Professional communication of a medical worker. Ethical, deontological and legal aspects of an emergency doctor Department of outpatient and emergency medical care, VolgGMU

Our article will be devoted to the medical ethics of paramedics. It will indicate what medical ethics and deontology are.

To begin with, it is worth establishing. As a rule, this is a set of rules and criteria for the behavior of a medical worker (paramedic) during working hours in the circle of victims and those present at the initial examination. It is worth noting that such a set of rules applies to all medicine as a whole and includes individual units for each class of doctors.

Medical ethics puts forward special requirements for ambulance workers. Particular emphasis is placed on the fact that proper behavior is of great importance not only for the victim, but also for his relatives. According to the code, an employee must have the following qualities:

• good physical and mental health;
• increased level of endurance;
• equilibrium;
• heightened professional observation;
• optimism (within reason);
• high level of training;
• the ability to restrain oneself and remain calm;
• willingness to make decisions regardless of time and circumstances;
• sociability;
• ability to empathize and support the patient.

As a rule, the above qualities are only part of a system called "medical ethics". A very difficult and responsible job falls on the shoulders of the workers in the sphere under consideration, but this does not relieve them of the obligation to relentlessly observe the rules described by such a concept as deontological ethics. And this means that despite the friendly atmosphere in the team, a strict hierarchy and ranking must be present and maintained. And this means that the instructions of the senior brigade must be carried out unquestioningly and immediately. This situation should also be maintained in extreme conditions. It also means that in case of execution of an incorrect order, the entire responsibility lies with the head of the group. This is how responsibility is shared.

The arrival of the ambulance is always eagerly awaited. And, as a rule, every minute in obscurity and expectation leads to an increase in moral tension in a group of people. A similar reaction is observed both in the patient and in those accompanying him (relatives, relatives, friends or family). Therefore, how a medical worker shows his preparedness and awareness will affect the condition of patients.

It is also important that at the time of arrival, the paramedic must have a fundamentally well-groomed appearance, behave confidently and purposefully, not create fuss and confusion, give only specific orders. By such behavior, the doctor should inspire confidence and hope. It is worth noting that in such situations, according to the charter, the entire group of people present at the time of the arrival of doctors is credited to the rank of patients. Medical ethics unequivocally defines the fact that help should be provided to everyone. As a rule, people who are very unwell for unknown reasons experience a strong fear of death, so the doctor must provide not only medical assistance on the spot, but also psychological.

The most difficult case in the medical practice of an ambulance is the departure directly to the scene. In such situations, the regulation prescribes the following actions:

• Avoid fuss, crowds, nervousness.
• Provide the maximum available free space.
• Do not enter into disputes with "advisers" and "critics".
• The sight of blood causes inappropriate behavior - you need to stop the hysteria.

Introduction

medical ethics(lat. ethics, from Greek. ethics- the study of morality, morality), or medical deontology(gr. deon- duty; the term "deontology" has been widely used in the domestic literature of recent years), - a set of ethical norms and principles of behavior of medical workers in the performance of their professional duties. According to modern concepts, medical ethics includes the following aspects:

· scientific - a section of medical science that studies the ethical and moral aspects of the activities of medical workers;

· practical - the area of ​​medical practice, the tasks of which are the formation and application of ethical norms and rules in professional medical activity.

Medical ethics studies and defines the solution to various problems of interpersonal relationships in three main areas:

· medical worker - patient,

· medical worker - relatives of the patient,

· medical worker - medical worker.

The four universal ethical principles include: mercy, autonomy, fairness and completeness of medical care.Before discussing the application of the principles in practice, let us give a brief description of each of them.

The principle of mercy says:"I will do good to the patient, or at least not harm him." Mercy implies a sensitive and attentive attitude towards the patient, the choice of methods of treatment proportional to the severity of the condition, the willingness and ability of the patient to cope with the prescribed medical intervention. The main thing is that any action of a medical worker should be directed to the benefit of a particular patient!

The principle of autonomyrequires respect for each patient's personality and decisions. Each person can be considered only as an end, but not as a means to achieve it. Related to the principle of autonomy are such aspects of the provision of medical care as confidentiality, respect for the culture, religion, political and other beliefs of the patient, informed consent to medical intervention and joint planning and implementation of the care plan, as well as independent decision-making by the patient, or decision-making by a legal representative. this patient.

Principle of justice/do no harmrequires equal treatment of medical workers and the provision of equal care to all patients, regardless of their status, position, profession or other external circumstances. This principle also determines that whatever assistance a medical professional provides to a patient, his actions should not harm either the patient himself or others. When faced with a situation of conflict between a patient and his relatives or other medical professionals, guided by this principle, we must be on the side of the patient.

The principle of completeness of medical careimplies the professional provision of medical care and a professional attitude towards the patient, the use of the entire available arsenal of healthcare for high-quality diagnostics and treatment, the implementation of preventive measures and the provision of palliative care. This principle requires absolute compliance with all legal norms related to healthcare, as well as all provisions of the code of ethics. The moral responsibility of a medical worker implies compliance with all the principles of medical ethics.

Chapter 1

Analyzing the content of codes of medical ethics (starting with the Hippocratic Oath and ending with national codes, including the Russian Doctor's Code of Ethics, 1995, the Russian Nurse's Code of Ethics, 1997), one cannot fail to notice the transformation of their content.

Firstly. The list of persons whose relationships are subject to ethical regulation has been extended. Today, along with patients, doctors and nurses, it includes service personnel and society.

Secondly. The duties of a doctor and a nurse are formulated in a qualitatively new way. They can no longer be expressed simply and unequivocally "to help and not to harm." It is necessary to provide high-quality medical care (care), based on a sense of compassion, respect for human dignity, striving for therapeutic cooperation with the patient, his environment; respect the rights of their colleagues, junior medical personnel. This transformation reflects the changes that have taken place in public consciousness over the past two decades.

.1 Medium therapy

Most of the new medical psychiatric institutions take into account not only the requirements of aesthetics and hygiene, here they strive to help a sick person, creating around him a pleasant, truly homely atmosphere, all possible conveniences. For a modern psychiatric department, curtains on the windows, paintings on the walls, in many places the patients wearing their personal clothes are not new. There is a radio, television, library. However, all this had its opponents: why aesthetics, modernity in the psychiatric department, where most of the people are out of touch with reality, mentally ill, largely suffering from schizophrenia? The complete failure of such an approach has now been proven, since the influence of the environment is of extreme importance precisely on such patients, it is precisely this that contributes to their return to reality. Great achievements in the field of occupational therapy and psychotherapy, the use of modern methods of drug treatment have led to many fundamentally new conclusions that have created the possibility of more effective treatment of the mentally ill.

.2 Behavior Therapy

.3 Relations with relatives

Meeting with persons who played a significant role in the occurrence or exacerbation of the disease is not indifferent to patients. Therefore, allowing visits or not visiting psychiatric wards is one of the means of treatment. The second essential difference is that a considerable part of the relatives of the mentally ill are, to a greater or lesser extent, sick people themselves. Even if they did not play a role in causing the disease in their loved one, then by their inappropriate behavior due to the disease, they can disturb the peace of the patient they visited and prevent his successful treatment. If the patient's environment is favourable, there is no need to forbid his visits to his relatives, or even short visits to his home can be allowed. If visiting the patient with relatives is fraught with the danger of sharp clashes, then a ban should be considered. Disputes with relatives, reproaches, accusations, etc. have a harmful effect on the patient. The activity of the patient connected with the outside world also deserves special attention. A paranoid patient with a litigious syndrome may continue the work he has begun orally or in writing, a jealous husband will use visits to return the "lost" feelings of his wife. Various reactions of relatives of patients associated with a closed department are also known. Often they do everything in their power to resist the fact that a person close to them is brought here (primarily those who feel a sense of their own guilt). "There is no reason to put a child there"... "His condition will only get worse there"... They often compensate for their behavior, dictated by feelings of guilt, by blaming doctors, nurses, and the entire treating team. They consider them responsible for what they themselves are to blame for: "He is treated badly" ... "He does not receive the necessary medicines", "Far from everything that is needed is being done" ... It is characteristic that often those who at first resisted and resented, they are in no hurry to take the recovered home... Despite all these difficulties, despite the fact that often working with relatives of patients means a lot of work, we can get very valuable data, analytical information regarding the patient from them. Of course, if possible, it is better to deal with the whole family at once, and not individually with its members. In this way, the possibility of group (family) therapy opens up before the specialist. The importance of this for the treatment and rehabilitation of the patient, for the prevention of recurrence of the disease is obvious.

