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Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care discount 10 mg aristocort otc allergy shots tendonitis, 7th Edition order aristocort 15mg on line allergy symptoms dry mouth. Independence: Home care nurses enjoy practic- The home healthcare nurse must identify the needs ing in an autonomous setting where they can of the family and caregiver and assesses whether use their expertise in an expanded role purchase aristocort 4mg free shipping allergy treatment chiropractic. The nurse can also help the patient accountable to the patient best 10 mg aristocort allergy induced asthma, the family, and the and family identify and use community resources primary healthcare provider. Patient advocate: Protecting and supporting the overwhelmed, the nurse can provide resources to patient’s rights—the home care nurse helps a relieve the stress. Coordinator of services: The home care nurse is diabetes, hypertension, and renal disease. What would be a successful outcome for this visiting the patient—the home care nurse helps patient? Educator: Home care nurses spend time teaching and other related diabetic conditions. Califano lists resources that may be contacted nutrition, medications, or treatment and care of to assist with care in the home setting as necessary. Anything the nurse takes out of the bag must be the healthcare delivery system to meet the needs cleaned before returning it to the bag. Anytime the nurse needs to access the bag, Technical: ability to adapt technical nursing handwashing must take place first. The bag should be placed on a liner before numerous health concerns setting it down in the patient’s home. Teaching is geared to the patient’s readiness to learn resources to ensure safe quality home care and adapted to the patient’s physical and emotional Ethical/Legal: ability to practice in an ethically and status. Information that is essential to keep patients legally defensible manner in home settings safe until the next visit is the major focus. Community services, housekeeping services, home Incentives to learn include knowledge of serious healthcare services consequences as well as positive benefits of carrying through with certain behaviors. The focus is on improving the quality of life for the patient and preserving dignity Prioritization Questions for the patient in death. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. The skills necessary to use the nursing process successfully include intellectual, technical, inter- e f a b g d c personal, and ethical/legal skills, as well as the willingness to use these skills creatively when working with patients. Medical diagnosis, nursing diagnosis, all pertinent in the process is a one-time phenomenon; each clinical data step is fluid and flows into the next step. Scientifically based, holistic, individualized care that are most important to the patient and b. The opportunity to work collaboratively with match them with appropriate nursing actions. Continuity of care working knowledge of the nursing process, they Nursing: can apply it to well or ill patients, young or old a. Achievement of a clear and efficient plan of patients, in any type of practice setting. Purpose of thinking: This helps to discipline achieve results for patients thinking by keeping all thoughts directed to b. Opportunity to grow professionally when eval- judge whether the knowledge available to uating the effectiveness of interventions and you is accurate, complete, and relevant. If you variables that contribute positively or reason with false information or lack important negatively to the patient’s goal achievement data, it is impossible to draw a sound 2. Potential problems: As you become more skilled enables the nurse to systematically collect in critical thinking, you will learn to “flag” or patient data and clearly identify patient remedy pitfalls to sound reasoning. Planning and implementing the care: The nurs- to recognize their limits and seek help in reme- ing process helps the nurse and patient develop dying their deficiencies. Critique of judgment/decision: Ultimately, fies both the desired patient goals and the nurs- you must identify alternative judgments or ing actions most likely to assist the patient to decisions, weigh their merits, and reach a meet those goals and execute the plan of care. Practice a necessary skill until you feel plan of care in terms of patient goal confident in its execution before performing it achievement. Take time to familiarize yourself with new equip- centered, goal-oriented method of caring that pro- ment before using it in a clinical procedure. Identify nurses who are technical experts and The goals of the nursing process are to help the ask them to share their secrets. Never be ashamed to seek assistance if you feel holistically, and creatively to promote wellness, unsure of how to perform a procedure or man- prevent disease or illness, restore health, and facili- age equipment. