Define complementary and alternative medicine (CAM).
List some common misconceptions about CAM.
Using the NIH website, how would you describe CAM and the typical person who uses CAM?
What are the percentages of people using CAM with prayer and those who do not?
Write a short (50-100-word) paragraph response for each question posed below. Submit this assignment as a Microsoft Word document.
1. Define CAM.
2. Describe the patient who uses CAM the most.
3. List some common misconceptions about CAM.
4. Identify methods of including the use of CAM in patient education.
5. Discuss the safe use of CAM.
6. List ways in which conventional medicine and CAM can be integrated.
7. Define ethical theories, ethical principles, and values.
8. Provide examples of ethical issues in patient education and compliance, and describe ways in which an effective professional/patient relationship and a poor health professional/patient relationship can impact these issues.
9. Explain what is meant by “ethical patient education practices”.
10. Explain the purpose of informed consent.
11. Discuss what factors determine the patient?s ability to give informed consent.
12. Compose a sample informed consent form. .
13. Discuss the process of communication to use with the patient and the family when obtaining informed consent.
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Safonte-Strumolo, N., & Dunn, A. B. (2000). Consideration of cultural and relational issues in bereavement: the case of an Italian American family.
The Family Journal: Counseling and Therapy for Couples and Families, 8(4), 334?340.
Schears, R. M. (1999). Ethical issues in emergency medicine: Emergency physicians? role in end-of-life care. Emergency Medicine Clinics of North
America, 17(2), 539?559.
Shields, C. E. (1998). Oncology: Giving patients bad news. Primary Care: Clinics in Office Practice, 25(2), 381?390.
Siegler, E. L., & Levin, B. W. (2000). Communication between older patients and their physicians: physician?older patient communication at the
end of life. Clinics in Geriatric Medicine, 16(1), 175?204.
Soriano, R. (2007). Overview of palliative care and non-pain symptom management. In R. Soriano (Ed.). Fundamentals of geriatric medicine: A case
based approach (pp. 547?572). New York: Springer.
Stanley, M., Blair, K. A., & Beare, P. G. (2005). Gerontological nursing: Promoting successful aging with older adults. Philadelphia: F. A. Davis.
Taylor, E. J. (2006). Spiritual assessment. In B. R. Ferrell & N. Coyle (Eds.). Textbook of palliative nursing (2nd ed., pp. 581?594). New York: Oxford
Tulsky, J. A. (2005). Beyond advance directives: Importance of communication skills at the end of life. Journal of the American Medical Association,
Vincent, J. L. (2001). Cultural differences in end-of-life care. Critical Care Medicine, 29(2 Suppl), N52?N56.
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Ethical Issues in Patient Teaching and Patient
All health professionals have a code of ethics by which they are to abide. Ethics is a system of values that guides
health professionals in their behavior toward patients in a variety of situations. Although each profession?s code
of ethics provides a statement of responsibilities for members of that profession, the code alone is not adequate
for every decision and action with which health professionals may be confronted (Cottone & Tarvydas, 2007).
Some situations confronting health professionals in the healthcare setting are straightforward; however, other
situations raise ethical issues that involve questions not so easily resolved.
Health professionals sometimes perceive ethical decisions made in one situation as applicable to all similar
situations. However, a more appropriate description of ethical decision making is determining what is better or
best in a particular situation under the given circumstances. Ethical principles do not determine absolute, eternal
law. What is considered ethical in one situation may not necessarily be considered ethical in a similar situation
that is under different circumstances. Ethical principles provide guidelines by which health professionals can
reach decisions about what should be done in a particular situation after considering all relevant factors.
Ethical theories provide a broad framework of rules and principles that serve as a foundation for judgments or
courses of action. There are two major types of ethical theory: (1) teleologic and (2) deontologic.
Teleologic theory, sometimes called utilitarian theory, pertains mainly to consequences or results of action.
