Delivery Exam 2

PP PT 1

-10% of nation workforce in health sectors -half the occupations are 70% female -2.9 million RN(largest occupation) -1.1 million physicians -OT is the largest smallest occupation

Guidelines?

-18 or older -Diagnosed w terminal illness and die within 6 mo -Have cognitive/mental ability to make decision -Resident in state w bill passed -Oral and Written request signed by 2 witnesses w one not being a family member that gain anything from death and separated requests by 2 weeks -Diagnosis confirmed by two different physicians -Be cleared by mental health practitioner to verify your cognitively able to make this decision -Be able to swallow and take medication on own -Physician has to notify pt of other options -Provider and pharmacist participation is voluntary bc not all prescribe this medication -Pt can rescind at any time and j bc you have it doesnt mean you have to take it -Only thing against the law is you can't take it in public or cross state lines and take it in another state and take it and death is ruled suicide(family cant get life insurance) -If choosing not to take medicine, the nurse assigned to case has very specific way of getting rid of medication

PP PT 2

-4 med schools in 1800 -med school recquires BS and lasts 4 years then hospital expirience -Male domination= surgery/pain based -Female domination= PCP or specialty based, peds/hospice/dermatology -physicians are granted licensure thru the states, 25% recieve training outside of us

STAT Article Notes:

-A lot more white people have comfort in pushing for self advocacy -Mass general is a hospital trying to largely combat this systemic racism on a large scale -Although there is a lot more change to come, it is very easy to ensue and solve the existing problems that they have already solved -Elite hospitals have a lower population of POCs that receive treatment at these hospitals -Covid made the journey to equity a lot more recognized -A lot of people have a hard time accepting the prominence of healthcare disparity based on racism -Debriefs on care based on race is uncomfortable but is a great place to call out biases -Racial gap in the patients that get restraINED -No show patients are usually minority groups as they do not trust the care they are receiving -Data is key

Oppositions?

-AMA= against euthanasia but physcians should respect pt decisions but assisted suicide is against the AMAs wishes -77% of AMA individually said that their opposition was outdated and instead a now neutral stance -ANA= should not participate be it goes against the morales of this do not reflect, should not administer but help pt be as comfortable as possible and listen to what the pt want

Who is allowed to use death w dignity and who is not?

-Adult who deemed terminally ill w 6 mo left to live; must be able to swallow themselves and competent and leave out ppl with MS, alzeihmers, dementia, have to have residency in a state

AD and living wills?

-Advanced directive= legal document that outlines/explains what your medical choices to be when you can speak for yourself and wasn't enacted until you're not competent and varies by state -Importance of talking to pt bc if they're moving AD may not always transfer in another state -Nurses are good to initiate those conversations with pt -A certain person is selected to make those decisions -Don't need to be old or sick to make an AD -Not set and stone, can make as many changes as many times you want -Usually have these happen during hospice

Difference between aided dying, physician assisted suicide, and euthanasia and pros ad cons?

-Aided dying and physician assisted suicide= hand in hand and perscribed dose that the patient themselves is ending their lives with this doseage, suicide has a negative connotation so we steer clear -euthanasia= someone else is killing pt, Kavorkian helped people who were actively very ill and would inject with lethal dose -pros= ends suffering before it gets worse, get to say goodbyes -cons= get to say goodbyes, unnatural, certain religions may not support it, more vulnerable groups taking advantage of this to end suffering bc they cant afford to continue to used

What kind of conversations need to happen aBOUT death and when?

-Ask pt what they want -Weigh out pros and cons -Talk to doctor in great depth but dont have doctor with bias to live -Need pt to stll be cohort and not earlier than later -Shouldnt wait until pt is sick to have these conversations -Preventative and proactive conversation -Family members included -Death conversations were taken out of affordable care act

The Dangerous Rise of the IUD as Poverty Cure

-BC is a god tool to combat poverty -Between 1909 and 1979, about 20,000 people were involuntarily sterilized in California — one of 33 states where compulsory sterilization in the name of eugenics and social well-being was legal in the 20th century. -resisting requests to take out BC

Dying while black: Perpetual gaps exist in health care for African-Americans

-Black patients recieve the worst pain management in PCP and ER -Black people expierience less pain treatment even in peds and in death -Black people expirience ignored symptoms that cause death in addition to less interactionDying while black: Perpetual gaps exist in health care for African-Americans

What are our current state policies regarding an individual's right to die and what states passed death w dignity laws and years?