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Do I own my personal strengths and weaknesses Prioritization Question and seek assistance as needed? Make a judgment about a patient’s need for ethical/legal competencies are most likely to bring nursing. Refer the patient to a physician or other health- Intellectual: knowledge of the science of nursing care professional. Plan and deliver individualized, holistic nursing Technical: ability to competently change dressings care that draws on the patient’s strengths. Patient: Most patients are willing to share infor- Interpersonal: ability to counsel Ms. Horvath who is mation when they know it is helpful in planning finding it difficult to respond to the challenge of their care. Support people: Family members, friends, and Ethical/Legal: commitment to patient safety and caregivers are helpful sources of data when a quality care, including the ability to report problem patient is a child or has a limited capacity to situations immediately share information with the nurse. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Open-ended questions: by different members of the healthcare team pro- How will you modify your diet now that you vides information essential to comprehensive have been diagnosed with diabetes? Reflective questions: progress notes: Sources that record the findings What effect will diabetes have on your life? Patient’s health orientation: Patients must iden- can either confirm or conflict with data collected tify potential and actual health risks and explore during the nursing history or examination. Patient’s developmental stage: Nursing assessments their findings and note progress in specific areas are modified according to the patient’s develop- (e. Other healthcare professionals: Other nurses, will interact with the patient for a short or long physicians, social workers, and so on can provide period and the nature of nursing care needs information about a patient’s normal health influence the type of data the nurse collects. Purposeful: The nurse must identify the purpose reading material far away from his face) of the nursing assessment (comprehensive, 9. Immediate communication of data is indicated focused, emergency, time-lapsed) and then whenever assessment findings reveal a critical gather the appropriate data. Complete: All patient data need to be identified to necessitates the involvement of other nurses or understand a patient’s health problem and develop healthcare professionals. Relevant: Because recording data can become The nurse should assess the patient’s body image an endless task, nurses must determine what and self-esteem needs. Working collaboratively with type of data and how much data to collect for other members of the healthcare team, the nurse each patient. Patient should know the name of his/her primary ethical/legal competencies are most likely to bring nurse and what he/she can expect of nursing. Patient should sense that the nurse is competent Intellectual: knowledge of the signs and symptoms and cares about him/her. Patient should know what is expected of Interpersonal: demonstration of strong people skills him/her in terms of developing the plan of care for dealing with individuals experiencing and participating in its execution. Closed questions: ness to use them for patients needing assistance How long have you been experiencing these 4.

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In 1985 Houghton introduced his tea bag method for the rapid solid phase multiple peptide synthesis generic 4mg aristocort with mastercard allergy treatment san antonio. The use of the bag makes it easy to purify the resin beads by washing with the appropriate solutions buy aristocort 4 mg allergy medicine reactions. Furthermore aristocort 40mg on-line allergy symptoms and headaches, the method has considerable flexibility and has been partly automated buy aristocort 10mg cheap allergy symptoms from nuts. Combinatorial synthesis on solid supports is usually carried out by using either the parallel synthesis (see section 6. The precise method and approach adopted when using these methods will depend on the nature of the combinatorial library being produced and also the objectives of the investigating team. However, in all cases it is necessary to determine the structures of the components of the library by either keeping a detailed record of the steps involved in the synthesis or giving beads a label that can be decoded to give the structure of the compound attached to that bead (see section 6. The method adopted to identify the components of the library will depend on the nature of the synthesis. The array of individual reaction vessels often takes the form of either a grid of wells in a plastic plate or a grid of plastic rods called pins attached to a plastic base plate (Figure 6. The position of each synthetic pathway in the array and hence the structure of the product of that pathway is usually identified by a grid code. Consider the general theoretical steps that would be necessary for the prepar- ation of a combinatorial library of hydantoins by the reaction of isocyanates with amino acids (Figure 6. X8) are placed in the well array so that only one type of amino acid occupies a row, that is row A will only contain amino acid X1, row B will only contain amino acid X2 and so on (Figure 6. Beads are added to each well and the array placed in a reaction environ- ment that will join the X compound to the linker of the bead. In other words, compound Y1 is only added to row one, compound Y2 is only added to row two and so on (Figure 6. Each well is treated with 6 M hydrochloric acid and the whole array heated to simultaneously form the hydantoins and release them from the resin. Although it is possible to simultaneously synthesize a total of 96 different hydantoins (Z1–Z96, Figure 6. Each stage is carried out in the general manner