ABSTRACT
A study was undertaken in 372 consecutive patients undergoing non-elective cesarean delivery to explore the incidence and nature of conflicts between physician and patient surrounding the decision to undergo non-elective cesarean delivery; to examine the adequacy of informed consent at the time of non-elective cesarean delivery; and to describe the importance of a preventive ethics approach to non-elective cesarean delivery. During a 6-month interval, all patients who underwent non-elective cesarean delivery and their physicians were asked to take part in a survey in the early postpartum period concerning their response to recommendations for cesarean delivery. The survey included demographics as well as questions pertaining to informed consent and the presence and nature of patient-physician conflict. Of the 326 patients who were interviewed, 319 (98%) agreed to the recommendation for non-elective cesarean delivery and 7 patients (2%) initially disagreed. Reasons for disagreeing included: feared surgery (4 of 7), needed husband's approval (1 of 7), and questioned the medical necessity of surgery (2 of 7). In all 7 cases of initial disagreement, cesarean delivery was eventually performed with the patient's consent. The mean age of patients who initially disagreed was younger (24.7 +/- 6) than that of those who agreed (31.0 +/- 4 [p < 0.05]). Conflicts were present in 7 of 113 clinic patients and 0 of 213 private patients (p < 0.05). Of those surveyed, 26 (8.7%) indicated that they did not have adequate input in the decision for non-elective cesarean delivery. Patients with inadequate input expressed significantly more concerns with regard to the effect of surgery on their own health (p < 0.05) as well as its effect on the baby (p < 0.05). Our findings suggest that even though the incidence of physician-patient conflict about non-elective cesarean delivery was quite low, a significant number of patients (1 in 12) may have reservations concerning the informed consent process at the time of non-elective cesarean delivery. Patients with reservations are more likely to have greater concerns with regard to maternal and fetal risks, suggesting that a more detailed risk disclosure prior to the procedure is warranted for all pregnant patients. Perhaps by incorporating the preventive strategies discussed, the adequacy of informed consent and therefore the patient's autonomy could be enhanced, thus diminishing patient reservations and preventing physician-patient conflict in the intrapartum period.
Subject(s)
Cesarean Section/psychology , Disclosure , Dissent and Disputes , Ethics, Medical , Group Processes , Informed Consent , Physician-Patient Relations , Pregnant Women , Adult , Case-Control Studies , Female , Humans , Patient Acceptance of Health Care , Patient Participation , Personal Autonomy , Pregnancy , Risk Assessment , Truth DisclosureABSTRACT
The effects of experimental procedures believed to increase cytosolic calcium on basal and vasopressin-stimulated osmotic water flow and transepithelial sodium transport were examined in the toad urinary bladder. Exposure of isolated toad bladders to quinidine, calcium ionophores (A23187, X537A), or low-sodium or potassium-free serosal solutions resulted in a dose-dependent decrease in the hydrosmotic response to vasopressin or exogenous adenosine 3',5'-cyclic monophosphate (cAMP). The degree of inhibition of cAMP-induced water flow induced by low-sodium or potassium-free serosal bathing media varied, and in a similar manner, with the serosal calcium concentration. The effects of quinidine sulfate (2 X 10-4 M), X537A (2 X 10(-5) M), and low serosal sodium (20 mM), but not that of A23187 (10(-5) M), were readily reversible. Exposure to quinidine (4 X 10(-4) M), A23187 (10(-5) M), X537A (5 X 10(-6) M), or low serosal sodium (2 mM) also inhibited the basal short-circuit current (SCC). Vasopressin, 4-20 mU/ml, completely overcame the inhibition of the SCC induced by quinidine, A23187, or low serosal sodium, but a submaximal dose of hormone (4 mU/ml) failed to fully reverse the inhibitory effect of X537A, 5 X 10(-6) M. These results are consistent with the view that 1) a Na-Ca exchange process operates across the basolateral surface of the granular epithelial cells of the toad urinary bladder in vivo, and 2) the level of free calcium in the granular cell cytosol plays a modulatory role in the control of apical membrane water and sodium permeability by vasopressin, and in the regulation of the basal rate of transepithelial sodium transport.