-CA(2016), ME(2019), VT(2013), CO(2016), NJ (2019), WA(2009), DOC(2017), NM (2021), HI(2018), OR(1997) *DC IS INCLUDED AS PLACE* -Currently in the process of making it legal to die in CT, about -10 times has this law come up but bill is not moving forward -OR was first state to pass this law] -Newest state was NM -3 considering, MT, NY, PA -10 official passed bill

Medical school applications surge as COVID-19 inspires Black and Latino students to become doctors:

-Going to the doctor isn't the first choice for most minorities -The disproportionate amount of death from covid of minority groups than white people -Lack of role models and less easy to get scholarships as a POC -There's more recognition for the importance of POC doctors -Increased diversity → increased education → increased better healthcare for POIC -COVID proved the badness of the racism in healthcare

How to Die in Oregon Film

-He drank the drink and created him to be in a coma which he then dies -They are the ones in charge, she makes sure they know what they're doing and why their doing it is a terminal illnessHow to Die in Oregon Film

Diversity in Healthcare and the Importance of Representation

-Lack of diversity in today's healthcare -Minority groups face a lot of obstacles as both the patient and the provider -POC have greater incidence and severe cases of diseases -Unfavorable things to POC like access to education, house, food, etc. -With increased healthcare diversity there's more PT UNDERSTANDING, RETENTION, engagement, communication, trust, and reduced disparities -We can increase this trust and engagement by offering help beyond the 9-5 as a lot of ppl of lower socioeconomic status work in blue collar jobs with more hours during this time -Simple things like hanging diverse people in -Representation is a big one bc it has a positive impact on both the organization and the patient -white males are the most predominant in the medical field (theres clear discrimination if you are not a part of this group)

Despite Sweeping Aid-In-Dying Law, Few Will Have That Option

-Less specificity, more compassion -Less than 6 months of living is big news thats hard to take regularly -Euthanasia means that a medical professional have to administer the medication -More often than not the people that do obtain these drugs opt not to take them -The laws on the right to die are extremely subjective depending on the state or country that theyre made -Trying to find ways to make going from alzeihmers or dementia a lot easier and less painstaking

Statistics?

-Mostly men but not that much of a difference between men and women -Mostly 65-74 yr olds -Predominately white citizens and only 1 AA has used the act -Most are married or widowed -Most are educated(HS to college education) -Most diagnosis is cancer (61%) -90% of people that use ar on hospice at time of death -OR is top state in end of life care -1 in 3 ppl who obtain medicine chose not to use it

PP PT 3

-Nursing is largest and most popular profession -RN are highest paying endless opportunity job bc could go anywhere and do anything -LPN, RN w associates, RN w bachelors -LPN= under Rn, technical skills -RN w associate= less leadership than RN -Can get masters or doctorate -1861 was first nursing school founded -1978=NCLEX started

Nurse Practitioner Practice Authority: A State-by-State Guide

-Scope of practice: professional names of care that varies by state authorizing what an NP can do -NP can practice independently or under a physician -Full practice: full scope of practice without another physician, can have own practice but may need additional training -Reduced practice: some scope of practice wo supervision, no ordering of tests n stuff, not owning their own practice but within a physician practice and can fly solo -Restricted practice: scope under physician, not independent, experience gained=less restrictions -varies by state

Overkill

-There's a lot of unnecessary care occurring -We do a lot of things that don't necessarily help reduce risk or help that we do to patients

Can Health Care Be Cured Of Racial Bias?

-healthcare despairities are as big now as they were 50 years ago -we are more reactive in tense situations which is were these biasis come in -media is a heavy influencer -we need to slow down -destigmatize having a bias

International Medical Graduates (IMG)

-location of med school, not citizen of physician is an IMG -couldn't meet the demand in undeserved areas without IMGs

Difference between hospice and palliative care?

-palliative= get treatment for relief, don't need to have terminal illness to have this, usually chronic diseases for comfort and pain management -hospice= 60 mo or less to live is NEEDED, get care, no need to pay back if you outlive 6 mo, 2 weeks usually die on hospice, not only about the pt but about the family and helping them deal, follow family members up to a year after death, can have it at home, hospital, and hospice facility, covered by medicare if terminal and medicaid depends or state and physicality

Doctors and Racial Bias: Still a Long Way to Go

-research shows AA are treated differently -The researchers also cautioned that these biases are likely to affect diagnosis and care. -differences specifically in cardiac issues

Implicit Bias

-subconscious, influence how we act, rapid and automatic mental associations, can have effect on employment, education, healthcare, incarceration -Lead to difference in treatment of pain, cardiac problems, implicit preference for white patients -Decades worth of research showing this -Often surface when multitasking, stressed, in tense situations with not a lot of time to think -It's not just white people that have these biases, it is everyone and how it affects our interactions with others, doesn't make us prejudiced -Media is a big contender towards implicit bias based on how the media choses to portray certain groups of people -implicit bias is preventable and you can unlearn

Which of the following is NOT a type of implicit bias?

A negative belief that you suppress

Which one of the following statements are true about the Implicit Association Test (IAT) with respect to the different sets of trials?

Any differences in response speed between different sets of trials matter. Faster response times in some trials reflect stronger associations for those specific concept pairings.

What is NOT a benefit of becoming aware of your biases?

By bringing awareness of your automatic attitudes to the surface you can work to suppress them.