described for the previous example. However, at each stage only either the numbered or lettered rows are used, not both, unless a library of mixtures is required. Finally, the products are liberated from the resin by the appropriate linker cleavage reaction (see Figure 6. The pin array is used in a similar manner to the well array except the array of crowns is inverted so that the crowns are suspended in the reagents placed in a corresponding array of wells (Figure 6. Reaction is brought about by placing the combined pin and well unit in a suitable reaction environment. The parallel and pin methods are not the only solid support methods of obtaining combina- torial libraries. It may be used to make both large (thousands) and small (hundreds) combinatorial lib- raries. Large libraries are possible because the technique produces one type of compound on each bead, that is, all the molecules formed on one bead are the same but different from those formed on all the other beads. Each bead will 13 yield up to 6 Â 10 product molecules, which is sufficient to carry out high throughput screening procedures. The technique has the advantage that it reduces the number of reactions required to produce a large library. The beads are divided into a number of equally sized portions corresponding to the number of initial building blocks. Each starting compound is attached to its own group of beads using the appropriate chemical reaction (Figure 6. All the portions of beads are now mixed and separated into the number of equal portions corresponding to the number of different starting compounds being used for the first stage of the synthesis. One reactant building block is added to each portion and the reaction carried out by putting the mixtures of resin beads and reactants in a suitable reaction vessel. After reaction all the beads are mixed before separating them into the number of equal portions corresponding to the number of reactants being used in the second stage of the synthesis. One of the second stage building blocks is added to each of these new portions and the mixture allowed to react to produce the products for this stage in the synthesis. This process of mix and split is continued until the required library is synthe- sized. A−D−G A−E−H A−F−I B−D−G B−E−H B−F−I C−D−G C−E−H C−F−I A−E−G A−D−H A−E−I B−E−G B−D−H B−E−I C−E−G C−D−H C−E−I A−F−G A−F−H A−D−I B−F−G B−F−H B−D−I C−F−G C−F−H C−D−I Figure 6. Unlike in parallel synthesis the history of the bead cannot be traced from a grid reference; it has to be traced using a suitable encoding method (see section 6. Encoding methods use a code to indicate what has happened at each step in the synthesis. They range from putting an identifiable tag compound on to the bead at each step in the synthesis to using computer readable silicon chips as the solid support. These tag compounds are sequentially attached in the form of a polymer-like molecule to the same linker or bead as the library compound at each step in the synthesis (Figure 6. The amount of tag used at each step must be strictly controlled so that only a very small percentage of the available linker functional groups are occupied by a tag. At the end of the synthesis both the library compound and the tag compound are liberated from the bead. The tag compound must be produced in a sufficient amount to enable it to be decoded to give the history and hence the possible structure of the library compound. Key: A−B−C−B−C−etc Library compound Building block Code compound A R B S Resin R−S−T−S−T−etc Code compound C T bead Figure 6. This amplification of the yield of the tag makes it easier to identify the sequence of bases, which leads to a more accurate decoding. At each stage in the peptide synthesis a second parallel synthesis is carried out on the same bead to attach the oligonucleotide tag (Figure 6. In other words, two alternating parallel syntheses are carried out at the same time. On comple- tion of the peptide synthesis, the oligonucleotide tag is isolated from the bead and its base sequence determined and decoded to give the sequence of amino acid residues in the peptide. The sequence of amino acids in the encoding peptide is determined using the Edman sequencing method. This amino acid sequence is used to determine the history of the formation and hence the structure of the product found on that bead. One or more of these tags are directly attached to the resin using a photolabile linker at the appropriate points in the synthesis. They indicate the nature of the building block and the stage at which it was incorpor- ated into the solid support (Table 6. They are selected on the basis that their retention times are roughly equally spaced (Figure 6. The gas chromatogram is read like a bar code to account for the history of the bead. The presence of T1 shows that in the first stage of the synthesis the first amino acid residue is glycine. This residue will be attached via its the C-terminus of the peptide if a linker with an amino group was used and its N-terminus if a linker with an acid group was used. The presence of T3 shows that the second residue is also glycine, whilst the presence of T5 and T6 indicates that the third amino acid in the peptide is serine. Silicon chips can be coded to receive and store radio signals in the form of a binary code. The silicon chip and beads are placed in a container known as a can that is porous to the reagents used in the synthesis.

