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By L. Stan. Wake Forest University.

For example buy antabuse 500 mg with visa, "We will Emotion-Handling Skills send a nurse to your home to check in on you in a couple One barrier to eliciting patient affect is the fear of being of days generic antabuse 500mg overnight delivery, and if you’d like, I could ask the chaplain to pay unable to manage the patient’s emotional response. The primary goal of emotion handling say, "After you gave me the results of the test, I thought is to convey a sense of empathy. Tulsky concerns about cancer that will be helpful in planning patient’s specific fears and concerns are. Here is how the physician might approach the patient41: Communicating Bad News MD: Is there anything that you are particularly worried that this might be? Communicating bad news draws upon the skills discussed PT: I guess anyone would be scared that it is cancer. Many protocols exist for the delivery of bad MD: I’m afraid that it might be cancer. There are other news; however, the behaviors tend to be grouped into things that it might be too, however. That’s why several key domains that include preparation, content we are going to do the biopsy—to find out. What of message, dealing with patient responses, and ending 40,41 worries you most about cancer? She suffered preparation (getting the setting right, getting needed terribly with it. Content of Message At the end of this exchange, note how the physician Knowledge of what the patient already knows or believes begins to find out what the patient’s fears are in an effort is extremely valuable to have before revealing bad news to to anticipate the patient’s reactions to the news if the test a patient. One might ask, One should avoid spending any time "beating around the "Is there anything that you are particularly concerned bush" before sharing the news. Find out what patient knows and believes The clinician should remain silent and allow the patient Find out what patient wants to know an opportunity for the news to sink in. One can strike an Suggest a supportive person accompany the patient Learn about the patient’s condition empathic stance, maintain comfortable eye contact, and Arrange the encounter in a private place with enough time perhaps use a nonverbal gesture, such as reaching out and Content touching the patient’s hand. However, silence is impera- Get to the point quickly tive to allow the patient an opportunity to process the Fire "warning shot" (example: "I have bad news") information, formulate a response. The clinician who feels uncomfortable Avoid false reassurance during this silent phase needs to appreciate that the dis- Make truthful, hopeful statements comfort is rarely shared by the patient, who is engrossed Provide information in small chunks in thought about the meaning of the news and thoughts Handle patient’s reactions about the future. Furthermore, very little that is said by Inquire about meaning of the condition for the patient NURSE (Name, Understand, Respect, Support, Explore) expressed the physician at this time will be remembered by the emotions patient, so it is best not to say it at all. If the patient makes Assure continued support no verbal response after perhaps 2 minutes, it can be Wrap-up useful to check in: "I just told you some pretty serious Set up a meeting within the next few days news. Do you feel comfortable sharing your thoughts Offer to talk to relatives/friends Suggest that patients write down questions about this? It is also important to explore the Ending the Encounter meaning the news has for the patient and to achieve a The clinician must end the encounter in a way that leaves shared understanding of the disease and its implications. Support can be provided through meeting patients’ MD: What is most troubling to you about having cancer? One must treat pain PT: It’s a death sentence—my mother died from and palliate other symptoms. I guess it’s my how they plan to cope with the news, and if their response turn now. Last, one should provide a specific follow-up plan: "I’d PT: So this won’t kill me? Hopeful provide concrete evidence of the ongoing connection to messages need to be tailored to patients’ specific con- the physician and help a distressed patient to remember cerns, particularly addressing patient misconceptions the plan. Once patients’ concerns have been explored, of this conversation is not to leave a happy patient. When effective is rarely possible (or even desirable) after delivering bad treatment is available,this fact should be explained. Instead, one hopes to leave a patient who feels the treatment options are poor, hope may be found by supported and cared for and who can look forward to a alleviating patients’ worst fears. These aims include preparing for death and relationships with others, and from finding meaning in dying, exercising control, relieving burdens placed on their lives. Although physicians with their values, and leaving patients feeling supported 45 may have a desire to make an overly reassuring statement and understood. Unfortunately, frequently many of to the patient right after revealing the diagnosis, hopeful these goals are not met. Audiotape studies of actual dis- statements that are truthful and that are made after taking cussions about advance care planning demonstrate that the time to explore the patient’s concerns first are more information is frequently presented in ways that may not likely to be accepted by the patient.

