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ABSTRACT
Objectives:
Since the Human Rights Act was published by
the United Nations in 1948, patients' rights
have become an important issue worldwide. The
aims of this study were to call our residents'
attention to this subject, to define their knowledge
and thoughts, the factors related, and to identify
their deficient points.
Methods:
In this cross-sectional study, an anonymous,
volunteer-based, structured questionnaire consisting
of 31 open- and closed-ended questions about
socio-demographic features, thoughts and knowledge
level of residents on patients' rights, informed
consent, and euthanasia was applied to the residents
of a university hospital. Chi square and student
t- tests were performed for the statistical
evaluation. A p value smaller than 0.05 was
accepted as statistically significant.
Results:
There were in total 123 residents, and, 88 (71.5%)
of them participated in the study. The mean
age was 30.04±3.7 (23-39) years. The
ratio of the residents who had read the PRR
was 26.6%. Residents, who had read the PRR and
who had more years of higher service, had fewer
problems in patient-doctor communication. The
mean knowledge score was 7.2±1.9, and
obtaining 9 points or more was considered to
be "sufficient". Of the total, only
23.9% was determined as having sufficient knowledge
about patients' rights, informed consent, and
euthanasia and 52.3% declared that they needed
education about these subjects.
Conclusion:
The knowledge level and awareness of residents
about patient rights, euthanasia, and informed
consent was insufficient. These issues should
be included in the undergraduate and postgraduate
medical education curriculum.
Key
Words: patients' rights, euthanasia,
informed consent, residents.
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Introduction
Since
the Human Rights Act was published by the United Nations
in 1948, patients' rights have become an important
issue worldwide(1). Since then, patients' rights have
been addressed in many global meetings. At the beginning
of the 1990s, the European Office of World Health
Organization (WHO) declared the Rights of Patients.
With respect to the patients' rights laws, Turkey's
basic laws are concordant with those of other western
countries(2). The Turkish constitution, which was
ratified in 1982, states that the Government has to
provide necessary interventions to maintain physical
and psychological health for everyone. It also states
that without the patient's approval, an individual
cannot be used as a research subject, and no part
of their body can be touched other than for medical
necessity and legal requirements(3). Although, there
is a code for patients' rights (Patients' Rights Regulation-PRR),
which was legislated in 1998, to date, there is no
law about this issue in Turkey. Currently in Turkey,
the Turkish Physician Association Law, Turkish Penal
Code, and the Code for Medical Ethics regulate physician's
practices(4). Turkish Ministry of Health require
all hospitals to display a copy of the Patients' Rights
Regulation (PRR), in abbreviated form, in a visible
place where it can be easily accessed by patients,
healthcare professionals and visitors.
Informed
consent is the autonomous authorization of an individual
for medical intervention(5). In professional and
legal regulations, informed consent is considered
to be an important element of good clinical practice
and one of the indispensable issues of patients' rights(6).
The
researcher is required to inform research subjects
in lay terms about the research goal, methodology,
expected benefits and potential side effects according
to the Code for Medical Ethics. This code also states
that written informed consent has to be arranged(1).
The Turkish Ministry of Health requires all hospitals
to display a copy of the Patients' Rights Regulation
(PRR), in abbreviated form, in a visible place where
it can be easily accessed by patients, healthcare
professionals, and visitors.
Euthanasia
is a Greek word, which means willing for terminating
the life of oneself in a painless way(6). Regarding
euthanasia, laws around the world vary greatly. Although
it is generally disapproved and punished in many countries
like Turkey from Hippocrates till now, it is legal
in some nations(7). Nowadays, this issue is being
discussed as it can cause moral conflicts for the
individual and among different cultures, religions,
and other groups. To our knowledge, in Turkey, there
are only a limited number of studies that present
physician's thoughts, knowledge, and attitudes about
euthanasia.
Residents
in tertiary care hospitals deal with the majority
of the population as tertiary care is mostly preferred
and used as primary care by the public in Turkey.
Typically, the residents are a patient's first point-of-contact
for both in- and out-patient care(8). Physicians'
thoughts and understanding of patients' rights, informed
consent, and euthanasia may affect their attitudes
toward the patients. If a physician contravenes the
rights of a patient, the patient may sue the physicians.