Things to note in ethical decision making

Capacity- does the patient have the cognitive ability to make a choice for him/herself? Are there psychological issues that may impair the decision making (or substance abuse issues)?- or what about a cognitive deficit (like dementia or Alzheimer's)? Consent- Can the patient provide consent? Are they provided with enough information to make an informed decision? Confidentiality- It is always between you and the patient- unless there is a request BY THE PATIENT for someone else to be brought into the decision making Disclosure- Is there any other information that needs to be disclosed (or told to the patient)? This is usually in reference to both the risks and the benefits. Surrogate- Is there someone else that can make decisions for the patient? This usually requires legal documentation

Only negative biases can have negative outcomes.

False

People know all their own biases; they just know they cannot or should not say those beliefs aloud, so they hide them.

False

T or F, the IAT is the only way to assess implicit attitudes.

False

True or False, In order to accurately measure implicit biases, you must become consciously aware of the associations you hold.

False

WoMan Ted Talk Video Notes:

If we engage in our implicit bias it adds to the race issue even if we do or do not do it We need to listen and to stop fighting when things aren't about you Practice be judgment free Marginalizing is the enemy and means for a unproductive conversation where no one really listens to anyone Racism is not the southern stereotype but it dress dup and can be seen everywhere

Man Ted Talk Video Notes:

Inadequate amount of discussion of racial bias If we want to stop the racism in everyday lives is to address implicit bias Implicit bias runs contrary to conscious beliefs Focusing on implicit bias means less harm towards minorities, it can be predictive and preventative,

Implicit Bias Modules (Mod 1)

Mod. 1 Lesson 1. -bias=evaluation or belief (pos or neg); neutral term -Rely on illicit process to move through the world -Implicit bias= hidden bias were not consciously aware of, attitudes or stereotypes, tool to use for understanding -This can be inaccurate stereotypes and affect our behaviors stereotypes= beliefs mentally associated in a given category Mod. 1 Lesson 2 -Automatic, adaptive, and associative nature of our brains are very natural -Concepts seen regularly, although wrong information, will manifest itself in brain -Can only consciously process 5-9 stimuli at a time' Mod. 1 Lesson 3 -Ability to make connections to two things is associative learning -Pavlov study with the dog and the bell w food is how we associate characteristics with people -We internalize associations at a young age and is largely based on our childhood

Implicit Bias Modules (Mod 3)

Mod. 3 Lesson 1. -2 ways to measure implicit bias: examine behavior and neurological assessment -Quicker and more accurate at grouping concepts when there are connections in our minds Mod. 3 Lesson 2 -IAT → implicit association test Strength of associations between pairs and concepts Mod. 3 Lesson 3 -IAT tests Mod. 3 Lesson 4 -"expecting to do well"=no bias -try to challenge the biasis to ensure the comfortability of others

What is the main distinction between our implicit and explicit biases?

Our implicit preferences tend to engage our automatic processing while our explicit preferences involve more deliberate processing

GI Bill

Post WWII cheap mortgages and free continued education access only to white veterans leading to increased job prospects and equity, lead to a lot of the systemic racism now

Systemic Racism Videos

Systemic Racism Video 1 -National Multi racial organization -Wealth gap: disproportionately lower amount of wealth in minority population as opposed to white populations Systemic Racism Video 2 -Employment: black unemployment is 2x lower then white unemployment -White people or white sounding names are 50% more likely to get a callback than those who don't Systemic Racism Video 3 -Housing discrimination: racist housing policies from 100s of years ago are still being in effect today and determine the safety, access, to foods, etd Systemic Racism Video 4 -Government surveillance: government use tax dollars the invasion privacy to look at minorities much more than white people for doing daily things Systemic Racism Video 5 -Incarceration: war of drugs has a lot more people in prison, specifically black people who don't get a lot of rights Systemic Racism Video 6 -Drug arrests: 40% of arrests come from simple possession of marajuana -White and black people both use the same amount of marajuana but black people get arrested for it for much more Systemic Racism Video 7 -Immigration policy: mostly focused on south of the border when its really people from everywhere Systemic Racism Video 8 -Infant mortality: no knew news

Explicit Bias

consciously set held of beliefs acting on certain groups, very aware

Implicit Association Test (IAT)

measures the strengths with certain concepts and are associated with attributes are good or bad, not a perfect measure but is widely used, from Harvard

Patient Self-Determination Act

passed in 1991, federal law that ensures the pt right to self determination in healthcare decisions; healthcare professionals to require conversations with pt about advanced directives

Hospitalists

physicians who specialize in the care of patients who are staying in the hospital

Oregon Law Timeline

•1994-Legislation to legalize physician assisted suicide passed (Death with Dignity Act). Subsequent court injunction prohibited implementation for several years. •1997-Legislation to repeal the measure was defeated by Oregon voters. •2006-U.S. Supreme Court upheld Oregon law.

medical futility

•Interventions that will not achieve the intended result •Conflicts re: benefit/burden of treatment •Often involve communication failures •Limits of usefulness of prognostic data and policies

Factors Influencing Ethical Issues in HCDS

•Social/family systems •Medical futility •Fear of litigation •Aging population •Lack of professional knowledge •Legalization of assisted suicide •Access to care •Legal/bureaucratic obstacles •Reimbursement