T. Gorok. Carson-Newman College.
The "Continuous Care" level beneﬁt provides intensive Many people approaching death fear pain and physical hospice services for a minimum of 8 h and up to 24 h per suffering generic roxithromycin 150 mg with amex. Respiratory Address social discount roxithromycin 150mg on-line, emotional generic 150mg roxithromycin fast delivery, and spiritual issues suppression from opioids is rare when doses are begun Weigh treatment options discount roxithromycin 150mg line, including nonmedical interventions, with the low and titrated gradually to relieve dyspnea. Primary Psychiatric Symptoms care physicians can manage the majority of pain Anxiety experienced by patients. Cognitive impairment should not deter providers from assessing pain, as even markedly Anxiety occurs commonly in dying patients, either impaired patients can describe pain and alternative independently or as a result of symptoms such as pain or assessments and standards can be applied to patients dyspnea. The When anxiety relates to fear of being alone, it can be assessment and evaluation of pain in the elderly patient addressed by the companionship of family or volunteers. The cornerstones of anxiolytic medication are the short- to moderate-acting benzodiazepines, such as lorazepam (Ativan) or oxazepam (Serax). Occasionally, Respiratory Symptoms buspirone (Buspar) or antidepressants [including parox- Dyspnea or difﬁculty breathing is a subjective symptom etine (Paxil), mirtazapine (Remeron), nortriptyline and should be distinguished from tachypnea (increased (Pamelor), nefazodone (Serzone), trazodone (Desyrel), rate of breathing), hyperpnea, and hyperventilation or doxepin (Sinequan, Adapin)] may be employed to (increased ventilation). Some elderly individuals respond para- on patient report of the sense of difﬁculty breathing using doxically to psychoactive medications, so medication verbal descriptors, visual analogue scales, or numeric effect must be closely monitored. One study of elderly dying patients found 50% should be avoided as treatment for anxiety because of experienced respiratory distress and fearfulness. Oxygen may help alleviate symptoms of dyspnea even in 57 Depression those patients who are not signiﬁcantly hypoxemic. Benzodiazepines effectively relieve dyspnea, possibly by Approximately 25% of dying cancer patients are depressing the ventilatory response to carbon dioxide,58 61 depressed. In one study, more than half of terminally and relieve anxiety associated with dyspnea. Opioids ill patients with a pervasive desire for death were relieve the sensation of air hunger and are the most effec- depressed. Antidepressant therapy should be with moderate doses of sustained-release opioids. Par- tried for these patients, with careful assessment of mood enteral opioids (morphine 0. Dysphoria, particularly when by 1–2 mg q 10 min, then continuous dose at 50% of bolus it relates to sadness or anticipatory grief, may also dose or fentanyl beginning with 2–10 mg i. Care Near the End of Life 305 appropriate, even when the depressions "appropriate" to diagnosis of dementia and coordinated interdisciplinary the related loss of function or when approaching the end care for patients and their families across the continuum. Methylphenidate (Ritalin) and other psychostimu- Speciﬁc palliative care programs to care for severely lants are effective in improving mood, alertness, and demented individuals reduce measures of discomfort in appetite and in reducing apathy in some patients and these patients and reduce overall costs of care when com- have the advantage of rapid onset of action. The tricyclic antidepressants have a lag to use of antibiotics and diagnostic testing. Doxepin and mirtazapine may also have the advantage Anorexia of stimulating appetite. Early in the course of the disease, encouraging adequate nutrition may enhance strength and a sense of well-being. Confusion and Delirium Many dying patients become profoundly anorexic (92% Most individuals fear the loss of mental capacity. Except of patients in one small series),70 and the goal of feeding in cases of intractable symptoms, an effort should be may shift to satisfying appetite and avoiding hunger, made to titrate therapies to maintain alertness. A patient may develop confu- processes, odynophagia, or dysphagia, can be helpful. For example, peptic ulcer ium on an H2 blocker or other agent they previously tol- disease may present as anorexia or nausea, and abdomi- erated. When caused by opioid analgesics, delirium may nal vascular disease or biliary disease may be associated resolve with dose reduction change to a different opioid with decreased food intake. Apathetic delirium is Nausea is mediated through the chemoreceptor trigger characterized by somnolence or decreased level of con- zone (CTZ) on the ﬂoor of the fourth ventricle and the sciousness and is as distressing to the patient and family vomiting center (VC) in the medulla. Antipsychotic therapy is effective receptors are the principal receptors in the CTZ, and and is indicated in both apathetic and agitated delirium. Serotonin (5-HT3) receptors are present Dementia in both locations, and in vagal afferents.