.4 Relationship between patients

Usually the patient enters the ward of preliminary observation, from where he is then transferred to where he should be. Naturally, in such cases, the spontaneous desire of the patient to establish contacts, relationships with others, to group with other patients should be taken into account. Therefore, if possible, people of opposite views, different temperaments, different types of personality should not be placed together. In the event of collisions, friction between patients, it is necessary to regroup the patients in the ward, transfer some of them from there; Of course, this should be carried out in such a way that the patients see in these measures not a punishment, but a general restructuring that has affected them as well. And here we should dwell on the question of visiting mentally ill relatives and friends.

.5 Relationships with colleagues

A nurse is required to maintain polite, respectful relationships with colleagues.

Loud conversations, quarrels between staff in the presence of patients are unacceptable, they contribute to an increase in tension and motor excitement in patients, and most importantly undermine the authority of the staff. When communicating with colleagues, the nurse must observe subordination (subordination of the junior to the senior). Compliments in business communication are welcome: saying good words to a person is never harmful. Team relationships don't always go smoothly. There are resentments and disappointments. But even if this is so, the requirements of etiquette must be observed regardless of the mood or state of relations with one or another member of the team.

Chapter 2

mental patient medical deontology

They are based on the following: special knowledge, a constant interest in the work performed, an ever-growing level of training and, of course, a healthy personality. In the specialized literature, many times it was pointed out the harm that people with an unhealthy psyche can cause in their work with the mentally ill, seeking in this work the resolution of their personal mental conflicts. We must not forget that the work of people caring for the mentally ill is fundamentally different from the work of caring for patients of a different profile, since along with the skills of physical care for the sick, they must also master the skills of mental influence. In addition to the usual tasks of caring for the sick (measuring temperature, distributing medicines, making beds), they also have to carry out work of a completely different quality. Many of them learn certain methods of working with the mentally ill, becoming occupational therapists, for example. The personality of orderlies and nurses can affect the state of the mentally ill in different ways. Strong, determined personalities induce a feeling of confidence in immature, infantile patients, while paranoid patients may enter into sharp confrontations with them. A person of a schizotimal warehouse is easier than anyone else to understand a person suffering from schizophrenia. However, all this does not relieve people caring for the mentally ill from the need to constantly develop, expand and improve their knowledge, their personal qualities. Those who work with the mentally ill satisfy the demands of their profession most if they are able to understand the experiences of the patients entrusted to them, to respond accordingly to them, to embrace them in their entirety and complexity.

.1 Speech question

question about speechmedical workers require special attention. All physicians should know that the speech of an employee of any status must comply with the norms of the Russian literary language, excessive saturation of speech with terms in communication with the patient is not welcome. But the use of colloquial or slang vocabulary is also not welcome. This depersonalizes the patient and makes him identical with the disease (“interesting schizophrenia”, “banal suicide”). It is also unacceptable to conduct a conversation with patients and relatives with hard-to-disguise irritation and demonstrate one’s own significance and workload (“there are many of you, but I am alone at my post”), “rewarding” patients with offensive nicknames (“viscous epileptic”, “demented old woman”). The speech of any medical worker is a very striking characteristic of a specialist; its importance should not be underestimated. When teaching the patient, patience must be exercised. Repeat the information as many times as needed. Make sure you understand it correctly. To do this, it is better to use phrases such as: “Let's check if you understood everything”, “What questions do you have?”. And the replicas “I repeat for the especially gifted” or “You need to listen with your ears!” can't even be said as a joke.

With the written method of transmitting information to patients or their relatives (memos, information stands, announcements, etc.), it is also necessary to remember ethics. Various memos, leaflets begin with a polite address (for example, "Dear patient!"). Texts addressed to patients or their relatives should not be categorical (“Do not smoke!”, “Do not leave the ward after 22:00!”, etc.). It is better to replace them with phrases with a positive sound: "We do not smoke", "Please be quiet." Following these rules, respect is expressed both for the patient and for oneself.

It is unacceptable to discuss the state of health or personal life of the patient with colleagues, and even more so with other patients. This is a violation of medical secrecy and entails criminal liability.

.2 Business etiquette in the professional activities of a nurse

The first impression that people or institutions make on us is the most enduring. Acquaintance with a medical institution begins, as a rule, with the nursing staff. Each of us - some less often, some more often - turns out to be a patient of health care services, while a person entrusts the physician with the most valuable thing he has - his health, dignity, life itself, rightfully counting on a certain level of qualification and skill of a professional. That is why, since ancient times, society has made high demands on the moral qualities of nursing staff.

It is better to address the patient by name and patronymic, benevolently and calmly. If you don’t know the patient’s name, use impersonal constructions: “Come in, please,” “Be kind,” etc. The addresses “sick”, “man”, “woman” are not allowed. These seemingly obvious truths, unfortunately, have not yet become the norm.

During the procedures, the nurse comments on her actions for the patient. Such a comment is intended not only to realize the patient's right to information, but also to relieve psychological stress. At the same time, it is necessary to speak in a language understandable to the patient, minimizing special terminology.

.3 Psychological tactics of the nurse's work with the mentally ill

First of all, the nurse must be able to listen to the patient. To understand a mentally ill patient, his thoughts, the peculiarities of his reaction that contradict a sober mind, to be able to understand them, to determine the pathological structure of thoughts and actions is a very difficult task. Therefore, in psychiatry there is an increased requirement for the personality of a nurse, for the development and formation of professional skills in communicating with mentally ill patients. Naturally, condescension, disdain in conversation with patients should be avoided.

Chapter 3

The correct approach to the mentally ill and the establishment of the necessary contact between them and the medical personnel helping in the care of the sick and in the treatment is not possible without sufficient endurance, tact, patience and sensitivity towards the patient, which both the doctor and the paramedic should equally show. , and a nurse, and a nurse, and a nurse.

The main rule, which the middle and junior service personnel must constantly adhere to, is the honest fulfillment of the doctor's prescriptions. Without a doctor's prescription, neither an additional sedative (for example, sleeping pills) can be given, nor can the patient be transferred from one room to another or from bed to bed, or allowed to walk.

The correct approach to the mentally ill and taking into account all the features of caring for them are inconceivable without knowledge of the basics of psychiatry. Arrogance, arrogance, overestimation of their knowledge by staff who have been working within the walls of a psychiatric hospital for many years can bring great harm to the patient. A false belief that it is possible to change the patient's regimen without a doctor's prescription can be the cause of an accident. There was such a case in the practice of one psychiatric medical institution. The patient formally behaved correctly, answered all questions, did not violate the regime, denied any gloomy thoughts and other painful experiences, i.e., in other words, dissimulated (deliberately concealed) her experiences. The paramedic did not take his duties seriously, overestimated his knowledge of psychiatry and, without the consent of the doctor, at his own discretion, allowed the patient to walk without increased supervision. The patient, taking advantage of this, ran away from the walk and threw herself under the train with the aim of suicide.

It is unacceptable that the staff treated the patient with hostility, with antipathy due to the unpleasant features of his mental state. Any manifestation of malice, hostility and even aggression on the part of the patient should be considered and regarded only as a manifestation of a disease state and should not cause a negative or fearful attitude towards him among the staff.

In no case should you raise your voice, be sharp and vicious in dealing with patients, rude shouting, intimidation of the patient are unacceptable. It must also be remembered that patients with catatonic syndrome, who are in a state of complete stupor and as if not reacting to what is happening around them, at the same time record and remember everything very subtly and clearly. Any carelessly spoken word relating to such patients (for example, “he should be sent to the colony, he is a chronicler,” etc.) remains in their minds for a long time. After coming out of the catatonic state, patients with amazing accuracy talk about the behavior of the staff.

Sometimes establishing a patient's contact with a doctor is more difficult than with middle and junior staff. Patients, communicating with them more, get used to them, their relationship is regarded as benevolent. Often patients share with the middle and junior staff such experiences that they do not tell the doctor at all, they turn to them for advice. It is necessary to be able to maintain this trust of the patient. It often helps the doctor in recognizing the patient's hidden experiences.

All correspondence of patients (letters, statements) transmitted through the staff should be received by the doctor for review. The patient cannot be fooled. If the patient asks about the outcome of the disease, the degree of its curability, the date of discharge, the method of treatment and the effect of therapeutic agents on the body, you need to reassure him, without convincing him of anything false. Deception of the patient, failure to fulfill this or that promise not only undermines the authority of the staff, but also increases the distrust, tension, and delusional mood of the patient.

