Background   The patient's rights to self-determine their own health care is described in Swedish legislation and guidelines. However, due to infancy, unconsciousness, severe brain damage or certain diseases, some patients might be unable to make such decisions. Ethically difficult situations do occur, not infrequently associated with culture. Since the patient is vulnerable, there is a risk that the patient in the treatment and care can not be bothered to maintain right to autonomy and that the nurse violates patient integrity. Aim                 The aim of this study was to illustrate the nurse's dilemma when the patient refuses vital caring efforts. Method           A literature review of eight scientific articles with a qualitative approach was performed. Results           The results revealed the following domains to describe the nurse's dilemma when the patient refuses vital care interventions: patients’ reasons for treatment refusal, the nurse's understanding of the patient's refusal of care and contradictory legislation Conclusion     More knowledge and discussion of the patient's decision-making competence is needed for both the nursing profession and those who make decisions on legislation.

Thesis (M.S.)--University of Wisconsin--Madison, 1992. / Typescript. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 49-53).

Thesis (M.S)--University of Florida, 2005. / Typescript. Title from title page of source document. Document formatted into pages; contains 35 pages. Includes Vita. Includes bibliographical references.

Thesis (Ph. D.)--University of Washington, 2008. / Vita. Includes bibliographical references (p. 86-93).

A tuberculose à uma doenÃa infecciosa e contagiosa causada por uma bactÃria, o Mycobacterium tuberculosis. O abandono do tratamento da tuberculose pulmonar por pacientes com baciloscopia positiva favorece a manutenÃÃo da cadeia de transmissÃo, assim como o aumento das populaÃÃes bacterianas resistentes à quimioterapia de primeira linha. Iniciar o tratamento, desistir dele, retratar, abandonar novamente... situaÃÃo cada vez mais frequente na populaÃÃo acometida por tuberculose e usuÃria de drogas, lÃcitas ou ilÃcitas. O consumo de substÃncias psicoativas cresceu assustadoramente a partir da segunda metade do sÃculo XX, configurando-se nas Ãltimas dÃcadas como um fenÃmeno de massa e como uma questÃo de saÃde pÃblica. Segundo a OMS, cerca de 10% das populaÃÃes dos centros urbanos de todo o mundo, consomem abusivamente substÃncias psicoativas, independentemente da idade, sexo, nÃvel de instruÃÃo e poder aquisitivo. O presente trabalho tem como objetivo avaliar a influÃncia do uso abusivo de drogas ilÃcitas no abandono do tratamento para tuberculose pulmonar em uma Unidade de AtenÃÃo PrimÃria à SaÃde no municÃpio de Fortaleza. Por meio de estudo epidemiolÃgico observacional, retrospectivo, foram analisamos fatores socio-epidemiolÃgicos e fatores clÃnicos de pacientes em tratamento para tuberculose pulmonar, verificando-se a presenÃa do uso abusivo de drogas nesta populaÃÃo, e a influÃncia destas no abandono do tratamento, utilizando para isso questionÃrios estruturados (questionÃrio geral e ASSIST). Resultados: dos 116 casos de tuberculose investigados, 68,9% sÃo do sexo masculino, com mÃdia de idade de 37,5 anos, de cor parda (72,4%), solteiro (56,9%), com ensino fundamental incompleto (50%). A situaÃÃo de emprego da maioria (37%) era de desemprego. Quanto ao perfil epidemiolÃgico do caso, 84,4% eram de casos novos, 13% de reingresso apÃs abandono e 2,6% de recidiva. O motivo que levou ao encerramento do caso mostrou-nos um dado alarmante: 36% dos pacientes abandonaram o tratamento. Comparando as diferenÃas entre o grupo de cura e o de abandono, nÃo houve diferenÃa significativa entre a mÃdia das idades dos dois grupos (p > 0,75). Em ambos os grupos houve predomÃnio do sexo masculino, porÃm observamos uma diferenÃa significativamente maior no grupo do abandono (p = 0,0001). No grupo abandono o nÃvel de escolaridade foi inferior ao do grupo cura/conclusÃo (p = 0,017). Houve associaÃÃo entre abandono e desemprego (p < 0,0001) e reingresso apÃs abandono. Pelo resultado do questionÃrio ASSIST, a frequÃncia do uso de drogas na vida correspondeu a 95,1% para o Ãlcool, seguido do tabaco.