Using this theory as a basis for ethical problem solving would mean that health professionals would consider the
consequences of performing or not performing an act and base their decision on which course of action would
bring the greatest good to the greatest number of people.
Consider the following example of applying teleologic theory to patient teaching. A health professional
developed new patient teaching materials that he was interested in marketing to a publisher of patient teaching
materials. Before approaching the publisher, however, the health professional was interested in testing the
effectiveness of the materials with regard to enhancing patient adherence, to have a means of comparison. In so
doing, the health professional decided to give one group of patients, the patient teaching materials that were of
lesser quality and that did not contain all the relevant information about their condition and the potential side
effects of treatment. In determining whether this practice was ethical or not, the health professional reasoned
that the action was justified because a greater number of people would benefit in the long run by knowing which
material would produce the greatest results.
A problem with this approach, of course, is that it is often difficult to measure or to reach general agreement
on what is the ?greatest good.? ?Good? may be based on an individual?s values, which may differ significantly
from the values or perception of good held by others.
The other major type of ethical theory, deontologic, sometimes called formalist theory, pertains to duty or
obligation. In this case, health professionals would consider their own motivation when justifying an action rather
than considering the consequences of the action itself.
For instance, consider the same preceding example, but with deontologic theory applied instead. In this case,
the health professional would consider his motivation for giving the patients the patient teaching materials that
had incomplete information. If, in self-evaluation, the health professional believed that the real reason he was
giving the patients the inferior materials was not to form a valid comparison, but rather to be assured that his
materials would look better (making it more likely that the publisher would accept the brochure, thus resulting in
financial profit for him), he may determine that the action is unethical.
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Autonomy is the degree to which individuals are allowed to make their own choices and choose their own
destiny. To be autonomous, people must be self-governing, having the ability to exercise control over their own
actions and circumstances. This means that to be autonomous in decision making, individuals must make
decisions voluntarily without coercion and without undue influence. Autonomy is, however, based on a
presumption of the individual?s competence to understand information needed to help him or her make decisions
and on his or her ability to understand fully the consequences of the decisions.
In patient teaching and patient adherence, the principle of autonomy is used when health professionals allow
patients to make their own choices about which instructions they will follow and the extent to which they will
follow them. Health professionals are, at times, reluctant to afford patients autonomy, believing that patients do
not have the full range of knowledge that would allow them to make reasonable decisions. In other instances,
health professionals allow their own values to affect those of patients in deciding what is best. There are
limitations to autonomy. No principle is absolute. When allowing patient autonomy would threaten the autonomy
or well-being of others, patient autonomy does not take precedence. Take, for example, an individual who has
been diagnosed with active tuberculosis but refuses to take the medication needed to treat the disease. To allow
the patient complete autonomy in this decision and not attempt to influence him or her to take the medication
would not be responsible on the part of the health professional, since actions of not following the treatment
protocol could impinge on the health or well-being of others.
Most health professionals hope to do what is ultimately best for the patient to further enhance the patient?s
welfare or well-being. In holding this view, the health professional is guided in promoting the patient?s best
interest by preventing harm.
Beneficence is in conflict with autonomy, and like autonomy, it is not absolute. Beneficence is ethically
applied if, in so doing, the individual generally believes that what is done will cause more benefit than harm. It is
not justified, however, if the individual applying the principle of beneficence has an ulterior motive, such as his or
her own gain, or if the benefit would not be experienced by the patient but by others. Although beneficence, when
applied appropriately, can be noble, it must be applied with caution so as not to infringe on the patient?s rights.
Nonmaleficence can be defined simply as ?do no harm.? Although it may be difficult to see how providing patient
teaching information could ostensibly harm an individual, the information could cause harm if it encouraged the
patient to engage in behavior that was ultimately harmful, or if information was withheld from a patient, harm
could be caused because he or she was denied information that could have prevented harm.
Health professionals would not, of course, deliberately give patients information or withhold information
knowingly that would cause patients harm. However, when determining if or to what extent health professionals
should attempt to coerce patients to follow treatment recommendations, or to what extent information should be
withheld or emphasized for this purpose, awareness of this principle is important.