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The purpose of this chapter is to illuminate the Theory of notion of political/economic caring in the current health-care environment aristocort 4 mg with visa allergy shots blood donation. Ray’s (1989) original Theory of Bureaucratic Caring included political Bureaucratic and economic entities as separate and distinct structural caring categories cheap 15mg aristocort with mastercard allergy kit test. The revised Theory of Bureaucratic Caring cheap aristocort 4mg on-line allergy shots bad for you, however order aristocort 4mg fast delivery allergy medicine high, is represented Caring as a complex holographic theory. Turkel dimensions of bureaucratic caring as portrayed in this chapter are illuminated as interrelated constructs. The political and economic dimensions of bu- Current Context of Health-Care reaucratic caring encompass not only health-care Organizations reform at the national level, but also refer to the po- litical and economic impact of these changes at the Review of the Literature: Political organizational level. Through sections on the cur- and Economic Constraints of rent context of health-care organizations, review of Nursing Practice the literature related to the political and economic constraints of nursing practice, economic caring Economic Implications of Bureau- research, political and economic implications of cratic Caring Theory: Research in bureaucratic caring, and visions for the future, we Current Atmosphere of Health-Care learn how the Theory of Bureaucratic Caring Reform applies. Economic/Political Implications Current Context of of Bureaucratic Caring Health-Care Organizations Summary In the wake of the controversial health-care reform References process that is currently being debated in the United States, the central thesis in today’s economic health-care milieu in both the for-profit and not- for-profit sectors is managed care (Williams & Ray (1989, p. Managed care is an economic con- tion of America and other health care systems to cept based on the premise that purchasers of care, corporate enterprises emphasizing competitive both public and private, are unwilling to tolerate management and economic gain seriously chal- the substantial growth of the last several years in lenges nursing’s humanistic philosophies and theo- health-care costs. Managed care involves managed ries, and nursing’s administrative and clinical competition and is based on the assumption that policies. Within traditional complex health-care or- nursing services to the bed rate for patients ganizations, community or public health agencies, (Shaffer, 1985). This new form of health-care fi- trators who must determine how these resource nancing, based on the ratio of benefits over costs or dollars will be allocated within their respective the “highest quality services at the lowest available institutions. When professional nursing salary outcomes are paramount to health-care organiza- dollars are viewed as an economic liability that tional survival and the economic viability of pro- limits the potential profit margins of organiza- fessional nursing practice. From an economic per- executives attribute these workforce reductions to spective, health-care organizations are a business. It is imperative to the future of is becoming stronger, cost controls are becoming professional nursing practice that the economic tighter, and reimbursement is declining. However, value of caring be studied and documented, so human caring is not subsumed by the economics of The human dimension of health care is health care. Review of the Literature: the human dimension of health care is missing from the economic discussion. Political and Economic In the economic debate, the belief in caring for Constraints of Nursing Practice the patients as the goal of health-care organizations has been lost. Ray (1989) questioned how eco- In order to use the economic dimension of the nomic caring decisions are made related to patient Theory of Bureaucratic Caring to guide research, care in order to enhance the human perspective nursing administration, and clinical practice, it is within a corporate culture. When patients are hos- necessary to understand both the way in which pitalized, it is the caring and compassion of the reg- health care has been financed and the current reim- istered nurse that the patients perceive as quality bursement system. Nurses, who understand the care and making a difference in their recovery economics of health-care organizations, will be (Turkel, 1997). The concerns of patients themselves able to synthesize this knowledge into a framework are not about costs or health-care finance. Yet, in a for practice that integrates the dimensions of climate increasingly focused on economics, it has economics and human caring. Consequently, newer cost systems, such work and charitable religious organizations as managed care, do not look at human caring (Dolan, 1985). Prior to the establishment of or the nurse-patient relationship when allocating Medicare and Medicaid in 1965, the health-care resource dollars for reimbursement. Nursing Historically, nursing care delivery has not been students subsidized hospitals, and hospital-based financed or costed out in terms of reimbursement nursing care was not considered a reimbursable as a single entity. As nursing education As a result of the prospective payment system, moved away from the hospital setting to universi- hospital administrators were pressured to increase ties in the late 1950s and as the role of the student efficiency, reduce costs, and maintain quality. Research was con- the retrospective reimbursement of Medicare ducted in order to examine the costs associated and Medicaid in 1965 allowed for hospital prof- with nursing (Bargagliotti & Smith, 1985; Curtin, itability and the issue