According to the Ministry of Health's instructions(9),
malpractice trials have increased in recent years.
So to avoid these trials, physicians need to understand
and obey the legal rules regarding patients' rights.
Currently, this subject is not included as part of
residency training. In Turkey, there are a limited
number of research studies investigating physicians'
knowledge of patients' rights and their associated
responsibilities.
Therefore the goals of this
study are:
- to call our residents'
attention to this subject;
- define their knowledge
of and thoughts regarding patient rights and determine
any related factors;
- identify any deficient
points; and
- to educate our residents
on this subject.
Methods
Data
were collected from December 1, 2005 through to January
31, 2006. Our target population was all residents,
who were dealing directly with patients in Adnan Menderes
University Research Hospital.This hospital serves
a population of about 2 million in the Eagean part
of Turkey, which is considered as developed and has
a better socio-economic status.Departments of clinical
medical sciences can be divided into two basic parts:
internal medicine and surgical. There were 19 departments,
which have both out- and in-patient clinics.Each department
was visited once in the morning and then at the end
of the day to collect the questionnaires. An anonymous,
volunteer-based, structured questionnaire was developed
and used.The questionnaire consisted of 31 open- and
closed-ended questions about socio-demographic features,
thoughts and knowledge level of residents on patients'
rights, informed consent, and euthanasia.The residents
who did not volunteer or who were absent on that day
were not followed up.
The
cut-off point of the total knowledge score was determined
to be 9 out of 14 because 8 was the mean knowledge
score of the residents (7.2±1.9). Obtaining
9 points or more was considered to be "sufficient"
for this study. Years of service in the medical profession
was grouped as Group I = "5 years or less"
and Group II = "6 years or more."
The
answers for open-ended questions were categorized
for data entry. The data were presented numerically
and in percentages. The socio-demographic features
were given as means ± standard deviations (SD).
Chi square and student t- tests were performed for
the statistical evaluation. A p value smaller than
0.05 was accepted as statistically significant.
Results
There
were totally 123 residents (41 were from surgical,
82 were from internal medicine departments). Of the
total, 88 (71.5%) participated in the study. The mean
age was 30.04±3.7 (23-39) years. The mean of
the years of service in the medical profession was
6.1±3.6. Table 1 shows the distribution of
residents according to departments and gender.
Table
1. Residents according
to gender and departments
| |
|
Departments |
|
| Gender |
|
Internal |
Surgical |
Total |
| Female |
30 |
9 |
39 |
| Male |
32 |
17 |
49 |
| |
Total |
62 |
26 |
88 |
The
ratio of the residents, who read PRR, was 26.6%. Residents
who read the PRR had a better mean knowledge score
on patients' rights (p=0.004). There was no statistical
significance of the residents' knowledge of patients'
rights after reading the PRR based on their gender;
however, the more years of service of the residents
(p=0.041) did correlate to an increased understanding
of patients' rights after reading the PRR. Residents
who read the PRR and who had more years of service,
had fewer problems in patient-doctor communication,
but these findings were not statistically significant
(p= 0.063 and p=0.059, respectively).
The
mean knowledge score was 7.2±1.9, and of the
total, only 23.9% was determined as having sufficient
knowledge about patients' rights, informed consent,
and euthanasia. Of the total, 52.3% declared that
they needed education about these subjects. The remainder,
who declared that they did not need any education
on these subjects, thought that their knowledge was
sufficient. There was no relationship between the
resident's knowledge level and gender, department,
years of service, or wish to be educated.
Of
the group, 79.7% thought that they obeyed the PRR
rules, but 40.5% thought that other doctors did not
obey those rules. 74.1% of participants stated that
patients' rights should not be considered as more
important than the rights of the doctors. Residents
in Group I supported this idea much more than those
in Group II (p=0.003). There was no statistical significance
according to gender, department, or knowledge level.
Of
the participants, 71.6% declared that they had problems
with their patients. 40.2% indicated that they had
had problems with their doctors when they were the
patient. When they were dealing with patients, 37.3%
of doctors complained about problems originating from
their patients, 37.3% experienced problems resulting
from a lack of communication, and 25.4% thought that
the problems were due to the health system. When the
doctors were in another doctor's office as a patient,
lack of communication accounted for 37.5% of the problems,
and problems originating from their doctor's behaviors
comprised 62.5%.