Take the case of Mrs. Raines, admitted to the hospital because of chest pain. Mrs. Raines underwent a
series of tests indicating no permanent myocardial damage, but tests did demonstrate compromise of oxygen to
her heart upon exercise. Believing that a more thorough evaluation of her coronary arteries and cardiac function
should be obtained, the physician recommended that she undergo cardiac catheterization. The nurse spent
considerable time explaining the procedure to Mrs. Raines, including risks and benefits. Mrs. Raines became
quite frightened at the information and declined to have the procedure done. The physician and nurse continued
to talk with her, insisting there was nothing to fear from the procedure, but also alluding to a scenario that unless
she had her condition evaluated so she could be properly treated, she could put herself at considerable risk of
sudden death. The doctor also talked with Mrs. Raines? family members, encouraging them to influence her to
have the procedure done, emphasizing that not doing so could have grave consequences. Finally, Mrs. Raines
consented to the procedure, only to suffer a cardiac arrest from which she could not be resuscitated during the
When encouraging patients to follow recommendations, health professionals must keep in mind that they
have no way of knowing all the potential risks of treatment or whether side effects or risks will occur if the
recommendations are followed. Therefore, providing factual, truthful information that enables patients to be
aware of all potential risks, and consequently to weigh risks and benefits based on their own values, helps to
ensure that the principle of nonmaleficence is not violated.
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Although the basic assumption of nonmaleficence underlies all patient teaching activities, it is not often
made explicit. Giving information is at times taken for granted as an innocuous activity that has the potential for
influencing behavior and enhancing well-being but has little potential for causing harm. As illustrated in the case
above, patient teaching has the potential to do both.
Justice is a principle that implies fairness and consistency. In other words, justice implies equality in all cases.
More broadly, justice may be viewed in terms of how decisions should be made when the interest of one person
or group competes with the interest of another person or group. Whatever decision is made, the principle
mandates that individuals should be treated impartially and not in a capricious manner. An example of application
of this principle to patient teaching may be found in a situation in which there are limited resources, so patient
teaching is not available for all patients. In this situation, of course, a decision about which patients will receive
patient teaching would need to be made. If, in making the decision, the health professional based his or her
reasoning on patients? ethnic or religious background alone, the principle of justice would be violated, and the
process used by the health professional to make the decision would be considered unethical. If, however, the
health professional made the decision based on a process in which there were equal criteria applied to
determine distribution of patient teaching, the principle of justice would be appropriately applied.
CONFIDENTIALITY AND PRIVACY
Confidentiality relates to the concept of privacy. Privacy is a broader concept that relates to the right to be free
from interference from others (Grace, 2004) and to decide what information will or will not be shared with others.
Confidentiality refers to protection of individual information and specifically of healthcare information (Grace,
2009). Most health professionals understand that information gained from the patient is to be considered
confidential and not to be shared with others without the patient?s expressed consent. The Health Insurance
Portability and Accounting Act took effect in 2003 and protects patients? health information in practice as well as
research (Olsen, 2003). In practice, this means that patients? health information, such as information about their
mental or physical health, any care they have been provided, or any other related health information that identifies
them may not be disclosed without their written consent. As applied to research, this means that attaining
information from patients? record, or sharing information for research purposes without their expressed written
consent is forbidden. Even with the patient?s consent, patient information must not be readily identifiable.
In the case of patient teaching, however, this principle may at times be overlooked. Take, for example, the
case of Mrs. Wells, who had recently referred her husband for Alzheimer?s disease screening at a local medical
facility. As part of the screening protocol, patients and families were asked to participate in a patient teaching
program in which they learned about Alzheimer?s disease. A few weeks after they had participated in the patient
teaching session, Mr. and Mrs. Wells returned to the medical facility to receive results of the screening that Mr.