(51,6%). A Cannabis sativa, a cocaÃna e o crack foram citados por 41,9% dos questionados. Inalantes como lolà e cola de sapateiro jà haviam sido provados por 19,3%. O uso de crack necessita de intervenÃÃo com indicaÃÃo para tratamento intensivo na maioria dos usuÃrios (61,9%), o que demonstra a forÃa de dependÃncia quÃmica que essa substÃncia causa. ConclusÃo: O abandono do tratamento da tuberculose se mostra um risco significativo nos pacientes usuÃrios de drogas, em especial as ilÃcitas onde observa-se um consumo abusivo, necessitando-se de intervenÃÃo, seja uma intervenÃÃo breve ou tratamento mais intensivo. / Tuberculosis is an infectious and contagious disease caused by a bacterium, Mycobacterium tuberculosis. Treatment Refusal for pulmonary tuberculosis in patients with smear-positive favors the maintenance of the transmission chain, as well as increased resistance to first-line chemotherapy. Starting treatment, give it up, portray, leave againâ situation increasingly common in the population affected by tuberculosis and uses drugs, licit or illicit. The consumption of psychoactive substances has increased since the second half of the twentieth century, becoming a mass phenomenon in recent decades and a public health problem. According to WHO, about 10% of the populations of urban centers world consume abusively psychoactive substances, regardless of age, sex, education level and purchasing power. This study aims to evaluate the influence of the abusive use of illegal drugs in the abandonment of treatment for pulmonary tuberculosis in a Unit of Primary Health Care in Fortaleza. Through a epidemiologic, observational and retrospective study, socio-demographic factors and clinical factors were analyzed in patients treated for pulmonary tuberculosis, verifying the presence of substance abuse in this population, and the influence of these in abandonment of treatment, using structured questionnaires (general questionnaire and ASSIST). Results: of the 116 TB cases investigated, 68.9% are male, with a mean age of 37.5 years, mulatto (72.4%), single (56.9%), with incomplete primary education (50%). The employment status of the majority (37%) were unemployed. As to the epidemiological profile of the case, 84.4% were new cases, 13% of return after default and 2.6% of recurrence. The cause of the closure of the case was by treatment refusal in 36% of patients. Comparing the differences between the group cure and abandonment, there was no significant difference between the mean ages of the two groups (p> 0.75). In both groups there was a predominance of males, but had a significantly greater difference in the dropout (p = 0.0001). In the group abandoned, the education level was lower than the cure group (p = 0.017). There was an association between dropout and unemployment (p <0.0001) and return after default. The ASSIST questionnaire showed that the frequency of drug use in life corresponded to 95.1% for alcohol, followed by tobacco. (51.6%). Cannabis sativa, cocaine and crack were cited by 41.9% of respondents. Inhalants like lolo and glue had already been tried by 19.3%. The use of crack needs intensive treatment in the majority of users (61.9%), demonstrating the chemical addiction to this substance. Conclusion: The abandonment of tuberculosis treatment shows a significant risk in patients using drugs, especially illicit substances with abuse use, necessitating the intervention, whether a brief intervention or more intensive treatment.