Not all requests of the patient should be fulfilled, since the most innocent at first glance request (give a sharpened pencil or pen with a pen in order to write a letter) may hide the patient's desire to use these items to cause physical harm to himself or others. On the other hand, all the patient's requests that do not contradict the rules of the hospital department, for example, to give a newspaper or a book to read, must be fulfilled within the promised time. Patients whose behavior remains formally correct, but who seem apathetic, indifferent to what is happening around them, require constant monitoring. It is impossible to allow the patient to cover himself with a blanket with his head, since in this position, unnoticed by others, he can tighten a loop around his neck from the sleeve of a shirt, sheet, towel. The staff on duty in the ward must strictly ensure that the towel always hangs in a conspicuous place. Patients with delusions often hide their painful interpretations of the surrounding reality and their thoughts, consider themselves healthy, without sufficient reason placed in the hospital. Such patients may escape from the hospital, unexpectedly show aggressive actions towards other patients and attendants, including them in their delusional experiences. You should never confirm the delusional conclusions of patients and agree with them, just as any joking remarks of the staff, carelessly thrown words, are completely inappropriate and harmful. It is necessary to avoid conversations with patients that irritate them, excite them and contribute to the development of delirium. This is how the active objection of the staff to the delusional beliefs expressed by the patient usually works. It requires endurance, calmness and patience in all cases when the patient feels the need to talk about his experiences. Rough, abrupt, impatient treatment of such patients creates favorable conditions for the development and deepening of delirium. A soft, tactful approach to the patient, distracting him with some activity, as a rule, helps to calm him down. It alleviates the patient's condition by distracting him with some kind of labor process. With a skillful, patient, cordial attitude towards the mentally ill, excessive sweetness and simplicity in a conversation with them should be considered completely unacceptable.

Conclusion

Thus, knowledge of the basics of psychiatry, the strictest discipline, endurance, constant monitoring of the behavior of patients, the absence of arrogance and complacency are the main requirements for the middle and junior staff of a psychiatric medical institution.

The ability to establish proper contact with the mentally ill is also an important and necessary condition for the work of staff. The staff is required to have an even, calm, attentive, sensitive and at the same time strict attitude, the same towards all patients. Also, it should not be forgotten that the legal maximum applies to those who do not comply with the ethical minimum.

Bibliography

1.Andrusenko A.I. Psychological aspects of the work of a nurse in a psychiatric hospital. A.I. Andrusenko, O.B. Kuklina // Head nurse, 2013, No. 6 - p.31-332

Medical ethics and medical deontology - Publication access mode: URL: http://screens.fatal.ru/etica

Petukhov Yu.L. Organization of training on ethical and deontological aspects of the activities of junior medical staff of a psychiatric hospital./Yu.L. Petukhov, V.V.

Filatkina N.V. The role of a nurse in creating comfortable conditions for the stay of disabled people in a psycho-neurological boarding school / N.V. Filatkina / / Head Nurse.-2014 No. 6 p54-61

ChernovV.N. Nursing in psychiatry with a course in narcology. Part 1. - 2nd ed., add. And a reworker. - M.: FGOU "VUNMTS Roszdrav", 2012. - 224p.

Yashina E.S. Ethics and deontology in the activities of a nurse / E.S. Yashina, E.V. Karpova // Nurse - 2013 - No. 1 - p. 32-40

Medical ethics is a section of the philosophical discipline of ethics, the object of which is the moral aspects of medicine. Deontology (from the Greek. depn - due) is the doctrine of the problems of morality and ethics, a section of ethics. The term was introduced by Bentham to designate the theory of morality as a science of morality.

Subsequently, science has narrowed down to characterizing the problems of human duty, considering duty as an internal experience of coercion, given ethical values. In an even narrower sense, deontology was designated as a science that specifically studies medical ethics, rules and norms for the interaction of a doctor with colleagues and a patient.

The main issues of medical deontology are euthanasia, as well as the inevitable death of the patient. The goal of deontology is the preservation of morality and the fight against stress factors in medicine in general.

There is also legal deontology, which is a science that studies the issues of morality and ethics in the field of jurisprudence.

Deontology includes:

• 1. Issues of observance of medical secrecy
• 2. Measures of responsibility for the life and health of patients
• 3. Relationship problems in the medical community
• 4. Relationship problems with patients and their relatives

Medical deontology is a set of ethical standards for the performance of their professional duties by health workers. Those. Deontology presupposes predominantly the norms of relationships with the patient. Medical ethics provides for a wider range of problems - the relationship with the patient, health workers among themselves, with the relatives of the patient, healthy people. These two trends are dialectically related.

Understanding medical ethics, morality and deontology

At the beginning of the 19th century, the English philosopher Bentham defined the science of human behavior of any profession with the term "deontology". Each profession has its own deontological norms. Deontology comes from two Greek roots: deon-due, logos-teaching. Thus, surgical deontology is the doctrine of due, these are the rules of conduct for doctors and medical personnel, this is the duty of medical workers to patients. For the first time, the main deontological principle was formulated by Hippocrates: "You should pay attention that everything that is applied is beneficial."

The word "morality" comes from the Latin "togus" and means "temper", "custom". Morality is one of the forms of social consciousness, which is a set of norms and rules of behavior characteristic of people in a given society (class). Compliance with moral norms is ensured by the power of social influence, traditions and personal conviction of a person. The term "ethics" is used when they mean the theory of morality, the scientific justification of a particular moral system, a particular understanding of good and evil, duty, conscience and honor, justice, the meaning of life, etc. However, in a number of cases, ethics, like morality, means a system of norms of moral behavior. Consequently, ethics and morality are categories that determine the principles of human behavior in society. Morality as a form of social consciousness and ethics as a theory of morality change in the process of development of society and reflect its class relations and interests.

Despite the difference in class morality characteristic of each type of human society, medical ethics at all times pursues the universal non-class principles of the medical profession, determined by its humane essence - the desire to alleviate suffering and help a sick person. If this primary obligatory basis of healing is absent, it is impossible to speak about observance of moral norms in general. An example of this is the activities of doctors and scientists in Nazi Germany and Japan, who during the Great Patriotic War made many discoveries that mankind still uses today. But as an experimental material, they used living people, as a result of this, by decisions of international courts, their names are consigned to oblivion both as doctors and as scientists - “The Nuremberg Code”, 1947; International court in Khabarovsk, 1948.

There are different views on the essence of medical ethics. Some scientists include in it the relationship of the doctor and the patient, the doctor and society, the doctor's professional and civic duty, others consider it as a theory of medical morality, as a section of the science of moral principles in the activities of a doctor, the moral value of behavior and actions of a doctor in relation to patients. According to S. S. Gurvich and A. I. Smolnyakov (1976), medical ethics is "a system of principles and scientific concepts about the norms and assessments of regulating the behavior of a doctor, coordinating his actions and the methods of treatment he chooses with the interests of the patient and the requirements of society."

The above definitions, despite their seeming difference, do not differ so much from each other as complement the general ideas about medical ethics. Defining the concept of medical ethics as one of the varieties of professional ethics, the philosopher G.I. Tsaregorodtsev believes that it is "a set of principles of regulation and norms of behavior of physicians, due to the peculiarities of their practical activities, position and role in society.

According to modern concepts, medical ethics includes the following aspects:

• Ш scientific - a section of medical science that studies the ethical and moral aspects of the activities of medical workers;
• Ш practical - the area of ​​medical practice, the tasks of which are the formation and application of ethical norms and rules in professional medical activity.

Medical ethics studies and defines the solution to various problems of interpersonal relationships in three main areas:

• SH medical worker - patient,
• SH medical worker - relatives of the patient,
• SH medical worker - medical worker.

The four universal ethical principles include: mercy, autonomy, fairness and completeness of medical care.

The principle of mercy states: "I will do good to the patient, or at least not harm him." Mercy implies a sensitive and attentive attitude towards the patient, the choice of methods of treatment proportional to the severity of the condition, the willingness and ability of the patient to cope with the prescribed medical intervention. The main thing is that any action of a medical worker should be directed to the benefit of a particular patient!

The principle of autonomy requires respect for each patient's personality and decisions. Each person can be considered only as an end, but not as a means to achieve it. Related to the principle of autonomy are such aspects of the provision of medical care as confidentiality, respect for the culture, religion, political and other beliefs of the patient, informed consent to medical intervention and joint planning and implementation of the care plan, as well as independent decision-making by the patient, or decision-making by a legal representative. this patient.