of nursing care costs was not 1983; McCormick, 1986; Walker, 1983). Hospital administrators were under process did not include the humanistic, caring considerable pressure to control costs. It Foshay (1988) investigated 20 registered nurses’ was assumed that the rising costs of health care perceptions of caring activities and the ability of were due to nurses’ salaries and the number of reg- patient classification systems to measure these car- istered nurses (Walker, 1983). Findings from this study revealed that a percent of hospital charges could not be identi- patient classification systems could not address the fied, because historically they had been tied to the emotional needs of patients, the needs of the eld- room rate. Specific car- care costs continued to rise and did not follow ing behaviors that could not be measured included traditional economic patterns. Cost-based reim- giving a reassuring presence, attentive listening, and bursement altered the forces of supply and de- providing information. In the traditional economic marketplace, Other research of this time period focused on when the price of a product or service goes up, the the cost and outcomes of all registered nurse demand decreases and consumers seek alternatives staffing patterns (Dahlen & Gregor, 1985; Glandon, at lower prices (Mansfield, 1991). However, in the Colbert, & Thomasma, 1989; Halloran, 1983; health-care marketplace, consumers did not seek Minyard, Wall, & Turner, 1986). These studies an alternative as the price of hospital-based care showed that nursing units staffed with more regis- continued to rise (DiVestea, 1985). This imbalance tered nurses had decreased costs per nursing diag- of the supply-and-demand curve occurred because nosis, increased patient satisfaction, and decreased consumers paid little out-of-pocket expense for length of stay. Government expenditure for the cost- Helt and Jelinek (1988) examined registered based reimbursement system was predicted to nurse staffing in five different hospitals over two bankrupt Social Security by 1985 unless changes years. It was shown that, al- Economic Implications though the acuity of hospitalized patients in- of Bureaucratic Caring creased, the average length of stay dropped from 9. Nursing produc- Theory: Research in tivity improved and quality of care scores increased Current Atmosphere with the increased registered nurse staffing. The of Health-Care Reform higher costs of employing registered nurses was off- set by the productivity gains, and the hospitals net- Investigation of the economic dimension of bu- ted an average of 55 percent productivity savings reaucratic caring is being explicated in part in nurs- (Helt & Jelinek, 1988). Findings from these research Hospital administrators had made budgeting studies have been valuable when linking the con- and operating decisions based on the undocu- cepts of politics, economics, caring, cost, and qual- mented belief that nursing care accounted for 30 ity in the new paradigm of health-care delivery. However, Although caring and economics may seem para- documented nursing research showed this assump- doxical, contemporary health-care concerns em- tion to be in error. A study conducted at Stanford phasize the importance of understanding the cost University Hospital found that actual nursing costs of caring in relation to quality. Similarly, the Ray (1981, 1987, 1989), Ray and Turkel (2000, Medicus Corporation funded a study in which data 2001, 2003), Turkel (1997, 2001), and Valentine were collected from 22 hospitals and 80,000 patient (1989, 1991, 1993) have examined the paradox be- records. Direct nursing care costs represented, tween the concepts of human caring and econom- on average, only 17. However, any bursement and operating room nursing costs, efforts to reshape the health-care system in our nursing represented only 11 percent of the total country must take into account the value of caring. Nyberg’s (1990) research findings indicated that By the time nursing researchers had demon- nurses were extremely frustrated over the economic strated the difficulty of costing out caring activities pressures of the past five years but that human care with patient classification systems and the effective- was present in nurses’ day-to-day practice. With the nurses see human care as their responsibility and introduction of managed care and increased corpo- goal. One ment was changing faster than nurse researchers nurse administrator proposed “caring as the mis- could document the impact of these changes on sion of the hospital with economic and manage- clinical practice. Although there were organiza- industry is now faced with a shortage of registered tional differences, results showed a high correlation nurses. According to statistics provided by the of caring attributes among the various settings. Department of Interviews conducted with nurses indicated a con- Health and Human Services (2000), over the next cern that their “ability to be caring was in jeopardy. These nurses felt that the practice these studies did not merge economic concepts into of caring was being seriously threatened by the nursing research or theory. As the nursing practice economic pressure associated with health-care environment has continued to change, new re- changes. Foa (1971), an ex- Narrative examples of the attribute, exchanging change theorist, designed an economic theory that commodity values, were “making caring tangible” and “patient care is a commodity (economic good could bridge the gap between economic and or value). In this model, noneco- gotiating the politics were “the nurse administrator nomic resources (love, status, and information) is a system coordinator, nurses are the system and were correlated with economic resources (money, know what impinges on them,” and “nurses are po- goods, and services).