Physicians were paid to endorse various pharmaceutical products buy roxithromycin 150 mg cheap, for example roxithromycin 150mg lowest price, indicating that one drug was superior to its competitors order 150 mg roxithromycin with mastercard. During this period discount roxithromycin 150 mg with amex, physicians sometimes strayed from their areas of expert- ise and endorsed other products as well. The most controversial of these actions involved the endorsement of various cigarette brands. Doctors were paid to attest that Brand X was healthier for the consumer to smoke than Brand Y. The influence of the AMA and other forces were eventually brought to bear, and such practices were eliminated. These experiences led to a virtual prohibition, enforced by the AMA, of marketing on the part of physicians. The AMA’s 1947 prohibition on physician advertising contin- The Challenge of Healthcare M arketing 39 and affect a small segment of the population. The marketing of such serv- ices represents a particular challenge for marketers who are faced with a disconnect between the service and the anticipated need. A second factor is the fact that the end user may not be the target for the marketing campaign. In virtually every other industry the end user is responsible for the purchase decision, and the decision maker actually consumes the good or service. Thus, a physician is likely to determine the what, where, when, and how much of the service provided. The decision maker may be a provider, a health plan, or a family member, not the party who eventually consumes the service. The marketer is faced with the chal- lenge of determining where to place the promotional emphasis under these circumstances. Healthcare is also different in that the product may be highly complex and not lend itself to easy conceptualization. This issue was raised ued through 1957, when it was modified to only restrict physicians from soliciting patients. These restrictions did not affect such traditional marketing activities as networking and entertaining would-be referring physicians, and it was even customary at that time for doctors to provide kickbacks (in the form of "fee splitting") to referring physicians. The AMA eventually backpedaled from its strong stance against physician advertising, and in the 1990s many physicians initiated aggressive marketing campaigns. While hospitals were not constrained to the same extent, many hospital administra- tors also had ethical qualms concerning marketing (or at least the advertising dimension of marketing). These qualms did not restrict marketing activities such as public relations, edu- cational activities, and communication strategies, but they did discourage many hospitals from overt media advertising. Ultimately, practical considerations on the part of hospitals and health systems overcame any lingering reluctance related to marketing. Much of the controversy surrounding marketing in healthcare has involved the pharmaceutical industry. The marketing of over-the-counter drugs is covered by federal regulations that control the claims that can be made with regard to their efficacy. The marketing of prescription drugs directly to consumers is tightly controlled by federal regulation; until the end of the twentieth century pharmaceutical companies were prohibited from marketing directly to consumers. Even today, there are strict limits on the claims that can be made in the advertising. Drug manufacturers have focused their marketing activities almost exclusively on the physicians who prescribe drugs to their patients, and this area has created the most controversy. Pharmaceutical companies spend up to 25 percent of their budgets on mar- 40 arketing Health Services keting and sales activities, and the bulk of this has historically been allocated to adver- tisements in medical journals, support of educational programs, and direct sales to physi- cians. Pharmaceutical companies’ longstanding practice of providing free samples of drugs to physicians eventually came under fire and is facing restrictions.