The principle of fairness of non-harm requires equal treatment of medical professionals and the provision of equal care to all patients, regardless of their status, position, profession or other external circumstances. This principle also determines that whatever assistance a medical professional provides to a patient, his actions should not harm either the patient himself or others. When faced with a situation of conflict between a patient and his relatives or other medical professionals, guided by this principle, we must be on the side of the patient.

The principle of completeness in the provision of medical care implies the professional provision of medical care and a professional attitude towards the patient, the use of the entire available arsenal of health care for high-quality diagnostics and treatment, the implementation of preventive measures and the provision of palliative care. This principle requires absolute compliance with all legal norms related to healthcare, as well as all provisions of the code of ethics.

The moral responsibility of a medical worker implies compliance with all the principles of medical ethics.

ETHICAL, MORAL, PROFESSIONAL STANDARDS OF BEHAVIOR

The duty of a medical worker provides for the qualified and selfless performance by each medical worker of his professional duties, provided for by the norms of moral, ethical and legal regulation of medical activity, in other words, the duty of a medical worker:

• moral - providing medical care regardless of social status, religion, etc.
• professional - never, under any circumstances, do anything harmful to the physical and mental state of people.

Rules of conduct for a medical worker in the team of a medical institution.

External culture of behavior:

• Appearance (clothes, cosmetics, hairstyle, shoes),
• Observance of external decorum: the tone in which they speak, do not use swear words, rude words.
• Internal culture of behavior:
• attitude towards work
• maintaining discipline,
• Friendliness, observance of subordination.

The main qualities of the internal culture of behavior:

• modesty,
• · justice,
• · honesty,
• · kindness.
• The basic principles of nursing ethics and deontology are set out in the F. Nightingale Oath, the Code of Ethics of the International Council of Nurses and the Ethical Code of Nurses in Russia:
  • 1. Humanity and mercy, love and care.
  • 2. Compassion.
  • 3. Goodwill.
  • 4. Selflessness.
  • 5. Diligence.
  • 6. Courtesy, etc.

Ethical foundations of modern medical legislation:

The ethical foundations define the ethical code of the nurse in each of the countries, including Russia, and are the standards of behavior for nurses and a means of self-government for a professional nurse.

Consciousness of responsibility for the patient's life requires special sensitivity and attention from the nurse. Sensitivity is not only empathy, deep penetration and understanding of the patient's experiences, but also the ability for selflessness and self-sacrifice. However, sensitivity and kindness should not turn into sentimentality, which deprives the nurse of composure and creative activity in the struggle for the health, and often the life of the patient.

Patients often ask nurses about their diagnosis and prognosis. In no case should a patient be told that he has an incurable disease, especially a malignant tumor. As for the forecast, it is always necessary to express firm confidence in a favorable outcome. At the same time, one should not assure a seriously ill patient that his illness is “trifle” and he will “be discharged soon”, since often patients are well aware of the nature of their illness and, with overly optimistic answers, lose confidence in the staff. It’s better to answer something like this: “Yes, your illness is not easy and it will take a long time to be treated, but in the end everything will be fine!” However, all the information that the nurse gives to patients must be agreed with the doctor.

Often, patients enter into a conversation with junior medical staff, receiving unnecessary information from him. The nurse must stop such conversations and at the same time constantly educate nurses, technicians, barmaids, explaining to them the basics of medical deontology, that is, relationships with patients. In the presence of a patient, one should not use terms that are incomprehensible to him and frightening: “arrhythmia”, “collapse”, “hematoma”, as well as such characteristics as “bloody”, “purulent”, “foetid”, etc. It must be remembered that sometimes patients who are in a state of narcotic sleep and even a superficial coma can hear and perceive conversations in the ward. The patient must be protected in every possible way from psychological trauma, which can worsen his condition, and in some cases lead to refusal of treatment or even a suicide attempt.

Sometimes patients become impatient, negatively disposed towards treatment, suspicious. They may have impaired consciousness, may develop hallucinations, delirium. In dealing with such patients, patience and tact are especially necessary. It is unacceptable to enter into disputes with them, but it is necessary to explain the need for therapeutic measures, to try to carry them out in the most gentle way. If the patient is untidy in bed, in no case should you reproach him for this, show your disgust and discontent. No matter how often you have to change bed linen, you need to do it in such a way that the patient does not feel guilty.

At the same time, some patients, as a rule, who are not in serious condition, show indiscipline, violate the treatment regimen: they smoke in the wards, drink alcohol. In such cases, the nurse must resolutely suppress violations of discipline, be strict, but not rude. Sometimes it is enough to explain to the patient that his behavior harms not only him, but also other patients (however, if a nurse who smells of tobacco conducts a conversation about the dangers of smoking, such a conversation is unlikely to be convincing). All cases of incorrect behavior of the patient must be reported to the doctor, as this may be caused by a deterioration in the patient's condition and, at the same time, it is necessary to change the treatment tactics.

Nurse - a nurse is always bound to be self-possessed, friendly, to contribute to the creation of a normal working atmosphere in a medical institution. Even if she is upset or alarmed by something, patients should not notice this. Nothing should be reflected in her work, in her tone in conversations with colleagues and patients. Excessive dryness and formality are also undesirable, but frivolous jokes are also unacceptable, and even more so familiarity in relations with patients.

The behavior of a nurse should inspire respect for her, create confidence in patients that she knows everything and can do everything, that she can be safely entrusted with her health and life.

Of great importance is the appearance of a nurse. Arriving at work, she changes into a clean, ironed dressing gown or into the uniform adopted in this institution, changes street shoes for slippers or special shoes that are easy to sanitize and do not make noise when walking. Hair is covered with a hat or scarf. The nurse leaves all work clothes and shoes in a special locker.

A neat, fit employee inspires confidence in the patient, in her presence he feels calmer and more confident. And, on the contrary, untidiness in clothes, a dirty dressing gown, hair sticking out from under a cap or scarf, abuse of cosmetics, long varnished nails - all this makes the patient doubt the professional qualifications of the nurse, her ability to work accurately, cleanly and accurately. These doubts are most often justified.

The nurse must strictly follow the instructions of the doctor and strictly observe not only the dosage of the medicine and the duration of the procedures, but also the sequence and time of the manipulations. When prescribing the time or frequency of administration of drugs, the doctor takes into account the duration of their action, the possibility of combining with other drugs. Therefore, negligence or mistake can be extremely dangerous for the patient and lead to irreversible consequences. For example, an untimely injection of heparin can cause a sharp increase in blood clotting and thrombosis of the coronary artery. For the same reasons, the nurse should in no case cancel the doctor's appointments on her own or do anything at her own discretion.

Modern medical institutions are equipped with new diagnostic and medical equipment. Nurses should not only know what this or that device is for, but also be able to use it, especially if it is installed in the ward.

When performing complex manipulations, a nurse, if she does not feel sufficiently prepared for this or doubts something, should not hesitate to ask for help and advice from more experienced comrades or doctors. In the same way, a nurse who is well versed in the technique of this or that manipulation is obliged to help her less experienced comrades master this technique. Self-confidence, arrogance and arrogance are unacceptable when it comes to human health and life!

Sometimes in the patient's condition there may be a sharp deterioration, but at the same time panic or confusion should not be allowed. All actions of the nurse must be extremely clear, collected and confident. Whatever happens (profuse bleeding, sudden cardiac arrhythmia, acute swelling of the larynx), it is impossible for the patient to see frightened eyes or hear a trembling voice. Also unacceptable are loud, to the whole department, cries: “Hurry, the patient has a cardiac arrest!” The more alarming the situation, the quieter the voices should sound. Firstly, the patient himself, if his consciousness is preserved, reacts badly to a cry; secondly, it sharply disturbs the peace of other patients, who can be seriously damaged by excitement; thirdly, shouts, continuous haste and often arising nervous squabble exclude the possibility of providing the patient with timely and qualified assistance.

In case of emergencies, orders are given by the head of the department or the most experienced doctor, and before the doctor arrives, by the nurse who works in this ward or office. The instructions of these persons must be carried out immediately and unquestioningly.

Silence in the department must be observed at all times, especially at night. A gentle regimen is a prerequisite for successful treatment, and no medicine will help the patient if he cannot fall asleep due to. loud conversations and the sound of heels in the hallway.