This distorted and disorganized vision is cer- tainly a trademark of schizophrenia with concomitant pervasive develop- mental delays buy antabuse 250mg fast delivery, yet in a child’s renderings it could designate a normal phase of development purchase antabuse 250 mg. I cannot stress enough the importance of understanding the develop- mental stages when interpreting the artwork, yet when utilizing art one must also take into account the chosen medium. The use of media can en- hance a client’s functioning, frustrate the client, or offer an inaccurate pic- ture of his or her personality and any developmental delays that may exist. He prefers to paint, and the majority of his projects, when he utilizes acrylics, turn out like the examples in Figure 2. He is never satisfied with the result and tends to sulk when the vision in his head is not replicated on the paper. These drawings, with their emphasis on simplistic geometric forms, look as though a child in kindergarten created them, and if these were all we had 50 Adaptation and Integration 2. These detailed and integrated renderings, done in marker, also point toward developmental delays, yet they look more like an 11-year-old’s drawings—a gain of 5 years, which is considerable, devel- opmentally speaking. Many examples could be offered that demonstrate developmental delays through the use of artwork. However, at this point I would like to introduce an extremely useful tool on behavioral patterns and modes of growth. It is at this juncture that clinicians often have difficulty in distinguishing the norms of development and instead be- lieve a delay is occurring rather than a period of growth and change. As these two tables indicate, the emerging adolescent not only proceeds forward on a predetermined growth pattern but reverts to preceding levels, much to the chagrin of parents and child therapists. Margaret Mahler (1975) also discussed this pattern in her review of the growing infant in the separation-individuation stage of development. Each subphase brings ex- ploratory behaviors that first focus on the mother (differentiation), then branch outward toward the environment (practicing), only to return to the reassuring closeness and safety of the mother (rapprochement). In the end the child (on the road to object constancy) is able to internalize the mother through a mental representation and thus no longer requires strict physi- cal closeness. These states of repetitious instability produce more than mere conflict, however: They help the individual grow into an indepen- dent being who is able to anticipate and weigh the consequences of be- havioral choices. Unfortunately, many clients, both adults and youths, exhibit a long- standing history of poor judgment. Couple this fact with the prevalence of institutionalized dependency, and frustration-based aggression can quickly become the norm. Just as the growing adolescent or grown adult will utilize manipulation, a child aged 3 has an instinctive understanding of what will be tolerated by those in his or her life. We can answer these questions by exploring those that have come be- fore, and this chapter concentrates most on the theories of Piaget, Freud, and Erikson. Jean Piaget Piaget’s stage theory of cognitive development in children outlined four major stages: (1) sensorimotor, (2) preoperational, (3) concrete opera- tions, and (4) formal operations. However, for the purposes of this book I will break down the two phases within the Preoperational stage, as these phases are exceedingly important to the growing child’s development. All of these stages not only occur in continuous progressions but allow the in- dividual to interact with the environment with increasing levels of com- petency and skill. With each stage a broader range of thinking develops as the individual forms a larger understanding of the world. This focus on the intellectual growth of the child and the lack of attention to emotional and social influences have brought criticism upon Piaget’s theory. However, at the same time, this focus on cognition parallels perfectly our understand- ing of a growing child’s repertoire of artwork. Piaget and others have provided evidence that learning is tied to maturation—a physiological, bi- ological functioning that is predetermined in each individual" (Lowenfeld & Brittain, 1982, p. Thus, a child will not be able to draw a circle un- til age 3, a square until age 4, a triangle until age 5, and a diamond until the age of 6 or 7. Lowenfeld and Brittain describe why this is so: For example, trying to teach a three year old how to draw a cube would be a big waste of time. What would be needed are a lot of pre-cube experiences: a year of scribbling to establish visual-motor control, a year of manipulation 53 Defense Mechanisms and the Norms of Behavior of objects to acquaint the youngster with two- and three-dimensionality, a year of two-dimensional drawing to establish drawing abilities, a year of physical expressiveness to perfect the understanding of left and right, up and down, front and back. The infant is said to go through six definitive stages, each indicating a broader range of thinking as accommodation and assimilation form an ever-growing understanding of the larger world.