Bakgrund: Antalet ovaccinerade barn ökar och ca 134 200 människor dör varje år i en sjukdom som kan förhindras med hjälp av de välutvecklade vaccinationsprogrammen. Majoriteten av dödsfall är barn under fem år. UNICEF och WHO har som målsättning att alla barn i världen ska ha rätt till ett fullständigt skydd mot de sex vanligaste barnsjukdomarna. Syfte: Syftet med denna litteraturstudie var att beskriva varför vissa föräldrar väljer att inte vaccinera sina barn samt att granska vilka datainsamlingsmetoder de inkluderade artiklarna har använt sig av. Metod: Den föreliggande litteraturstudien var av deskriptiv design där 12 stycken vetenskapliga artiklar granskats. De inkluderade artiklarna hade kvantitativ, kvalitativ eller mixad ansats. Huvudresultat: Föräldrar hade olika anledningar till varför de valde att avstå från att vaccinera sitt barn. Faktorer som visade sig påverka föräldrar i deras val att vaccinera sitt barn eller inte var bristande information, att vaccin ansågs vara onaturligt och farligt för barnets immunförsvar, att föräldrarna ansåg att de kunde skydda barnet från att bli smittad av sjukdomar, att biverkningar skulle uppstå samt påverkan från internet, familj och vänner. Studierna hade olika tillvägagångssätt för datainsamling. De var antingen enkäter, intervjuer eller insamlad data från journalsystem. Slutsats: Det är viktigt att sjukvården är medveten om de olika faktorer som påverkar föräldrar i deras val rådande vaccinationer för att kunna bidra med en individanpassad information utefter föräldrarnas kunskap och ställningstagande om vaccinationer. / Background: The number of unvaccinated children is increasing and approximately 134 200 people die each year from a disease that can be prevented with the help of the developed vaccination programs. The majority of the deaths are children under five. UNICEF and WHO is committed to give every child in the world the right to full protection against the six most common childhood illnesses. Aim: The aim of this study was to describe why some parents choose not to vaccinate their children. The aim was also to review what data collection methods that was used in the included articles. Method: The present literary study was of a descriptive design where 12 pieces of scientific papers had been reviewed. The including articles had either a quantitative, a qualitative or mixed approach. Main result: Parents had different reasons why they chose not to vaccinate their children. Factors found to influence parents in their choice to vaccinate their children or not was a lack of information, the vaccine was considered unnatural and dangerous for the child's immune system, the parents felt that they could protect the baby from being infected by the disease, the side effects that could occur and the impact of the internet, family and friends. The studies had different approaches to data collection. They were either surveys, interviews or data collected from medical journals. Conclusion: It is important that health care personnel is aware of the various factors that influence parents vaccine choices to provide a personalized information by the parents knowledge and position on vaccinations.

Background: A patient always has the right to refuse treatment due to various reasons, which can cause a number of different emotions. The nurse has a responsibility, function, and care science concepts to take into account such as responsibility and power. It's important that the nurse listen to the patient to understand the patient's reason for refusing treatment. Aim: The purpose is to describe nurses’ experiences of meeting patients who refuse treatment. Method: A literature-based study was conducted through a qualitative approach. Systematic searches were performed in the databases Cinahl and PubMed. Both general and specialist nurses were included. The study was based on seven qualitative articles. The analysis resulted in three themes and eight subthemes. Results: An internal conflict as a feeling was identified among nurses. The nurses had some tools to overcome the internal conflict but they felt lack of tools related to the situation not being discussed during their training. The nurses tried to increase the patient's competence about their choices. The asymmetric care relationship, on the other hand, became obvious in the form of the exercise of power and persuasion. Conclusion: Caring for a patient who refuses treatment is a complex situation for the nurse. The feelings the nurses expressed created a clear common pattern. By talking more about the internal conflict, a guide can be created in how the nurses’ feelings should be handled when a patient refuses treatment. / Uppsatsens syfte är att beskriva sjuksköterskors upplevelser av att möta patienter som avstår behandling. Som patient finns en rättighet över ett självbestämmande vilket kan innefatta att avstå behandling. Orsaken till att avstå behandling kan grunda sig i kognitiv nedsättning som