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A condemnatory report about a profes- sional colleague may cause great distress and a loss of reputation; prosecuting authorities may even rely on it to decide whether to bring homicide charges for murder (“euthanasia”) or manslaughter (by gross negligence) purchase aristocort 15mg with mastercard allergy forecast tyler tx. Reports must be fair and balanced; the doctor is not an advocate for a cause but should see his or her role as providing assistance to the lawyers and to the court in their attempt to do justice to the parties generic aristocort 4mg free shipping allergy treatment sugar. It must always be conisdered that a report may be disclosed in the course of legal proceedings and that the author may be cross-examined about its content order 15 mg aristocort free shipping allergy medicine memory loss, on oath order aristocort 15 mg mastercard allergy symptoms head, in court, and in public. A negligently prepared report may lead to proceedings against the author and perhaps even criminal proceedings in exceptional cases. Certainly a civil claim can be brought if a plaintiff’s action is settled on disadvantageous terms as a result of a poorly prepared opinion. The form and content of the report will vary according to circumstances, but it should always be well presented on professional notepaper with relevant dates and details carefully documented in objective terms. Care should be taken to address the questions posed in the letter of instructions from those who commissioned it. If necessary, the report may be submitted in draft before it is finalized, but the doctor must always ensure that the final text represents his or her own professional views and must avoid being persuaded by counsel or solicitors to make amendments with which he or she is not content: it is the 54 Palmer doctor who will have to answer questions in the witness box, and this may be a most harrowing experience if he or she makes claims outside the area of expertise or in any way fails to “come up to proof” (i. In civil proceedings in England and Wales, matters are now governed by the Civil Procedure Rules and by a Code of Practice approved by the head of civil justice. Any practitioner who provides a report in civil proceedings must make a declaration of truth and ensure that his or her report complies with the rules. Additionally, the doctor will encounter the Coroners Court (or the Procurators Fiscal and Sher- iffs in Scotland), which is, exceptionally, inquisitorial and not adversarial in its proceedings. A range of other special courts and tribunals exists, from eccle- siastical courts to social security tribunals; these are not described here. The type of court to which he or she is called is likely to depend on the doctor’s practice, spe- cialty, and seniority. The doctor may be called to give purely factual evidence of the findings when he or she examined a patient, in which case the doctor is simply a professional witness of fact, or to give an opinion on some matter, in which case the doctor is an expert witness. Usually the doctor will receive fair warning that attendance in court is required and he or she may be able to negotiate with those calling him or her concerning suitable dates and times. Many requests to attend court will be made relatively informally, but more commonly a witness summons will be served. A doctor who shows any marked reluctance to attend court may well receive a formal summons, which compels him or her to attend or to face arrest and proceedings for contempt of court if he or she refuses. If the doctor adopts a reasonable and responsible attitude, he or she will usually receive the sympathetic understanding and cooperation of the law- yers and the court in arranging a time to give evidence that least disrupts his or her practice. However, any exhibition of belligerence by the doctor can induce a rigid inflexibility in lawyers and court officials—who always have the ability to “trump” the doctor by the issuance of a summons, so be warned and be reasonable. A doctor will usually be allowed to refer to any notes made contemporaneously to “refresh his memory,” although it is courteous to seek the court’s agreement. Demeanor in Court In the space available, it is not possible to do more than to outline good practice when giving evidence. Court appearances are serious matters; an individual’s liberty may be at risk or large awards of damages and costs may rely on the evidence given. The doctor’s dress and demeanor should be appro- priate to the occasion, and he or she should speak clearly and audibly. As with an oral