Этические проблемы взаимодействия врачей с пожилыми пациентами на примере социальной группы военных пенсионеров

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Military forces and law enforcement agencies remain the one of the units of general system of the state’s special bodies, which provides national security. Their purpose presents specific requirements to serviceman’s personality and determines necessity of applying special approach to social protection of that category of population [3]. The country’s political leadership among the absolute priorities of military building ranks strengthening of social safeguards for military retirees. The results of combat injury, psychoemotional stress and influence of occupational hazard and negative factors of military work affect health condition of many military retirees. With the purpose of creating an effective behavioral strategy, the resigning officers should have a variety of resources including good health. Mostly the retired officers assessed equally the influence of different risk factors on their health. Meanwhile they put the lifestyle and the quality of medical care on the first place, then relationship in the family and material status. Almost every retired officer came through a serious illness, injury or operation [5]. An adequate drug and non-drug treatment methods should be selected for elderly and senile age patients, consider the peculiarities of physiological and pathological processes, but these patients are observed and treated by the therapists and general practitioners and are sent to specialists for consultation due to the lack of geriatricians in the Military medical administration. Because of such practice, the amount of prescribed medications increases with simultaneous growth of their 52 consumption against the background of pharmacokinetics and pharmacodynamics [6]. The patient’s satisfaction with the quality of medical care is defined not only by standard and protocol compliance but depends on the cooperation of physician and patient as social actors. In Russia, traditionally relationship between physician and patient had paternalistic nature. This type of communication as paternalism restricts patient’s rights, who has an autonomous personality, who independently and freely takes important decisions and controls one’s own condition [1]. Considering this, the compliance with ethics and deontology plays important part in practical work of a doctor who interacts with patients in the target group. The medical-sociological study was carried out to explicate ethical issues in the model of the relationship between doctor and patient. Materials and methods: The empirical base of the research is presented by the materials of the medical-sociological study, the results of the survey and the analysis of outpatient cards of military retirees (N=150; mean age -57±8). The author’s focus group with doctors of different specialties was created (N=11; the average length of service 14±7 years) to determine the relationship between the doctors and this group of patients. The norms of bioethics and privacy were used in relation to the respondents. Results of the research. The following results were obtained by the focus group of therapists and specialists. For the question: how often military retirees seek help of a doctor? We got the the following answers: these patients address more often, then the other - answered 58%; less often - 17%; difficult to answer - 25%. The question of compliance was raised in the focus group because chronic diseases are connected with prolonged use of maintenance doses of drugs. Most doctors (67%) believe that these patients, generally, respect the mode and duration of administration of drugs; 33% - does not follow the prescriptions. The lifestyle change, following a special diet, regular exercise, rejection of bad habits are integral parts of prevention and treatment of many acute and chronic diseases. Therefore, it is interesting to know the opinion of doctors if the studied group of patients follows such recommendations. Specialists think that 42% strictly follows the recommendations; 34% - sometimes follows the recommendations and 25% - occasionally follows the recommendations. For the question: are there any peculiarities in communication with military retirees? Most (66%) specialists answered positively. Representatives of this group were interested more often than patients of other social groups in problems of preferential provision of drugs and in prospect of improving their health. The specialists noticed that military retirees needed more time for talk about their health according to the patients from other groups. Moreover, often during doctor’s appointment they tried to discuss topics that were not connected with medicine (relationship in families, with children, grandchildren and politics). For many of them medical facility is the place where they can meet their former colleagues and this point can be a factor of maintaining social contacts. It was suggested that not always medical care, performed correctly according to medical standards protocols, created the loyal attitude to the doctor. Such patients more often complained about a doctor, however, some claims were not constructive. During military service, many of them had high military ranks and certain amount of subordinates. After retirement, the social status changes dramatically. This, obviously, has an impact on psychological component of military retirees’ health. They need time for adaptation to new conditions of life and this influence on their interaction with medical personnel. Military retirees belong to the working population and are involved in working activity according to early retirement. For the question: Which group of military retirees treats their health more carefully? Most doctors answered: 59% - thinks that continuation of working activity influences positively on medical activity; 33% - thinks that patients who do not work more often ask for help and 8% - does not note significant differences in these groups. The analysis of outpatient cards of the studied social group has revealed the following results. There has been a decrease of medical activity of military retirees after retirement. These patients more rarely go to the doctors with the preventive purpose than active military personnel, which undergoes annual health checks and preventive vaccination according to preventive calendar. We can note that the main reasons of visiting a doctor are acute disease, 53 exacerbation of chronic pathology, preferential drug provision and sanatorium treatment. Most of the patients from the study group think that the main problem is medicine provision, to be more specific, it is periodic absence of preferential medicines in departmental pharmacy. Therefore, they have to buy expensive drugs at their own expense. Some of the respondents say that they have difficulties with hospitalization because there was a reorganization of departmental medical institution not so long ago and partial reduction of hospital beds and specialists. Moreover, many elderly patients need high-tech treatment methods, which are not performed in the regional military-medical institutions. Sanatorium treatment is one of the important stages of therapy and medical rehabilitation of patients. The departmental system of sanatorium service avoided many transformations, which led to destruction of the health resort business in our country in the post-reform period. This system was not affected by the reorganization of the health resort centers that led to the displacement of the medical component of the health resort service, which became recreational [4]. The departmental systems of rehabilitation include health resort complex, department of rehabilitation and recreation centers. Sanatorium treatment is the most effective. There are some problems despite the opportunity to get discount vouchers for health resorts and free transportation to the place of treatment. The responders say that often in health resorts they get treatment of the main disease and have a few medical prescriptions for comorbidities. Besides, many patients tell that there are difficulties in getting permits for health resorts. At the same time, most of the patients notice affordability of vouchers, comfortable conditions, varied diet and respectful attitude of the medical staff of health centers. Therefore, the explicated problems of interaction between doctors and elderly patients demonstrate the necessity to create and introduce methods of the social rehabilitation of military retirees in medical activity. The ethical content of the problem determines the demand for integration in practice the principle of bioethics “The recognition of human vulnerability and respect for security of person” (point 8 of “The Universal Declaration on bioethics and human rights, 2005), which appeals to different aspects of vulnerability: biological, social and cultural [2, 7]. The principle of respect for vulnerability of the patient is determined by the sensitivity of the human personality. This principle is connected with the principle of security of person, because the functioning of individuals can easily be ruined be various outside factors, so not only the person health but also its existence will be in danger. According to the paradigms of modern bioethics, it is necessary to distinguish between several dimensions of vulnerability. The biological vulnerability (or corporal) correlates with a certain fragility of the human body, besides; here we can mention the natural threats, which occur from biological features of a person - aging and death. The social vulnerability of the patient is associated with reduced ability to adjust their own life and use the benefits and services. Medical professionals take into account the cultural vulnerability rarely, despite the fact that Russia is a multicultural and multi-religious state. So traditions and values, which are typical for the local cultures, should not be ignored during organization and realization of educational programs for the elderly patients with chronic diseases.

Об авторах

Е. Г. Агапова

медико-саниарная часть 02526

Email: ekaterin-agapov@yandex.ru
Врач-инфекционист

А. Д Доника

Волгоградский медицинский научный центр

Email: addonika@yandex.ru
доктор социологических наук, доцент, старший научный сотрудник Лаборатории этической, правовой и социологической экспертизы в медицине г.Волгоград

Ю. В Есипенко

медико-саниарная часть 02526

Врач-терапевт, кандидат медицинских наук

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