In addition to contacts with patients, the nurse often has to come into contact with their relatives and close people. It also needs to take into account many factors. Medical workers, hiding from the patient the presence of an incurable disease or a deterioration in his condition, must inform his relatives in an understandable and accessible form, but among them there may be sick people, in conversation with whom great care and tact should be exercised. It is also impossible to inform even the closest relatives, and even more so the colleagues of the patient, that he is undergoing some mutilation operations, especially when it comes to a woman. Before talking with visitors, you should consult a doctor, and sometimes ask the patient what you can tell them about, and what it is better to keep silent about.

You should be especially careful when giving information over the phone, it is better not to report any serious, especially sad information at all, but ask to come to the hospital and talk to the doctor in person. Approaching the phone, the nurse should first of all name the department, her position and last name. For example: "The fourth therapeutic department, nurse Petrova." Answers like "Yes!", "I'm listening!" etc. speak of the low culture of the medical staff.

Very often, visitors ask permission to help care for the seriously ill. Even if the doctor allowed relatives to stay in the ward for some time, they should not be allowed to perform any care procedures. Relatives should not be allowed to feed the seriously ill. Practice shows that no care of loved ones can replace the supervision and care of qualified medical personnel for a seriously ill patient.

Modern medical deontology is a complex of legal, professional and moral duties and rules of behavior of a doctor in relation to the patient, his relatives and friends, and colleagues. This is the doctrine of the doctor's duty to the patient and his relatives. Based on it, the relationship between health workers is determined. Medical deontology as a scientific discipline is the core basis of medical ethics. The issues of education, professional training, deontology and medical ethics should occupy one of the leading places in shaping the personality of a qualified SMP doctor. The profession of an emergency doctor is a heroic specialty. The work of an ambulance doctor can be fully and accurately performed only by an excellently and comprehensively trained general practitioner.

The following qualities should be fully inherent in an ambulance doctor: 1. good health, a balanced and mobile nervous system, sufficiently strong physical and psychological endurance; 2. special professional medical observation, determined by well-developed sense organs: vision, hearing, smell, touch, taste sensations; 3. a high sense of optimism, which is based on a fairly rich practical experience and good knowledge of one's specialty; 4. the ability to remain calm, composure and constant readiness to solve new problems in the diagnosis and treatment of urgent pathological conditions in patients and victims in an unusual situation at any time of the day, in the presence of high nervous and mental stress;

5. high professional readiness, namely: knowledge of all emergency conditions that may occur at the pre-hospital stage, the principles and methods of their recognition, the ability to quickly and efficiently carry out emergency medical measures, choose the best tactics; 6. the ability to quickly and easily get in touch with any patient and his relatives, despite the fact that the patient has a severe, sometimes incurable disease; 7. possession of logical thinking and reasoning, the ability to convince the patient and relatives of the correctness of their conclusions; 8. the ability to understand the patient, instill in him faith in recovery, dispel his doubts and fears, support him under any circumstances, no matter how unfavorable they may be for the patient; 9. exclusive discipline, modesty, cleanliness, high decency; special courtesy in relations with patients and their relatives; 10. Formation and constant maintenance of the high authority of colleagues and nursing staff among patients and their relatives.

Despite the complexity and great responsibility of the daily practice of an ambulance doctor, he needs to clearly and scrupulously follow the rules of medical ethics and deontology. The work of an ambulance doctor is constantly associated with the examination and treatment of a large number of patients. Hence, the most important thing in the doctor's activity is to win the trust of the patient. Undoubtedly, the doctor should always be calm, polite, avoid arrogance and haste. One of the important elements of medical ethics is the preservation of medical secrecy. Particularly carefully and punctually, this vow must be observed by the emergency physician.

In the spirit of a pedantic attitude to the preservation of medical secrecy, it is necessary to educate all members of the ambulance visiting team. The ambulance doctor should periodically remind members of his team that professional conversations after examining the patient should in no case be conducted in the apartment, in the kitchen, in the corridor, on the landing and stairs, since there is never a complete certainty that they are not may be accidentally or intentionally heard by unauthorized persons. The state of health of the patient must be very tactfully and briefly, without unnecessary details, reported only to his closest relatives in the absence of unauthorized persons. The emergency doctor also needs to be very careful in formulating his report to the responsible doctor or shift supervisor about making a call, especially if he does this using the patient's home phone.

Performing a visit to the patient, the emergency doctor should never show the appearance that he has little time, a lot of other challenges, and he is in a hurry. This usually makes a very bad impression. The conversation between the doctor and the patient should proceed without any haste, in an atmosphere of goodwill, the initiator should be the doctor who directs it in the right direction. A frank conversation helps the patient to speak out, to open up. The conversation should be conducted in a language understandable to the patient, and correspond to the level of his knowledge and intelligence. The doctor should always strive to ensure that, carefully following the course of the conversation, make the patient to some extent an assistant capable of contributing to the diagnosis and the success of treatment.

An ambulance doctor should be aware that at present, due to the growth of the general culture and education of the population, an increase in some people's interest in medicine, especially due to concern for their health, as well as relatives and relatives, the number of "enlightened patients" has significantly increased , especially from among the "militant amateurs". In a conversation with such patients, the doctor needs to be especially sensitive and patient. Before them, the ambulance doctor acts as an authorized representative of medicine and patiently convinces them of the correctness of the diagnosis and the need for the prescribed treatment.

A conversation between an ambulance doctor and suspicious patients who already presuppose the presence of a serious and incurable disease should have a completely different character. With such patients, one should always talk about their illness with a certain degree of optimism. If possible, then such a patient should be accurately informed of the diagnosis of his disease, in a simple presentation, reveal the essence of this disease and thereby try to involve him in active participation in the treatment.

Analysis of cases from the practice of an ambulance doctor As a rule, the ambulance either does not have its own “workforce” or it is not enough: the team is mostly women. When deciding on hospitalization, such a dialogue often arises: - Look for men, we have no one to carry! We don't have anyone either. You have a driver, we will pay him! He can't leave the car! Verbal duel, as a rule, leads to nothing. Try to start the conversation in a different way: “The patient needs to be carried on a stretcher, you see, we have only women, maybe you can help us find someone, because we don’t know anyone here.” This is how the conversation should go. No categoricalness, no "stubbornness", a friendly, calm tone. Then you can count on success.

Here is another situation: when transporting on a stretcher from some floor, relatives (surrounding) may be perplexed why the patient is carried “feet forward”, because he is still alive? In this case, the doctor or any member of the team should calmly, tactfully explain that this is not “feet forward”, but “feet down”. Because if you take it head first, then on the stairs it will be head down, which is not safe for a seriously ill patient. That is why "feet down" and not feet forward.

"Ambulance" is in a special position. Sometimes they call her without receiving a referral to the hospital from “their” district doctor or without waiting today for a doctor from the clinic ... But you never know what else! Even a conversation with the dispatcher prior to the arrival of the brigade can drive a sick person “out of himself”. And all the accumulated negative emotions will be thrown out on the one who is available, and from whom you can get the most specific and real help. But here you are “attacked” with a stream of claims to which you have nothing to do. Start immediately "defend" when the patient or relatives are still hot? This energy will involuntarily be transferred to you (mirror effect), you will get involved in a conflict, and it is possible that you will suffer from it. How to be? There is such an approach. Ask the essence of the claim (knowing very well that it is not for you) to state it again, explaining that you did not understand something. (Just don’t interrupt the patient, let him speak. The time spent on this will pay off by preventing a conflict, maybe even a complaint, which will then take much more time to resolve and not one, but several people. Do not forget to reflect this situation in the call card). You will notice that there will be less emotions. In extreme cases, you can ask to repeat some part of the entire claim again. The conversation will be very calm. You have given the patient the opportunity to "let off steam." This is just one way to avoid conflict.

It is known that one of the first duties of any doctor is to maintain the authority of his colleague. Unfortunately, in our country there are still doctors who can tell the patient: “You were not treated like that,” or “Yes, you have a completely different disease, you were diagnosed incorrectly,” or “Why were you operated on?” A well-mannered, highly qualified, knowledgeable ER doctor would never allow himself this. It is the duty of every physician to exercise reasonable tolerance for the opinion of his colleague. Attempts to create authority for themselves by belittling the authority of another doctor have never been successful.