Wells had undergone. The nurse, Ms. Lee, who had conducted the patient teaching session, saw Mr. and Mrs.
Wells in the waiting room and approached them, asking for feedback regarding the patient teaching program on
Alzheimer?s disease they had attended. Mrs. Wells became visibly upset and later complained to Ms. Lee?s
supervisor for what she considered to be a breech of patient confidentiality. Mrs. Wells had felt very ill at ease
taking her husband for Alzheimer?s screening, fearing that the possibility of such a diagnosis may have some
social stigma for them in their community. One of Mrs. Wells? neighbors had been in the waiting room.
Overhearing Ms. Lee?s comment, the neighbor later began questioning Mrs. Wells about why she had attended
the patient teaching session about Alzheimer?s disease. What Ms. Lee had considered a harmless comment,
Mrs. Wells considered a breech of confidentiality, which caused her considerable discomfort.
Health professionals? assumptions about the nature of patient teaching are based to a great extent on their own
values. These values in turn have a direct impact on how they conduct patient teaching. This includes goals
considered to be important, techniques and methods used, and the degree of responsibility shared by both health
professional and patient. It is important to distinguish fact from value (Rich & Butts, 2005).
The question of values permeates patient teaching. Health professionals? values inevitably affect patient
teaching. Health professionals should be clear about their own values and understand how their values influence
patient teaching. Being aware of his or her own values does not, however, mean that the health professional
should attempt to persuade a patient with different values to accept the values purported by the health
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Not all health professionals involved in patient teaching would accept this view. Some health professionals
believe that their role in patient teaching is to exert influence on patients to adopt health professionals? values.
These health professionals use patient teaching to direct patients toward attitudes and behaviors that health
professionals judge to be best. There is a delicate balance between providing information that, in the judgment of
the health professional, is considered best and being so concerned about protecting patient autonomy that the
health professional is lax in presenting information.
Patient teaching is not a form of indoctrination or a method to make patients conform to what the health
professional believes to be an acceptable form of behavior. No health professional has absolute wisdom
regarding what is best for the patients he or she serves. Health professionals have no way of knowing how
adhering to all the recommendations provided will affect the patient?s life or the extent to which adherence to
recommendations may be helpful or harmful.
However, patients do learn in both direct and indirect ways. If health professionals remain open to patients?
values that may be different from their own, presenting objective information that has basis in fact, an
atmosphere of respect and trust is created. In so doing, health professionals not only demonstrate respect for
patients? autonomy while also practicing beneficence, but also increase the possibility that patients will, through
informed choice, choose the behavior that is in their own best interest.
Health professionals who, on the other hand, attempt to be purely objective without introducing their own
personality may appear to be mechanical and routine in their approach to patient teaching, which can diminish
patients? sense that the health professional has interest in them as individuals and their particular needs and
circumstances, thus making patient teaching less effective. Patients generally expect more involvement from
their health professional than merely providing rote information. They want to know that the health professional
is concerned for them as individuals and often want to know the health professional?s opinion in order to test
their own thinking. Since trust is an important factor in patient teaching, it is important that health professionals
be honest but tactful about their own values when they are relevant to questions that arise. If health
professionals do relate their values to the patient, they should always make it clear they are presenting their
personal opinion, based on their own values and circumstances that may be totally different from those of the
patient and that may have entirely different consequences.
Health professionals convey values to patients in a number of ways other than verbally. In patient teaching,
whether intended or not, health professionals give patients positive and negative reinforcement with behavior as
well as words. A frown, a grimace, or a look of approval in response to a patient?s statement or behavior all
communicate something about the health professional?s values. Consequently, health professionals should be
aware of their own values and how those are demonstrated to patients both covertly and overtly.