depression, religionstillhörighet eller ett aktivt val. Resultatet visade att sjuksköterskor upplevde en inre konflikt när en patient avstår behandling, vilket var påfrestande. För att övervinna den inre konflikten hade sjuksköterskor olika strategier. Ett antal sjuksköterskor beskrev däremot att de inte hade en strategi, vilket de härledde till att situationen inte diskuterades under deras utbildning. För att vägleda patienten i sitt val försökte sjuksköterskorna öka patientens förståelse av sitt val, lyssna på dem och verkligen försäkra sig om att de hade förstått innebörden av att avstå behandling. I vissa fall när sjuksköterskan hade försökt lyssna på patienten och försökt öka patientens förståelse gick sjuksköterskan över till att försöka övertala patienten till vad som var enligt deras normer “rätt’’ val. Sjuksköterskorna visade sig överträda patientens självbestämmande och handla utifrån sina egna normer, utöva makt och således främja en asymmetrisk vårdrelation. Slutsatsen blev att en situation där en patient avstår behandling är en komplex situation för sjuksköterskan. Känslorna och upplevelserna skapade ett tydligt gemensamt mönster, genom att tala mer om den inre konflikten kan en vägledning skapas i hur sjuksköterskans känslor ska hanteras när en patient avstår behandling. Sjuksköterskan har sitt ansvar och sin funktion att sträva efter med grund i lagar och styrdokument. Samtidigt som sjuksköterskan har sitt ansvar och funktion har även patienten sin rätt till självbestämmande. Det är av vikt att sjuksköterskan respekterar patientens självbestämmande med hänsyn till den asymmetriska vårdrelationen. Sjuksköterskan ska ha sitt ansvar och sin makt i beaktning samtidigt som sjuksköterskan ska respektera patientens värdighet. För att kunna respektera patientens värdighet och självbestämmande är det av vikt att sjuksköterskan lyssnar på patienten för att verkligen förstå patientens vilja.

Bakgrund: Att en patient motsätter sig behandling kan vara av religiösa, etiska eller moraliska skäl. Eftersom sjuksköterskans huvuduppgifter i sitt arbete är att främja hälsa, förebygga sjukdom, återställa hälsa samt att lindra lidande så är det av intresse att undersöka sjuksköterskans upplevelse av att vårda patienter som motsätter sig behandling. Syfte: Syftet var att beskriva sjuksköterskors upplevelse av att vårda patienter som motsätter sig behandling. Metod: En allmän litteraturstudie med induktiv ansats genomfördes och fyra kategorier framkom. Resultat: Resultatet visar att sjuksköterskors upplevelser av att vårda patienter som motsätter sig behandling innebär att: ha en god relation med patienten, respektera patientens autonomi, argumentera för patientens behandling, samt känna emotionell påverkan av patientens beslut. Det visade sig att en god relation mellan patient och sjuksköterska var viktigt när patienten motsätter sig behandling. Sjuksköterskor respekterade patienters autonomi även om de ibland försökte argumentera för att patienter skulle ta emot behandling. Sjuksköterskor kunde uppleva starka känslor som maktlöshet, frustration och ilska när patienten motsatte sig behandling. Konklusion: Studien visade att relationen mellan sjuksköterskan och patienten var viktigt i vårdandet av patienter som motsätter sig behandling. Sjuksköterskorna var noga med att respektera patientens autonomi. Ville inte patienten ta emot behandling försökte sjuksköterskan att få patienten att ta emot behandling. Fungerade inte detta kunde starka känslor upplevas. / Background: A patient’s refusal of treatment may be for religious, ethical, or moral reasons. Since the nurse’s main task in her work is to promote health, restore health, prevent illness and relieve suffering, it is of interest to investigate the nurse’s experience of caring for patients who refused treatment. Aim: The aim of this study was to describe the nurse’s experiences of caring for patients who refused treatment. Method: A literature review with an inductive approach and four categories emerged. Result: The study shows that nurse’s experiences of caring for patients who refuse treatment are: have a good relationship with the patient, respecting the patient’s autonomy, arguing for the patient’s treatment, and feel an emotional impact. It turned out that a good relationship between the patient and the nurse was important when the patient refused treatment. Nurses respected patient’s autonomy even although they sometimes tried to argue that patients would receive treatment. Nurses could experience strong feelings such as powerlessness, frustration, and anger when the patients refused treatment. Conclusion: The study showed that a good relationship between the nurse and the patient was important in the care of patients who refused treatment. The nurses were careful to respect the patient’s autonomy. If the patient did not want to receive treatment, the nurse tried to get the patient to receive treatment. If this did not work, strong feelings could be experienced.