The ambulance doctor is obliged to pay constant attention to the relationship between the members of the ambulance team. There should be normal comradely relations between members of the brigade, which are built on mutual respect and maintaining the authority of each other, comradely mutual assistance. Such relationships determine a healthy psychological climate in the team, maintain a good cheerful mood among all its members. The ambulance doctor should understand that the arrogant and dismissive attitude of the doctor, the head of the team, towards junior and middle medical workers is especially intolerant. It is unacceptable when an EMS doctor refers to "you" and calls only by name a nurse, a nurse, a paramedic, a driver who are much older than him in age. This shows not only a disrespectful attitude towards a person, but also a misunderstanding of the important role that junior, middle and technical personnel play in ensuring the work of an ambulance brigade.

Who is morally responsible for human life and health? The answer to it depends on the system of values ​​in which life is considered, or rather, at what level of the value hierarchy: In the system of "human society", the state obviously bears moral responsibility for human life and health. It should ensure the possibility of survival of each person and the conditions for maintaining his health. All social institutions perform these functions to some extent.

In the “human social group” system, the responsibility for the health and life of a person obviously lies with the members of the group. In this sense, such a group as the family is indicative. This responsibility is less obvious in those groups that are called labor collectives. in terms of our consideration, there is a phenomenon of mutual responsibility of each for each.But if in ordinary interpersonal relationships this fact remains unconscious until something happens, then a completely different picture if one of the interacting people is a doctor. human responsibility for the life and health of a partner is enhanced by professional duty, duties assigned to him by society.Therefore, it seems that the only people who bear moral responsibility for the life and health of others are medical workers.

Who is responsible for the life and health of a person, except for those with whom he interacts? The answer is simple man himself. But this simplicity turns out to be inaccessible to the moral consciousness of many. Taking care of one's own health and the instinct of self-preservation is one thing, but responsibility to others for one's life and health is another. This is the norm of morality, which has not yet acquired an imperative character. A dependent position on the issue of one's own health leads, in fact, to new diseases. For medical professionals, the position of the patient in relation to his health is not indifferent, moreover, it is fundamentally important for the entire course of treatment. Therefore, the very principles of medical ethics, even if strictly observed, do not yet guarantee that morality will contribute to the success of treatment.

Principles of medical morality principle do no harm; principle do good; the principle of caring for the patient; the principle of respect for patient autonomy; the principle of maintaining medical secrecy; the principle of a differentiated approach to reporting a diagnosis; iatrogenic exclusion principle.

The principle of do no harm According to B.G. Yudin, the concept of harm from the point of view of a doctor can be considered in four senses: a) harm caused by inaction (failure to provide assistance); b) damage caused by negligence or malice; c) harm caused by unskilled (or thoughtless) actions; d) harm caused by actions necessary in a given situation. For example, untimely provision of assistance: A teenager was admitted to the traumatological department, who was injured as a result of a traffic accident (he was hit by a car while riding a bicycle). The doctor on duty had some time left before the shift and he decided not to help transfer the patient to the doctor who was changing him. The doctor who came on duty needed time to prepare for the implementation of therapeutic measures. As a result of untimely assistance, the child died. A fatal accident was the fact that the teenager was the son of a doctor who did not help the victim and did not even approach him. How to evaluate the act of a doctor? What is the punishment for the doctor? Or can it be considered already punished? It is obvious that there is: a) the fact of failure to provide assistance to someone in need of it, which is no longer subject to ethical, but legal regulation, and b) if the patient was admitted when the doctor’s working hours had already ended, the fact of failure to provide assistance is the subject of an ethical assessment, the principle of non-compliance is violated. harm, but also violates the principle of justice.

The principle of doing good It is possible to resolve the conflict between the doctor's values ​​and the patient's values, but how this is achieved will depend on the doctor's model of communication with the patient. There are four main models of interaction between a doctor and a patient: paternalistic, collegial, contractual and technocratic. The first (paternalistic) is the most common and implies that the doctor is wiser than the patient, knows more and must make decisions himself. According to this model, the conflict of values ​​is resolved in favor of the doctor. In the collegial model, there are high requirements for patient awareness, which ensures cooperation with the doctor on controversial issues. In the contract model, not only the patient, but also the doctor is morally protected. The technocratic model generally tries to eliminate the ethical issue, since the doctor acts as a mechanic who corrects a breakdown, i.e. participates in the treatment process only with his knowledge and skills, but without a personal component. Such a model also has the right to exist, but with a developed service of social workers.

The Principle of Respect for Patient Autonomy The principle of respect for patient autonomy is one of the most difficult principles in medicine. It lies in the fact that the patient himself must give consent to the treatment, moreover, it must be informed, i.e. the doctor must offer the patient all the options for assistance that he can provide with the justification and prediction of the consequences. This in itself can be problematic, and patients are often guided by non-medical considerations in choosing a treatment option.

The reasons leading to the violation of the patient's rights by the medical personnel of the EMS: 1st level ("horizontal") - the prerequisites for errors arise and are implemented at the level of the medical workers themselves due to: ignorance of these rights; failure to comply with known requirements related to the observance of the rights of the patient, including the achievement of informed voluntary consent to medical intervention; specific features of the work of the medical staff of the ambulance service. 2nd level ("vertical") - when the cause of violations of the patient's rights is erroneous recommendations or command instructions of officials, orders (often outdated) executed by doctors or paramedics (the so-called "commission errors").

The rights of persons who applied to the EMS service To respectful and humane treatment by medical and service personnel To examination, treatment and maintenance in conditions that meet sanitary and hygienic requirements To conduct a consultation and consultations of other specialists at his request To alleviate the pain associated with the disease and (or) medical intervention, available methods and means

The rights of persons who applied to the EMS service To keep confidential information about the fact of applying for medical care, about the state of health, diagnosis and other information obtained during his examination and treatment To informed voluntary consent to medical intervention, the patient must be warned about possible complications during conducting medical intervention To compensate for damage in case of harm to his health during the provision of medical care To refuse medical intervention.

Consent and Refusal of Patients from the Assistance of the EMS Service 1. When providing emergency care, oral consent of the patient for medical intervention must be obtained. 2. When providing SMP to persons under the age of 15, the consent of a parent or guardian is required. 3. In cases where the patient’s condition does not allow him to express his will or it is not possible to obtain the consent of the parent (guardian) in relation to persons under 15 years of age, and medical intervention is urgent, the issue of its implementation is decided by the doctor (paramedic) of the SMP with a mark in medical documentation and subsequent informing the administration of the institution about this fact. The patient's refusal to provide assistance is recorded in the documentation in the prescribed form. In these cases, in the event of death or harm to health, medical workers are not responsible.

4. The provision of medical care without the consent of the patient is allowed in relation to persons suffering from diseases or in a state that poses a danger to others. 5. Prior consent of the patient is excluded in the following cases: In case of incompetence of the patient (inadequate consciousness - alcohol intoxication, coma, psychosis, etc.) Urgency of action (cardiopulmonary resuscitation and other critical conditions). In these cases, the issue of providing assistance is decided by the doctor himself, if possible, involving specialists. A note is required in the documentation and informing the administration of the institution where the patient is delivered.

Types of responsibility of medical workers Directly or indirectly, all types of responsibility, except moral, are included in legal responsibility, which can be defined as state coercion to fulfill the requirements of law. Administrative liability is a type of legal liability for an administrative offense (offence), which is not regarded as strictly as the Criminal Code does. Disciplinary responsibility is a form of influence on violators of labor discipline in the form of disciplinary sanctions: remark, reprimand, dismissal on the appropriate grounds. Civil, or civil law, liability is a type of legal liability in which measures of influence established by law or an agreement are applied to the offender. Criminal liability is a type of liability that is regulated by the Criminal Code.

Group A “Violations of moral and ethical rules” includes: violations of elementary norms of culture and professional behavior; conflict relations between SMP workers; mutual confrontation between the EMS doctor and the patient, provoked by: the EMS team or the patient, and / or his relatives; mutual confrontation between employees of the SMP and other medical and preventive institutions (HCF), provoked by: health workers of the SMP, health workers of health facilities; some types of iatrogenic (therapeutic and psychological).

The doctor of the ambulance mobile team is responsible in accordance with the procedure established by law: 1. For the professional activities carried out in accordance with the approved industry norms, rules and standards for the medical personnel of the ambulance. 2. For illegal actions or omissions that caused damage to the patient's health or his death.

LEGAL DOCUMENTS OF THE FEDERAL LEVEL Constitution of the Russian Federation (Articles 41, 71, 72, 73) "Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens" dated July 22, 1993 N Federal Law of the Russian Federation "On the ambulance service and the status of its employees."

"Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens" dated July 22, 1993 N Article 54. The right to engage in medical and pharmaceutical activities: Persons who have received higher or secondary medical and pharmaceutical education in the Russian Federation have the right to engage in medical and pharmaceutical activities in the Russian Federation. Federations that have a diploma and a special title, and for engaging in certain types of activities, the list of which is established by the Ministry of Health of the Russian Federation, also a specialist certificate and license. A specialist certificate is issued on the basis of postgraduate professional education (postgraduate study, internship, residency), or additional education (advanced training, specialization), and a screening test conducted by commissions of professional medical and pharmaceutical associations, on the theory and practice of the chosen specialty, issues of legislation in the field of protection the health of citizens. Physicians during their training in institutions of the state or municipal health care system have the right to work in these institutions under the supervision of medical personnel responsible for their professional training. Students of higher and secondary medical educational institutions are allowed to participate in the provision of medical care to citizens in accordance with training programs under the supervision of medical personnel responsible for their professional training, in the manner established by the Ministry of Health of the Russian Federation. Persons illegally engaged in medical and pharmaceutical activities bear criminal liability in accordance with the legislation of the Russian Federation.

Federal Law of the Russian Federation "On the ambulance service and the status of its employees". Article 1 "Basic concepts": Emergency medical specialist - a doctor who has a certificate in the specialty "emergency medical care" and additional training in any specialty (pediatrics, psychiatry, cardiology, anesthesiology, toxicology, neurology, etc.). ). Article 15 "Admission of an ambulance doctor to professional activities": carried out on the basis of the federal regulation "On the admission of specialists to work in the ambulance service." Advanced training of an emergency physician is carried out at least once every 5 years on mandatory general improvement cycles in the specialty "emergency medical care" in accordance with programs approved by the Ministry of Health and Social Development of the Russian Federation, in institutions licensed to train in this specialty.

Normative documents of the Federal level Organizing Orders of the Ministry of Health of the Russian Federation for emergency medical care. Related orders of the Ministry of Health of the Russian Federation concerning some aspects of the activities of the EMS service. Decrees of the Government of the Russian Federation. Decrees of the relevant ministries and departments of the Russian Federation, instructions letters, guidelines, explanations, etc.

Organizing documents for the NSR. Order of the Ministry of Health of the Russian Federation 179 dated (ed. dated) "On approval of the Procedure for the provision of emergency medical care"

Organizing documents for the NSR. Order of the Ministry of Health of the Russian Federation 445n dated "On approval of the requirements for completing medicines and medical products for the installation of an ambulance team" Emergency"

Organizing documents for the NSR. Order of the Ministry of Health of the Russian Federation 942 dated "On approval of the statistical tools of the station (department), emergency hospital" (together with the "Instructions for filling out the form of industry statistical reporting N 40" Report of the station (department), emergency hospital), "Instructions for filling out accounting form N 109 / y "Ambulance call log", "Instructions for filling out the registration form N 110 / y "Card for an ambulance", "Instructions for filling out the accounting form N 114 / y" Cover sheet of the station (department) ambulance service and a coupon for it", "Instructions for filling out the registration form N 115 / y" Diary of the ambulance station") Decree of the Government of the Russian Federation N 101 dated (ed. from) "On the duration of the working hours of medical workers depending on the work their positions and (or) specialties "IX. Stations (departments) of emergency medical care, stations (departments) of emergency and emergency medical care, departments of emergency and advisory medical care of regional, regional and republican hospitals

Order of the Ministry of Health and Social Development of the Russian Federation 115n dated "On Approval of the Procedure for Providing Medical Assistance to the Population of the Russian Federation in Diseases of the Eye, Its Adnexa and Orbit" (together with the "Procedure for Providing Emergency Medical Care to the Population of the Russian Federation in Acute Diseases and Conditions of the Eye, Its Adnexa and Orbit" ) Order of the Ministry of Health and Social Development of the Russian Federation 966n dated "On approval of the procedure for providing medical care to patients with urological diseases" (together with the "Procedure for the provision of planned medical care to persons with urological diseases", "The procedure for providing emergency medical care to patients with urological diseases") Order of the Ministry of Health and Social Development of the Russian Federation 599n dated "On approval of the Procedure for the provision of planned and emergency medical care to the population of the Russian Federation in diseases of the circulatory system of a cardiological profile" Letter of the Ministry of Health and Social Development of the Russian Federation 15-4 / 10 / from "On the direction of the methodological letter of the Ministry of Health and Social Development of the Russian Federation "Primary and resuscitation care for newborn children" Annex 6. Report card medical institution of obstetric profile and ambulances for primary resuscitation of the newborn"

The rights of the doctor of the ambulance team. 1. If the patient refuses medical care and hospitalization, offer him, and if he is incapacitated, his legal representatives or relatives to confirm the refusal in writing in the "Call Card". 2. Allow relatives to accompany the patient (injured) in an ambulance. 3. To make proposals on improving the work of ambulance teams, improving the working conditions of medical personnel. 4. Improve your qualifications as an EMS specialist at least once every 5 years, pass certification and re-certification in the specialty in the prescribed manner. 5. To take part in production meetings, scientific and practical conferences, symposiums.

The doctor of the ambulance team is obliged to: 1. Ensure the immediate departure of the team after receiving a call and its arrival at the scene of the incident within the established time limit in the given territory. 2. Provide emergency medical care to the sick and injured at the scene and during transportation to hospitals. 3. To administer medicines to patients and injured for medical reasons, to stop bleeding, to carry out resuscitation in accordance with approved industry norms, rules and standards for paramedical personnel for the provision of emergency medical care. 4. Be able to use the available medical equipment, master the technique of applying transport splints, dressings and methods of conducting basic cardiopulmonary resuscitation. 5. Own the technique of taking electrocardiograms. 6. Know the location of medical institutions and the service areas of the station. 7. When transporting a patient, be next to him, providing the necessary medical care. 8. If it is necessary to transport a patient in an unconscious state or in a state of alcoholic intoxication, inspect for the detection of documents, valuables, money indicated in the call card, hand them over to the admission department of the hospital with a mark in the direction against the signature of the staff on duty. 9. When providing medical assistance in emergency situations, in cases of violent injuries, act in accordance with the procedure established by law. 10. Ensure infectious safety 11. Inform the administration of the EMS station about all emergencies that occurred during the call. 12. At the request of the employees of the Department of Internal Affairs, stop to provide emergency medical care, regardless of the location of the patient (injured).

Responsibility of medical workers of the ambulance service for violation of the rights of citizens 1. Medical workers of the ambulance service are liable in accordance with the legislation of the Russian Federation if they perform their duties in bad faith, resulting in harm to the health of citizens or their death. 2. Unreasonable refusal to service the call is the basis for termination of the employment contract. 3. The doctor of the mobile ambulance team is responsible for the organization and quality of work of the ambulance team in accordance with the approved industry norms, rules and standards for medical personnel of the ambulance service.

Responsibility for encroachment on the life or health of employees of the EMS An attack on the life or health of employees of the EMS service who are on duty is punished according to the norms in accordance with the criminal legislation of the Russian Federation. In the event of a threat to the life or health of EMS personnel, medical assistance to patients can only be provided in the presence of representatives of law enforcement agencies, who must guarantee the safety of EMS workers.

When a wise man was asked from whom he learned good manners, he replied: “From the ill-mannered. I avoided doing what they do." And, finally, the wonderful thought of the French encyclopedist Denis Diderot: “It is not enough to do good, you must do it beautifully.”

It would seem that such words as “doctor”, “paramedic” or, unfortunately, the forgotten phrase “sister of mercy”, on the one hand, and the concept of “deontology”, on the other, should, if not be synonymous, then be in an inseparable logical connections. It would seem ... In reality, everything is not so simple.

In addition to purely medical errors (therapeutic-diagnostic, tactical, etc.), it is customary to note deontological errors as well. They are understood as a violation of the rules of relations between a doctor and a patient, as well as between doctors of one or adjacent medical institutions (unfortunately, this happens!), As well as general ethical norms.