examination for medical finals or the defense of a writ- ten thesis, listen carefully to the questions posed. Think carefully about the reply before opening your mouth and allowing words to pour forth. Answer the question asked (not the one you would like it to have been) concisely and carefully, and then wait for the next question. There is no need to fill all silences with words; the judge and others will be making notes, and it is wise to keep an eye on the judge’s pen and adjust the speed of your words accordingly. Pauses between questions allow the judge to finish writing or counsel to think up his or her next question. If anything you have said is unclear or more is wanted from you, be assured that you will be asked more questions. Be calm and patient, and never show a loss of temper or control regard- less of how provoking counsel may be. An angry or flustered witness is a gift to any competent and experienced counsel, as is a garrulous or evasive wit- ness. Stay well within your area of skill and expertise, and do not be slow to admit that you do not know the answer. Your frankness will be appreciated, whereas an attempt to bluff or obfuscate or overreach yourself will almost certainly be detrimental to your position. Doctors usually seek consensus and try to avoid confrontation (at least in a clinical setting). They should remember that lawyers thrive on the adversarial process and are out to win their case, not to engage on a search for truth. Thus, lawyers will wish to extract from witnesses answers that best sup- port the case of the party by whom they are retained. However, the medical witness is not in court to “take sides” but rather to assist the court, to the best of the expert witness’ ability, to do justice in the case. Therefore, the witness should adhere to his or her evidence where it is right to do so but must be prepared to be flexible and to make concessions if appropriate, for example, because further evidence has emerged since the original statement was pre- pared, making it appropriate to cede points. The doctor should also recall the terms of the oath or affirmation—to tell the truth, the whole truth, and nothing but the truth—and give evidence accordingly. The essential requirements for experts are as follows: • Expert evidence presented to the court should be seen as the independent product of the expert, uninfluenced regarding form or content by the exigencies of litiga- tion (30). If the expert cannot assert that the report contains the truth, the whole truth, and nothing but the truth, that qualification should be stated on the report (32). In England and Wales, new Civil Procedure Rules for all courts came into force on April 16, 1999 (34), and Part 35 establishes rules governing experts. The expert has an overriding duty to the court, overriding any obliga- tion to the person who calls or pays him or her. An expert report in a civil case must end with a statement that the expert understands and has complied with the expert’s duty to the court. The expert must answer questions of clarifica- tion at the request of the other party and now has a right to ask the court for Fundamental Principals 57 directions to assist him in conducting the function as an expert. The new rules make radical changes to the previous use of expert opinion in civil actions. Most pit- falls may be avoided by an understanding of the legal principles and forensic processes—a topic of postgraduate rather than undergraduate education now. The normal “doctor–patient” relationship does not apply; the forensic physi- cian–detained person relationship requires that the latter understands the role of the former and that the former takes time to explain it to the latter. Meticulous attention to detail and a careful documentation of facts are required at all times. You will never know when a major trial will turn on a small detail that you once recorded (or, regrettably, failed to record). Your work will have a real and immediate effect on the liberty of the individual and may be highly influential in assisting the prosecuting authorities to decide whether to charge the detained person with a criminal offense. You may be the only person who can retrieve a medical emergency in the cells—picking up a subdural hematoma, diabetic ketoacidosis, or coro- nary thrombosis that the detaining authority has misinterpreted as drunken- ness, indigestion, or simply “obstructive behavior. Get it wrong, and you may not only fail to prevent an avoidable death but also may lay yourself open to criminal, civil, and disciplinary proceedings.

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