
various treatments on the quality of patients’ lives.
Foundation support could help put these powerful new outcome measures to work in a variety of actual settings. For example, such assistance
would help Ware’s team examine variations in the quality of care among
different health plans in a medical market area and determine how
employers and employees could use this information to help choose
among competing plans.
Patient education. John Wennberg of Dartmouth Medical School and
Albert Mulley of Massachusetts General Hospital have moved the valuation of “quality” even more toward the concerns of the individual
patient. They find that for a number of medical conditions, no amount
of objective clinical or physiologic data is adequate to make an appropriate clinical choice among competing therapies. For conditions such as an
enlarged prostate or breast cancer, the decision can be made only by
careful reference to a particular patient’s unique perceptions and valuations of the likely risks and benefits of alternative therapies,11
The implications of Mulley and Wennberg’s observation are immense.Qualified Nursing On Treating Incurable Patients Essay
It suggests a need to better inform patients about their illness and the
benefits and risks of alternative therapies and a need to develop better
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methods of such patient education. Office-based physicians cannot provide such detailed information regarding alternative treatments. The
harried physician, rotating a closed fist to illustrate the location of heart
ventricles and valves—just before introducing the choice between angioplasty or bypass surgery—should soon be an anachronism.
Mulley and Wennberg’s team is developing interactive video disks as
the patient education technology of the future.12
The disks use scripts and
graphics to convey the nature of an illness and the effects of alternative
treatments. They are based on the best clinical research and tested for
patient understanding. If the method proves successful, video stores
throughout the country may one day stock illness-specific educational
films, dramatically changing patients’ literacy about their conditions and
the caliber and frequency of participation by patients in their treatment.13
Foundation support would help these researchers broaden their work
to include additional clinical conditions. Such assistance could help
establish the probabilities that alternative treatments provide the outcomes that matter to patients; help this promising work address various
issues of patient comprehension; and devise new communications methods, such as the interactive video films, to help patients become fully
informed about the potential benefits and risks of various treatments.14
Physicians’ coaching skills. The practitioner’s skills as coach will take
on greater importance as care for chronic illness renders the patient’s
behavior itself—diet, exercise, lifestyle, medications—a more crucial part
of treatment. Sherrie Kaplan and Sheldon Greenfield of New England
Medical Center have demonstrated that coaching patients with chronic
illness to become more involved in their care can result in better physical
functioning, speedier recovery from illness, and greater ability to tolerate
pain and handle stress.15
They urge the medical system to teach and
reward practitioners who coach patients to think positively, teach selfhelp skills to aid recovery and coping techniques for pain and disability,
and give patients a greater sense of control over their functioning.
This approach is the least well funded type of outcomes research, so
evidence of its potential benefits remains thin. Foundation support would
enable researchers to address several limitations of existing studies.16
Foundation support could also illuminate how well various practitioners’
coaching styles work. The first major opportunity to examine the relationship between physicians’ coaching styles and improved patient functioning and well-being is now available through the Ware team’s work.
Their research should give important clues about which physician styles
lead to improved functioning and well-being in various types of patients.
It could open a “scientific” era of research and education on how to
improve physician coaching and patient motivation and compliance.

Patients’ Dignity and the Effects of Nursing Care
Modern healthcare is moving toward a patient-centered care, emphasizing patients’ autonomy, and participation in decision making about treatment. Despite these expectations, patients feel vulnerable not only due to disease process, but also due to the power exerted by the hospital system. Critical care settings often consider patient’s physical needs as the only aspect requiring care. The fast-paced focus and limited time in emergency department make it difficult to attend to the holistic needs of the patient. Qualified Nursing On Treating Incurable Patients Essay
Further, it is noted that a person’s dignity is a reflection of personal choices, values, ideals, conduct, and lifestyle (Haddock, 1996). Similarly, Mairis (1994) suggested that dignity relates to one’s cognitive skills, feeling comfortable with one-self, and having control over one’s surroundings, behavior, and treatment by others. On the other hand, not all patients are capable of autonomous thinking and choice. Gallagher (2004) argued that those incompetent of making any decisions deserve to be treated with the same respect and dignity as every one else. People have dignity regardless of their level of competence, consciousness, autonomy, or capability of communicating. The author informed that dignity is equal for all, as it is a basic moral right that all people are worthy of from the moment of birth. Moreover, dignity is concerned with the acknowledgement of humanity in people, alive or dead. Gallagher (2004) stated that dignity can apply to a range of situations from patient’s autonomy and treatment choice, through older confused, incapable of decision making patients, to people who are dying, and the dignity of the bodies of those who died. Walsh (2002) also acknowledged that there is dignity in death, and dead people have to be treated with dignity. Qualified Nursing On Treating Incurable Patients Essay

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