The control room is the place where the first meeting, albeit in absentia, between the caller and the ambulance takes place. And it depends on how it happens, whether the challenge will be accepted, if it is accepted, then what order it will receive, what psychological situation the patient will meet with the team. After Professor V.M. Tavrovsky, it turned out that the main thing a person thinks about when calling an ambulance is not to be refused a call. Therefore, to the dispatcher’s question: “What happened?” instead of a specific answer, a lot of unnecessary information “fell out”: about past and present merits, about participation in wars, about attaching to some “prestigious” hospital, etc. It is impossible to interrupt this “turbulent flow”, this will be regarded as disrespect to "merits". And although time was wasted, I had to put up with it. Only after that the dispatcher could proceed to the "extraction" of the necessary information. And in response to the question asked, hear: “What are you interrogating, come soon, you will see for yourself!”. But it is still unknown whether it is necessary to come, especially “quickly”, whether an ambulance is needed. Sometimes the dispatcher was engaged in moralizing, which is generally unacceptable: “Where were you before, why are you only now calling?”

Offering a new system for the control room, V.M. Tavrovsky recommended a completely different dialogue algorithm. The dispatcher must take the initiative "into his own hands", and this can be done by making it clear to the caller that there are no problems with receiving the call. It is clear that when calling to the street or to the apartment, the information about the patient cannot be the same. After the message about accepting the call, a recommendation is given, for example: "Seat (lay down) the patient, give nitroglycerin, if there is no effect, repeat after 3-5 minutes." Now the waiting time will not be so tedious. If the dispatcher is not sure about the need for the ambulance to arrive, he switches the caller to the senior doctor, who not only refuses to leave the team, but gives advice on managing the patient and recommends where to go.

So, if the challenge is accepted, the team went to the patient. Upon arrival, the medical worker should in no case start a conversation with dissatisfaction: why didn’t they meet, why did they call, we drove through the whole city, you are not from our district, the 9th floor, and the elevator does not work, etc. All this "verbal garbage" will immediately create a barrier and interfere with the main task: to make a correct diagnosis and, in accordance with it, provide adequate assistance.

Particular attention should be paid to the situation when assistance has to be provided on the street, at an enterprise (at the workplace), at other similar points (a store, a public transport salon, an underground passage) - in a word, wherever a person is, he may need emergency medical care . The best thing that can be advised in this situation is not to pay attention to others and confidently do your job. Do not enter into discussions, do not respond to remarks. It distracts from work, even if the remarks seem offensive. Be above it. It is necessary to bring the patient's condition to transportable as soon as possible, take him into the car and leave this place (if we are talking about the street). After that, all interest in others will disappear.

The issue of hospitalization of a patient from a public place is decided unambiguously - you can’t leave him on the street. But if you don't know where you need to be hospitalized yet, you can drive around the corner, stop, finish the examination if you haven't already done so, and contact the hospitalization bureau.

For the patient and his relatives, hospitalization is, if not a tragedy, then in any case a disaster, especially when it comes to a young person who is suspected (or diagnosed) of acute coronary syndrome (ACS). After all, yesterday the patient led an active lifestyle, and today he is forced to lie down, reducing his activity to a minimum.

It is necessary to understand the condition of the patient. There is no need for any "horror stories". The effect of them will be opposite to the expected.

Even if the doctor is confident in the diagnosis of ACS and sees that the patient is afraid of this diagnosis as a sentence, you can tell him that there is no heart attack yet, there is only a threat, and so that it does not develop, you need to do this and that. After such a conversation, you can hope that the patient will follow your recommendations for treatment and the need for transportation on a stretcher. As a rule, the ambulance either does not have its own “workforce”, or it is not enough: the team is mostly women. When deciding on hospitalization, the following dialogue often arises:

- Look for men, we have no one to carry!

We don't have anyone either. You have a driver, we will pay him!

He can't leave the car!

Verbal duel, as a rule, leads to nothing. Try to start the conversation in a different way: “The patient needs to be carried on a stretcher, you see, we have only women, maybe you can help us find someone, because we don’t know anyone here.”

This is how the conversation should go. No categoricalness, no "stubbornness", a friendly, calm tone. Then you can count on success.

It is important to remember that no reason (narrow corridor, steep stairs, etc.) can justify a violation of the hospitalization procedure, especially when a stretcher is needed. Realizing this, a competent doctor or paramedic will always find a way out: a chair, a blanket, etc.

Here is another situation: when transporting on a stretcher from some floor, relatives (surrounding) may be perplexed why the patient is carried “feet forward”, because he is still alive? In this case, the doctor or any member of the team should calmly, tactfully explain that this is not “feet forward”, but “feet down”. Because if you take it head first, then on the stairs it will be head down, which is not safe for a seriously ill patient. That is why "feet down" and not feet forward.

But here the patient is placed in the car. He may be alone, may be with relatives or colleagues. The patient is experiencing what happened. Agree that any extraneous conversations will rightly be perceived as disrespectful to his condition. Of course, no one requires the members of the brigade to accompany the patient with mournful faces. However, any talk about things that are not related to "this topic" will rightly be interpreted negatively. As a result, the heroic work done on call, at the bedside of the patient by you, by your colleagues, can be leveled. We must learn to empathize!

A sick person, due to his illness, has an altered psyche, he is exhausted by prolonged pains, perhaps by repeated, and even ineffectual, visits to medical offices. "Ambulance" is in a special position. Sometimes they call her without receiving a referral to the hospital from “their” district doctor or without waiting today for a doctor from the clinic ... But you never know what else! Even a conversation with the dispatcher prior to the arrival of the brigade can drive a sick person “out of himself”. And all the accumulated negative emotions will be thrown out on the one who is available, and from whom you can get the most specific and real help.

But here you are “attacked” with a stream of claims to which you have nothing to do. Start immediately "defend" when the patient or relatives are still hot? This energy will involuntarily be transferred to you (mirror effect), you will get involved in a conflict, and it is possible that you will suffer from it. How to be? There is such an approach. Ask the essence of the claim (knowing very well that it is not for you) to state it again, explaining that you did not understand something. (Just don’t interrupt the patient, let him speak. The time spent on this will pay off by preventing a conflict, maybe even a complaint, which will then take much more time to resolve and not one, but several people. Do not forget to reflect this situation in the call card).

You will notice that there will be less emotions. In extreme cases, you can ask to repeat some part of the entire claim again. The conversation will be very calm. You have given the patient the opportunity to "let off steam." This is just one way to avoid conflict. There is a popular wisdom: "Of the two arguing, the one who is smarter is to blame." And since you naturally consider yourself smarter, so try to make sure that the fire does not flare up.

Try to keep the members of your brigade from taking part in this duel. It will be easier for you. Here is the answer to the question: “Is it possible to be offended by a sick person?” Forgive him! He's sick. Leave your ambitions for later.

The provision of emergency medical care at the prehospital stage implies therapeutic measures not only on the spot, but also during the transportation of patients (injured) to the hospital. These features, in contrast to the conditions of a hospital, require additional attention to moral and legal problems. Here are the features.

The extreme nature of the situation requires urgent action, often performed without proper diagnosis (lack of time).

Patients are sometimes in an extremely serious, critical condition requiring immediate resuscitation.

Psychological contact between a medical worker and a patient can be difficult or absent due to the severity of the condition, inadequate consciousness, pain, convulsions, etc. etc.

Assistance is often carried out in the presence of relatives, neighbors or simply curious people.

The conditions for rendering assistance can be primitive (room, cramped conditions, insufficient lighting, lack of helpers or their absence at all, etc.).

The nature of the pathology can be very diverse (therapy, trauma, gynecology, pediatrics, etc.).

The listed features of work in emergency medicine create special ethical and legal problems that can be divided into two main groups:

Due to the specifics of the conditions for providing emergency care, as well as due to insufficient familiarity of medical workers with this problem, the rights of patients are often violated.

Errors in the provision of emergency assistance can occur mainly due to the extreme nature of the situation, sometimes due to criminal negligence.

Problems in the relationship between a medical worker and a patient can be built along two lines. One of them is ethical and deontological, when it is simply about the relationship between two people, which are regulated by moral and ethical frameworks, norms. The second line is legal. This is stated in the concept of informed voluntary consent (IDS). The most common causes of violation of the rights of patients in the provision of emergency care: 1) the lack of psychological contact with the patient (injured) and 2) the extreme nature of the situation. Sometimes the first may depend on the second, and more often both factors act simultaneously, which can lead to their mutual reinforcement. Unfortunately, we have to deal with one more factor: 3) ignorance of the patient's rights by the medical worker.

When a wise man was asked from whom he learned good manners, he replied: “From the ill-mannered. I avoided doing what they do." And, finally, the wonderful thought of the French encyclopedist Denis Diderot: “It is not enough to do good, you must do it beautifully.”