It must be remembered that values are often culturally inherited and determined. This may include religious
beliefs and values imbedded within the cultural milieu. Therefore, what one individual considers ethically correct
based on his or her own standards or values may not apply universally to all other individuals. Likewise,
overreliance on cultural and/or religious principles alone to determine an ethical course of action is not always
sufficient to reach an ethical decision acceptable or applicable to all individuals. The same cultural traditions or
religious beliefs may not be held by all parties. Consequently, using commonly shared principles rather than
personal, cultural, or religious values alone is a more reasonable approach to ethical decision making in
situations when a common view is not shared by all.
Religious beliefs and practices affect many dimensions of personal life as well as health and health care.
Differences in religious values, in particular, between patient and health professional can be a barrier to effective
patient teaching. Health professionals should examine their own religious values and be sensitive to how they
influence the way they teach patients. If health professionals have no religious affiliation or are hostile to
organized religion, they should be aware of how their own views may affect patient teaching of patients who hold
strong commitments to the beliefs of certain religions. It is important that health professionals maintain
awareness of the extent to which they understand their patients? religious beliefs and their meanings, and if
different from their own, how this affects their relationships with patients during patient teaching.
Take, for example, Mrs. Brown, a migrant worker who came for an individual prenatal teaching session with
the nurse, Mr. York. Mrs. Brown was expecting her ninth child. Both Mr. and Mrs. Brown were obviously excited
about the pregnancy in anticipation that the baby may be a boy, given that six of their eight children were girls. Mr.
York knew that the financial situation of the family was poor, although the children appeared well nourished and
well cared for. During the teaching session, Mr. York brought up the issue of birth control and the possibility of
sterilization after the birth of the baby. When Mrs. Brown seemed reluctant to accept the idea, Mr. York became
more coercive in his presentation, implying that under the circumstances, to have more children would be
irresponsible. Mrs. Brown looked shocked and attempted to explain that she and her husband believed strongly
that God would provide for any children that would be born. She said they believed that to do anything to prevent
pregnancy would be interfering with nature and a demonstration of lack of trust in God.
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Mr. York shook his head in despair and said coldly, ?I see.? He put away the teaching material and said to Mrs.
Brown, ?Then I guess that will be all. You obviously are not prepared to listen to reason. I need to devote my time
to patients I can help.? Mrs. Brown, although not saying anything, left with sadness, reluctant to bring up other
issues with Mr. York in the future.
Mr. York had, essentially, influenced Mrs. Brown?s behavior, but not necessarily in a positive way. Health
professionals must determine the extent to which they can remain true to themselves and at the same time allow
patients freedom to select their own course of action, even if it differs sharply from the action the health
professionals would choose. Health professionals should conduct patient teaching and present information in
such a way that patients are enabled to make an informed choice in accordance with their values. Referral to
another health professional should be made in situations where the health professional?s values are in conflict
with those of the patient to such a degree that the health professional believes his or her own ethical principles
would be compromised. Under these circumstances, referral should be approached with the patient in a
Health professionals who have liberal values may find themselves working with patients who have more
traditional values or vice versa. By questioning these values or imposing their own, health professionals do not
show respect for patients? beliefs and consequently lose credibility. In some instances, health professionals may
have a strong commitment to values they do not even question, promoting their views at the expense of providing
unbiased information that would help patients to reach their own informed choices. Health professionals should
be clear about their own values and how these affect patient teaching.
Values may also be related to personal characteristics of individuals. Health professionals should be aware
of their own biases and prejudices. For instance, the health professional may have a bias about individuals who
are elderly, who are from different racial or ethnic groups, who are physically disabled, who have a criminal
record, who abuse substances, or who are obese. Any of these biases, whether positive or negative, can affect
the content of or manner in which patient teaching is conducted. Take, for example, the situation described
Mr. Slavinsky was a 72-year-old man scheduled for an appointment for a consultation with Dr. Penn. When
calling for the appointment, Mr. Slavinsky had been reluctant to tell the appointment clerk the purpose of the visit,
saying only that it was ?a personal matter.? At the office visit, Mr. Slavinsky began by saying that he had not felt
well lately and that he had been tired with a slight cough. Dr. Penn examined Mr. Slavinsky briefly and concluded
that she could find nothing wrong. Mr. Slavinsky said shyly, ?I?ve been hearing a lot about AIDS lately and I just
thought I should get checked out. I don?t know very much about it.? Dr. Penn smiled and said, ?Oh, I don?t think you
have to worry about that at your age. You haven?t had any blood transfusions, so it?s unlikely that you would even
have been exposed to the virus that causes AIDS.?