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WHY AND (PROVISIONALLY) HOW DISEASE IS A RADIAL CATEGORY The "disease" category begins at the level of symptoms purchase antabuse 500mg mastercard, basic components of disease entities order 250 mg antabuse amex. It is apparent on first inquiry, although detailed empirical confirmation is needed, that the symptom, such as a "cut," a "bloody nose," a "headache," "blindness," "numbness," "vomiting" or "fever" is the level on which most of us would start to understand the whole system of concepts topped by "disease in general. In George Lakoff’s terms, embodied symptoms are "directly under- stood" whereas the understanding of disease as an underlying unified pattern of symptoms is indirect. Although the capacity to have symptoms is certainly healthy, within limits, the actual presence of them is not in most instances. If disease were entirely a social construction HEALTH AND DISEASE 55 there should be cultures that would embrace chest pain, headaches, arthralgias, sore throats and rashes as healthy. Any author denying that symptoms provide an experiential, cross-cultural foundation for disease ought to produce such examples for our edification. Having said that much about the most basic symptoms, there are some experi- ences which can be considered symptoms to a varying degree, and in some contexts these are not even thought of as symptoms. For example, shortness of breath, fatigue, anxiety, depression, forgetfulness and itching are almost always experiences we would rather get over, but the mere fact that they are generally unpleasant does not turn them into basic constituents of disease any more than unpleasantness renders hunger or homesickness pathological. Factors like the age of a person experiencing these discomforts, the reason for and nature of their onset as well as their intensity determine whether they are considered out of place. It is when they are wrong for the circumstances that they become symptoms, and then they function just like symptoms of the more incontrovertible type, i. They have other cognitive features which structure the symptoms, locate them in a context and assign them a history as well as meaningful implications. Although symptoms are the groundwork, a much larger semantic architecture is built on them. Notions of etiology, nature of onset, patterns of progression, symptom clusters, signs, pathophysiology, epidemi- ology and prognosis also constitute diseases. For this reason, symptoms are not diseases by themselves, and prototypical members of the "disease" category, such as pneumonia, are not at the most basic level in the cognition of illness. Individual diseases are instead complexes of features like those just mentioned, among which the symptoms are at the basic level. Whereas it is "self-evident" whether someone has a cough, a runny nose and a fever it is not automatically evident on the surface whether the person has a cold, influenza, whooping cough or pneumonia. In the case of a classical category, all members have essential defining features plus added features which differentiate them one from another. In contrast, the members of the "disease" category are generated from their connection to central members but do not have even all of the main features of these central members. In addition, an abstractionist analysis of the "disease" category will not work because any skeletal features which could be asserted to apply in common to all the varying members (i. Their number is always fluctuating and controversial, because of conflicting and evolving 56 CHAPTER 2 principles for lumping and splitting and disputes about the relative significance of "natural kinds" versus "social constructs. The cluster of ideal cognitive models is generated from the bottom up, starting with our experience of symptoms and what we have found out about their causes and cures. Beginning with symptoms, understanding builds up to individual disease concepts and their sub-categorical variants, then the classes of disease, like infectious diseases and vascular diseases, and at last, disease in general. The broader categories are understood in terms of the more specific ones, by and large. As we have already seen, there is no classical criterion, no univocal set of necessary and sufficient features to define disease literally. Depending on the vagaries of ongoing research, academic fashion and the mutually contradictory pronouncements of authorities at different times and in different places, category assignments shift, drift and are often in dispute. There is very little about this whole system which accords well with classical category structure. Central members of this category are extended by cognitive proximity, analogy and metaphor to increas- ingly peripheral examples. If a history of disease identifications were undertaken, I suspect that the central prototypes would be found to have been the first ones labeled as "diseases.

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The mode gives the impression of relating to the user and keeps him or her inside the colon discount 250mg antabuse with amex. It is helpful for quick examination of the colon and does not warn the user when he or she is stuck on the colonic wall buy antabuse 500 mg fast delivery. The three features allow the viewing position to be reset to an initial position and increase and decrease the scale. Much less patient discomfort results because there is no need to reposition the patient. The radiation dose used in virtual endoscopy is one half of one quarter of the average exposure in barium enema and an unlimited number of viewing angles can be exploited. There is also no need for sedation, and the patient can resume normal activities immediately after the CT scanning procedure. In addition, by adopting a virtual medical worlds interface, the pragmatics of de®ning and creating virtual envi- ronments are abstracted from the practitioner. A practitioner then has a choice, depending on the availability of supportive hardware, on how to visu- alize patient data. This chapter was not concentrated with the speci®cs of vir- tual reality techniques and did not provide detailed explanations of its use. It outlined a possible framework for how these advanced imaging techniques could be integrated into a general telemedical information society. Presently, the cost of VR hardware and software has restricted its usage to only a few medical institutions. However, it is envisaged that as these costs are reduced, the technology will become more widespread. Surgery planning programs such as VRASP are already available to allow a surgeon to practice an operation on a virtual model of the patient and then use this virtual operation to assist during the real operation. It seems quite REFERENCES 111 possible that this approach could be taken even further so that a surgeon could be in one location and either a robot or another, less specialized, surgeon could perform the operation at another location (112±118). This approach could be used in specialized cases, natural disasters, isolated regions, and even military situations. It is also possible that VR techniques could be used for telepresence to create a virtual practitioner to guide a less quali®ed practitionerÐa VR form of teleconferencing. However, with the introduction of any new technology the factors of its safe and healthy use need to be considered along with its ethics (119). Clearly, there are many diverse potential uses of VR techniques; and even through VR is in its development stages, it is providing another tool to aid practitioners not only in training but also in diagnosis and treatment planning (120, 121). It is my opinion that only if such techniques can be truly integrated into a uniform frameworkÐincluding telecommunications, computing, and data managementÐwith all other forms of medical imaging techniques and developing technologies (e. Applied virtual reality for simula- tion of endoscopic retrograde cholangio-pancreatoraphy (ERCP). Virtual endoscopy of the head and neck: diagnosis using three-dimensional visualisation and virtual representation. Towards performing ultrasound-guided needle biopsies from within a head-mounted display. The dimensionally integrated dental patient record: digital dentistry virtual reality in orthodontics. Paper presented at the 12th International Symposium on the Creation of Electronic Health Record System and Global Conference on Patient Cards. Merging virtual objects with the real world: seeing ultrasound imagery within the patient. A telemedicine testbed for developing and evaluating telerobotic tools for rural health care. Paper presented at the 19th Annual International Conference of the IEEE Engineering in Medicine and Biology Society. Paper presented at the International Conference and Exhibition on High Performance Computing and Networking (HPCN 1997).

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