Malgré les succès spectaculaires de l’immunisation comme mesure de santé publique, certains parents continuent de refuser de vacciner leurs enfants (Diekema, 2005). C’est pourquoi qu’au cours des dernières décennies, des éclosions de maladies évitables par la vaccination comme la rougeole et la coqueluche ont été observées au Canada, surtout chez la population non vaccinée (Hinman, 2000). Au Québec, depuis l’entrée en vigueur de la loi 90 en 2003, les infirmières peuvent procéder à la vaccination sans ordonnance individuelle ou collective conformément au Protocole d’Immunisation du Québec (PIQ). Les infirmières québécoises peuvent alors influencer positivement la couverture vaccinale (Sauvageau & al, 2005). Le but de cette étude est d’évaluer les retombées de la formation VIP (Vaccination par les Infirmières/Infirmiers-Prévention) sur les pratiques vaccinales rapportées par les infirmières (N=12) de CSSS, auprès des parents d’enfants de 0-5 ans lors d’un refus parental. En premier lieu, nous avons identifié et décrit treize pratiques vaccinales en réponse à un refus parental. Par la suite, nous avons identifié des modifications dans certaines des treize pratiques rapportées tel qu’une augmentation dans la description des pratiques de correction des fausses croyances des parents, une amélioration de la justesse des pratiques d’explication et une personnalisation des pratiques décrites. En conclusion, la formation offerte aux infirmières doit permettre à celles-ci d’identifier les préoccupations parentales et d’y répondre adéquatement en utilisant une information juste et individualisée. / In spite of the success of immunization as a public health measure, some parents refuse to vaccinate their children (Diekema, 2005). Over the last couple of decades, outbreaks of vaccine-prevented diseases like whooping cough and measles have been observed in Canada, particularly among the non-vaccinated population (Hinman, 2000). Since the adoption of law 90, nurses in Quebec can provide vaccination without a medical prescription while adhering to the PIQ (Quebec immunization protocol). Nurses in Quebec can, therefore, have a positive impact on immunization uptake in the province (Sauvageau, Boulianne, Clouâtre, Lavoie, & Duval, 2005). The goal of this study was to evaluate the effect of the VIP (Vaccination par les Infirmières/Infirmiers- Promotion) teaching program on the practices of community nurses (CSSS) when faced with a parent refusing vaccination. We first described the nursing practices of nurses (N=12) when faced with parents who refused vaccination. We identified and described 13 practices used by nurses when faced with parental refusal. Secondly, we identified modifications in some of the nursing practices after the VIP teaching program. Nurses must address the fears or questions of parents with pertinent and individualized information. Teaching programs must provide support for nurses to have and maintain an optimal practice.