When Mr. Slavinsky became more insistent about receiving information, Dr. Penn said gently, ?Mr. Slavinsky,
we have a very busy practice here. Although I would like to have the time to talk with patients about all kinds of
things, I have to limit my time to giving them information that is most relevant for them realistically. At your age,
you should be more concerned about keeping your blood pressure under control.?
Dr. Penn not only made some assumptions about Mr. Slavinsky that she did not attempt to explore for their
validity, she also imposed her own values on Mr. Slavinsky based on her bias regarding age and not on Mr.
Slavinsky as an individual.
There are many value-laden patient teaching situations. In all instances, it is important that health
professionals be clear about their own values and how they influence patient teaching. Values can affect not
only the way health professionals conduct patient teaching, but also in the end, how effective patient teaching
interactions will be.
IDENTIFYING ETHICAL ISSUES IN PATIENT TEACHING AND PATIENT ADHERENCE
Not every patient teaching situation has ethical ramifications; however, it is important that health professionals
be aware of potential ethical problems related to both patient teaching and patient adherence. As health care
becomes more complex, so do ethical issues related to patient teaching and patient adherence. Advances in
technology in medical care as well as economic issues have brought about significant changes in the healthcare
delivery system and subsequently in the amount of responsibility patients are expected to assume for their own
health and health care. Patients are often discharged from the hospital earlier and expected to manage more
complicated treatment regimens at home. Likewise, as more is learned about the role of lifestyle in the
development of chronic disease, issues of prevention have become more prevalent. Ethical issues related to
lifestyle and prevention occur in situations in which health professionals and patients have conflicting views
about the consequences of lifestyle decisions.
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Theoretically, the purpose of patient teaching is to enable patients to make choices that will maintain or
improve their health status. Often, this may involve behavior change. Behavior change may involve living a
healthier lifestyle to prevent disease or complications from occurring, or it may involve managing a disease or
condition by following specific treatment recommendations.
The underlying assumption of patient teaching is that the goal of both the health professional and patient is
to help the patient to attain his or her optimal degree of health. The patient and health professional may have
differing views, however, about what constitutes optimal health and what methods are best used to achieve it.
Take the example of Mr. Lopez.
Mr. Lopez was a serious jogger, running several miles every day. In addition to jogging for health reasons,
jogging also constituted a major portion of his social life, since he jogged with friends every morning and was
involved with a jogging club, which met for jogging followed by brunch every Sunday morning. During an
examination, Dr. Diego instructed Mr. Lopez that he must relinquish jogging because continuing it would only
further injure his knee, which had been previously injured. Mr. Lopez, however, continued to jog, a choice made
based on his own priority, believing that the other physical and psychological benefits he received from jogging
made the risk of continuing to jog worth the benefit, despite Dr. Diego?s instructions. Dr. Diego?s view was, of
course, much different, believing that the increasing damage from jogging would be a future
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impingement on Mr. Lopez?s well-being, having the potential to cause disability and potentially more
Looking at the situation described above from a patient adherence perspective, it would appear that the
patient teaching was ineffective, given that Mr. Lopez did not change behavior and therefore might be labeled as
non-adherent. Although this situation does not present an ethical dilemma per se, it might have if, for instance,
Dr. Diego had exaggerated his description about the degree of risk involved if Mr. Lopez continued to jog, or if Dr.
Diego had taken other steps to coerce Mr. Lopez into changing his behavior to coincide with his point of view.
The degree to which the health professional interjects his or her own personal bias into patient teaching has
ethical implications. Bias of the health professional may be reflected by th