As Derek Parfitt points out roxithromycin 150mg lowest price,22 there is a difference between doing something to be happy or satisfied and being happy because you did something buy generic roxithromycin 150 mg on-line. Bernard Williams argues cheap 150mg roxithromycin fast delivery, in a related vein discount 150 mg roxithromycin overnight delivery, that meaningfulness and happiness are not equated. It would be a poor artist whose main reason to paint was to attain a generic "happiness. I am not saying that all meaningful activity is an "end in itself" but that as an end or a means, its worth does not derive from "utility. Therefore, there is plausibly a numerical scale, the "utility scale" on which the alternatives are measured. But while choice often reveals preference, and preference means we would rather, say, have glasses than contacts, nothing is added to this fact by talking as though something quantifiable like "utility" or even "pleasure" lay behind the choice. When we say, "I would 126 CHAPTER 5 like the dining room blue, not green" it is because the quality of blue there is chosen over the quality of green. Liking, I would claim, is secondarily abstracted from the overall quality of blue in the setting, but it is really nothing separate from that overall quality, and a generic feeling of "liking" has nothing at all to do with this particular choice. We do not go through "liking" to get to "blue," but through "blue" to the generalization, "liking. As Dewey pointed out, we not only seek things we know how to value; we seek to find and experience things whose value is unknown before-the-fact. Then there is arbitrary choice, like picking one product off a shelf for no reason except to get the decision over. In sum, there are good reasons not to generalize the assumption of comparability beyond the original application to games of strategy and pure profit-seeking. Outside of these realms, decision making is partly a process of creating and discovering values, and only partly the business of realizing them in ways previously anticipated. For all these reasons, preference is not universally well-defined, "complete," or "comparable. Transitivity If A, B and C are set S of alternatives, when A is preferable to B and B is preferable to C, then A is preferable to C. An individual violating the transitivity axiom would pay to have B instead of C, pay again to have A instead of B, and pay yet again to have C instead of A. Assuming the process went on indefinitely, the inevitable result would be bankruptcy, with the individual repeatedly paying just to get back what she or he already had. Intransitivities are related to preference reversals, and can result from changes in the context of an evaluation or of the perceived baseline or status quo. Lichtenstein and Slovic showed in 1971 that both experimental subjects and real gamblers in a Las Vegas casino frequently and characteristically reversed preferences when their choices between alternative bets were compared with prices they would pay for the same alternative bets. PREFERENCE, UTILITY AND VALUE IN MEANS AND ENDS 127 First, the subjects were asked which of the bets they would choose. Although an approximately equal number of subjects chose each alternative bet, the $ bet was assigned a higher selling price about 88% of the time. Slavic notes "of participants who chose the P bet, 87% gave a higher selling price to the $ bet. In the example above, from Slovic’s early work, different procedures for determining the worth of a bet, i. Tversky and Kahneman found that preference reversals could be induced by alterations in the framing of situations. It appears that people avoid losses more fiercely than they seek gains in many settings. If Program C is chosen, 400 people will die, and if Program D is chosen, there is a 1/3 chance that no one will die and a 2/3 chance that 600 people will die. In problem one the reference state is 600 deaths and events are described as "lives saved. When our attention is focused on deaths, we seem unable to give lives saved the same value as when our attention is focused on lives saved. It appears that it is difficult to hold two different considerations before the mind in an equally vivid and efficacious fashion, even when the two considerations are so closely related as life and death.