Of
the total, 86.4% could describe what is meant by informed
consent, and the most common description was "giving
total information to the patients about the procedure
and their health status". Residents thought that
informed consent was required during interventions
and treatments in which the risk of death was higher.
Of
the residents, 43.2% declared that euthanasia is a
kind of suicide, and 38.6% thought that it was legal
in Turkey (which was the wrong answer). 54.3% thought
that euthanasia was one of the patients' rights (which
was the wrong answer, also). 46.2% of the residents
stated that euthanasia should be legal, and of those
residents, 20% indicated that the most important reason
for their statement was to alleviate the patient from
suffering pain. The second common reason for legalization
of euthanasia among the residents was their thinking
that euthanasia was one of the patients' rights. Among
the residents who thought that euthanasia should be
forbidden, the most common reasons given were the
probable abuse of legal and religious beliefs.
Discussion
Nowadays,
patient rights reflect human rights and are the basic
issues of patient care. The importance of ensuring
patients' rights is the need to provide better health
care. Considering laws on patients' rights, Turkey's
basic laws are concordant with many other countries.
This study indicates that 75% of our residents have
not read the PRR, and their knowledge about patients'
rights, informed consent, and euthanasia is minimal.
In a study by Özdemir et al.(10), 63% of the
physicians have not read PRR, and 40% of the physicians
were unaware of any legal arrangements associated
with patients' rights. These results are concordant
with our study.
We
found that when the years of service increased, the
number of doctors who had read the PRR also increased.
This finding is discordant with Özdemir's study
that found PRR reading decreased with years of service.
We also found that residents, who read the PRR and
had longer years of service, had fewer problems with
patients. This may indicate that reading the PRR and
experience in the profession can lessen the problems
as PRR reading significantly increased the mean knowledge
score of patients' rights.
In
our study, the knowledge level of our residents about
patients' rights was low, which was concordant with
other studies that were conducted in Turkey(10,11).
Despite the fact that less than 25% of the residents
had sufficient knowledge of patients' rights, only
half of them declared that they needed education about
this subject. This can be considered as an unawareness
of the residents about their knowledge level.
Years
of service was found to be an important factor with
regard to having read and understood the PRR. This
correlated to a doctor having fewer problems with
patients and giving priority to patient rights over
those of the physician(10). Most of the residents,
4 out of 5, thought they obeyed the PRR rules, but
of the total, 2 out of 5 declared that other doctors
did not. We considered this finding as a self-bias.
The ratio of the residents, who had problems with
patients, was 71.6%, and most of those were patient-related
problems.
For
the in-patient situation, 40.2% had problems with
other doctors and most of those were doctor-related
problems. This can be also considered as self-bias
and an unawareness issue.
The
ratio of the residents who knew the definition of
informed consent was 86.4%. This result is concordant
with the findings of Ozdemir's study(10).
Although
in Turkey, euthanasia is illegal, considered to be
assisted suicide, and accepted as violating the human
rights of the individual, less than half of the residents
knew this fact(12). Furthermore, 54.3% thought that
euthanasia was one of the patients' rights.
Nearly half of the residents stated that euthanasia
should be legal mostly because of alleviating a patient
suffering from pain. The remainder of the residents
thought euthanasia should be forbidden because of
religious beliefs, as suicide is considered to be
a sin in the Islamic religion.
Our
study can be considered as valuable because it is
one of the first studies which searches the residents'
knowledge and attitudes about patients' rights and
euthanasia. Although our questionnaire was not validated,
as participation rate was high, these findings can
be considered as representing all of our residents.
Further studies are needed to explore the real attitudes
of the residents and patients' satisfaction on residents'
care.
In conclusion, the knowledge level and awareness of
residents about patients' rights, euthanasia, and
informed consent was insufficient. Consequently, education
should be provided earlier because it takes a long
time for knowledge and opinions to change behaviors,
so these issues should be included in the undergraduate
and postgraduate medical education curriculum.
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