INTRODUÇÃO: O sucesso do tratamento de dependentes de álcool e outras drogas numa comunidade terapêutica (CT) depende fundamentalmente da adesão ao tratamento, ou seja, o tempo de permanência na comunidade. Sabe-se que pacientes que permanecem em tratamento por um período de pelo menos três meses têm uma evolução melhor do que aqueles que abandonam o tratamento precocemente. O ambiente emocional familiar tem grande influência na adesão ao tratamento, e pode ser medido por meio da emoção expressa EE). MÉTODOS: Foram avaliados familiares de 31 dependentes de substâncias psicoativas e/ou de álcool, internados involuntariamente, por meio da versão abreviada e traduzida para o português da Entrevista Familiar de Camberwell (EFC). A partir de então, mediu-se a taxa de permanência na CT após seis, 12 e 18 meses. Foram avaliados os aspectos hostilidade, superenvolvimento e calor afetivo. A hostilidade foi abordada como ausente (pontuação igual a zero) ou presente (pontuação igual a 1, 2 ou 3). O superenvolvimento e o calor afetivo foram considerados de forma contínua (pontuação de zero a 5) e categorizada. Todos os possíveis pontos de corte foram estudados na procura de novas relações e significados dos componentes da EE para esta população específica e os achados da amostra. RESULTADOS: Foram considerados com alta EE para hostilidade 41,9% dos familiares entrevistados e 71% para superenvolvimento emocional; 25,8% destes familiares pontua ram para ambos os componentes da EE (hostilidade e superenvolvimento). Dos 31 pacientes, cinco (16,1%) desistiram do tratamento até os seis meses; dois pacientes desistiram entre o 6 o e o 12 o mês (25% de desistência em 12 meses) e quatro abandonaram o tratamento entre o 12 o e o 18 o mês (47,8% de abandono em 18 meses). Houve uma associação significativa entre a presença de hostilidade e o abandono do tratamento antes dos seis meses (p = 0,008, teste exato de Fischer). Houve diferença significativa na frequência de superenvolvimento familiar entre o grupo que permaneceu 18 meses e o grupo que abandonou o tratamento (p = 0,037, teste de Mann-Whitney). Os pacientes que permanceram em tratamento até os 18 meses tiveram uma freqüência maior de familiares com alto nível de superenvolvimento familiar (> 4) (p = 0,012; teste exato de Fisher). Não houve nenhuma associação entre o tempo de permanência e o calor afetivo. CONCLUSÕES: Alta EE tem influência significativa sobre o tempo de permanência do dependente químico ou de álcool na CT. A presença de hostilidade foi mais freqüente no grupo com o abandono prematuro do tratamento, enquanto o alto superenvolvimento do familiar foi mais freqüente no grupo de pacientes que permaneceu em tratamento até os 18 meses. Estudos com uma população maior são necessários para apoiar esses achados. / BACKGROUND: The success of treatment for alcohol and other substance dependence in a therapeutic community (TC) depends greatly on the treatment adherence, i.e., the length of stay at the TC. It is well known that subjects who stay on treatment for ate least three months have a better outcome, compared with those who early withdraw. The family emotional environment can be measured through expressed emotion (EE) and has great influence on treatment adherence. METHODS: 31 key-relatives of alcoholics and other substance dependents, who involuntarily began a treatment in a TC, were assessed through the Camberwell Family Interview (CFI) (shorter translated to Portuguese version). The proportion of subjects who remained on treatment in the TC was then measured after six, 12 and 18 months. Evaluated aspects included hostility, overinvolvement and warmth. Hostility was assessed as absent (score = 0) or present (score = 1, 2 or 3). Overinvolvement and warmth were considered as continuous and categorized values (scores 0 to 5). Every possible cutoff points were studied, in order to find new associations and meanings of EE components of this specific population and the length pf stay in a TC. RESULTS: 41.9% of the relatives were considered as having high EE for hostility and 71% for overinvolvement; among those relatives with high EE, 25.8% had presence for both hostility and overinvolvement. Among the 31 patients, five (16.1%) abandoned treatment up to 6 months; 2 patients abandoned treatment between 6th and 12th month (25% treatment abandon in 12 months) and four abandoned the treatment between 12th and 18th month (47.8% treatment abandon at 18 months). There was a significant higher frequency of presence of hostility in the group that abandoned before six months (p = 0.008, Fischer exact test). A significant difference of familiar overinvolvement was found between the group who remained in the treatment up to 18 months and the group that abandoned treatment earlier (p = 0.037, Mann-Whitney test). Families with score = 4 for overinvolvement were more frequent in the group that remained on treatment up to 18 months (p = 0.0012; Fischer exact test). No correlation was found between warmth and length of stay at TC. CONCLUSIONS: High EE has a significant influence over the length of stay of the alcoholic or other substance dependent in a TC. The presence of hostility is more frequent among families of patients who prematurely abandon treatment, while higher score of overinvolvement was more frequent in the families of the group that completed 18 months of treatment in the TC. Further studies with larger population are needed to support those findings.