Videotaping of forward swing events for a competitive male tennis player show that the highest overall rotational velocity is typically ob- tained by the hand segment (40 rad/s) buy discount roxithromycin 150mg on line. The greatest contributor to the racket head’s forward speed at ball contact is upper arm internal rotation (8 m/s) purchase roxithromycin 150 mg on-line, followed by wrist flexion (7 m/s) and upper arm horizontal ad- duction (6 order roxithromycin 150mg with visa. In these cases order roxithromycin 150 mg without a prescription, one should also incorpo- rate the rotational velocity of the trunk into the expression for the end- point velocity. The angular velocity of the trunk provides the shoulder with a velocity and it contributes additionally to the velocity of the end- point through its long moment arm. The young golf pro Tiger Woods has one of the highest rotational speeds in the game. Pro golf players rotate their shoulders and hips exten- sively during the backswing phase of hitting a golf ball. The larger the gap between the turns of the shoulder and the hip, the greater the levels of torsional deformation imposed on the upper body. The more exten- sively the large muscles of the trunk are stretched in the backswing phase, the faster the body unwinds during the downswing. Then P can be expressed using the unit vectors of E or B: P 5 EP e + EP e 1 EP e 1 1 2 2 3 3 P 5 BP b + BP b 1 BP b 1 1 2 2 3 3 The time derivatives of P in E and in B are defined as EdP/dt 5 (dEP /dt) e 1 (dEP /dt) e 1 (dEP /dt) e 1 1 2 2 3 3 BdP/dt 5 (dBP /dt) b 1 (dBP /dt) b 1 (dBP /dt) b 1 1 2 2 3 3 Angular Velocity Let b1, b2, b3 be a right-handed set of mutually perpendicular unit vec- tors fixed in a rigid body B. This definition of angular velocity leads to the fol- lowing results: Rdb /dt 5 RvB 3 b 1 1 Rdb /dt 5 RvB 3 b 2 2 Rdb /dt 5 RvB 3 b 3 3 288 9. Three-Dimensional Motion Thus, for any vector P defined in the reference frames R and B: RdP/dt 5 BdP/dt 1 RvB 3 P If a series of succesive reference frames is used in the study of motion, the following equation holds: EvB5 5 EvB1 1 B1vB2 1 B2vB3 1 B3vB4 1 B4vB5 Velocity and acceleration of two points in a rigid body are related by the following set of equations: EvP 5 EvQ 1 EvB 3 rP/Q EaP 5 EaQ 1 EaB 3 rP/Q 1 EvB 3 (EvB 3 rP/Q) where EaB is the angular acceleration of the rigid body B. The angular ac- celeration is defined by the relation EaB 5 dEvB/dt Conservation of Linear and Angular Momentum Laws of motion for a body in three-dimensional motion are as follows: SF 5 m ac SMc 5 EdHc/dt where SF is the resultant external force acting on the body, SMc is the resultant external moment with respect to the center of mass, and ac is the acceleration of the center of mass measured in the inertial reference frame E. If a point within the body is fixed in the inertial reference frame E, then the following equation also holds SMo 5 EdHo/dt where SMo and Ho represent the resultant moment and the moment of momentum about O. For three-dimensional motion, one obtains the following expression for angular momentum: Hc 5 (Ic v 1 Ic v 1 Ic v ) 1 11 1 12 2 13 3 Hc 5 (Ic v 1 Ic v 1 Ic v ) 2 21 1 22 2 23 3 Hc 5 (Ic v 1 Ic v 1 Ic v ) 3 31 1 32 2 33 3 in which Hc and v are the components of angular momentum and an- i i gular velocity of the rigid body in reference frame E written in some ref- 9. These ij elements depend only on the geometry and mass density distribution of the rigid body. The angular momentum about the fixed point O has a similar expres- sion: Ho 5 (Io v 1 Io v 1 Io v ) 1 11 1 12 2 13 3 Ho 5 (Io v 1 Io v 1 Io v ) 2 21 1 22 2 23 3 Ho 5 (Io v 1 Io v 1 Io v ) 3 31 1 32 2 33 3 As shown in the chapter, once the inertia matrix Ic is derived, the ma- ij trix Io can be obtained from the matrix Ic by using a transformation ij ij equation (Eqn. A figure skater spins about her longitudinal axis b2 with constant angular speed of 5 rad/s (Fig. Determine the angular ve- locity of her arms (A) with respect to the inertial reference frame in E (EvA). Express this angular velocity in the auxiliary coordinate system B shown in the figure. The following equation relates the acceleration of two points in a rigid object: EaP 5 EaQ 1 EaB 3 rP/Q 1 EvB 3 (EvB 3 rP/Q) b2 b1 b3 FIGURE P. A figure skater spins about her longitudinal axis with constant angular speed of 5 rad/s. Three-Dimensional Motion Show that it can be written in the following form for the planar motion: EaP 5 EaQ 1 EaB 3 rP/Q 2 (EvB)2 rP/Q Problem 9. A gyroscope is a wheel mounted in a successive series of rings so that its axis is free to turn in any direction. When the wheel is spun rapidly, it will keep its original plane of rotation no matter which way the rings are turned. The unit vec- tors b, c, and d are parallel to the axes of B, C, and D, respectively. The angles of rotation shown in the figure were determined to obey the fol- lowing equations: u 522t3 f 5 15 2 5t C567t2 (all in radians) Determine SvB, CvB, SvD as a function of time t. Determine the mass moment of inertia matrix about the cen- ter of mass of the shapes shown in Fig. Answer: For the bent rod of length of 4L and mass 4m shown in the fig- ure, the mass moment of inertia matrix is equal to Ic 5 (2/3) mL2, Ic 5 (8/3) mL2, Ic 5 (10/3) mL2 11 22 33 Ic 5 Ic 5 mL2, Ic 5 Ic 5 Ic 5 Ic 5 0 12 21 13 31 23 32 Problem 9. A man stands still on a turntable that isolates his body from external torques around the vertical b3 axis (Fig. He then begins to swing his arms from one side to the other, as shown in the figure. The angular momentum of the swinging arms about the center of mass of the man is equal to 8 (kg-m2/s) b.