Ethical code

  Definition

 A code of ethics is a set of certain norms in a team that all employees of an organization must adhere to.

 The code of ethics regulates interpersonal relations in the organization, and gives moral meaning to the joint activities of people.  The main task of creating a code of ethics is to form a positive attitude towards an organization or profession in society.  Another equally important task of such a document is to help each employee in the team within the framework of the "correct" behavior in relation to colleagues and / and clients.

 General Provisions

 Medical ethics and deontology The philosophical discipline that studies morality and ethics is called ethics (from the Greek ethos - custom, disposition).  Another term, morality, has almost the same meaning.  Therefore, these terms are often used together.  Ethics is most often called science, the doctrine of morality and ethics.  Professional ethics are the principles of conduct in the process of professional activity.  Medical ethics is part of the general and one of the types of professional ethics.  This is the science of moral principles in the activities of doctors.  The subject of her research is the psycho-emotional side of the activity of physicians.  Medical ethics, in contrast to law, was formed and existed as a set of unwritten rules.  The concepts of medical ethics have evolved since ancient times.  In different historical epochs, the peoples of the world had their own ideas about medical ethics associated with the way of life, national, religious, cultural and other features.  Among the surviving ancient sources of medical ethics are the laws of Ancient Babylon (XVIII century BC, "Laws of Hammurappi", which read: "If the doctor performs any serious operation and causes the patient's death, he is punished by cutting off his hand")  ...  Hippocrates, the "father of medicine", the great physician of Ancient Greece, repeatedly emphasized the importance for the physician not only of the ability to heal, but also of strict adherence to the requirements of ethical standards.  It is believed that it was Hippocrates who formulated the basic principles of medical ethics ("Oath", "Law", "About doctors", etc.).  The views of the Tajik scientist of the 10th-11th centuries had a great influence on the development of medical ethics.  doctor Ibn Sinn (Avicenna).  The main ideas of his teaching are contained in the encyclopedic work "Canon of Medicine" and the essay "Ethics".  A well-known role in the development of modern principles of medical ethics was played by the Salerno Medical School, which arose in southern Italy in the 9th century.  and became part of the University of Salerno in 1213 as a faculty.  Representatives of this school put into practice the humane principles of ancient medicine.  A great contribution to the development of medical ethics was made by Russian clinicians M.Ya. Mudrov, S.G. Zabelin, D.S.Samoilovich and others. The concept of "deontology" first appeared in the 18th century.  This term was proposed by the English philosopher and jurist, priest I. Bentham in his book "Deontology or the Science of Morality", who put a religious and moral content into this concept, considering deontology as a doctrine of proper behavior for each person to achieve his goal.  The word "deontology" comes from two Greek words: deon means due and logos - doctrine.  The term "deontology" (the doctrine of the proper behavior of physicians, contributing to the creation of the most favorable environment for the patient's recovery) was introduced into domestic medicine by the outstanding surgeon N.N. Petrov, extending the principles of deontology to the activities of nurses.  Consequently, medical deontology is a part of medical ethics, a set of necessary ethical standards and prescriptions for medical workers in the implementation of professional activities.

 Article 184 Code of honor of medical and pharmaceutical workers of the Republic of Kazakhstan (Code of the Republic of Kazakhstan "About people's health and health care system" 2009)

 1. The Code of honor of medical and pharmaceutical workers of the Republic of Kazakhstan (further - the Code of Honor) defines the moral responsibility of medical and pharmaceutical workers for their activities before citizens and society as a whole.

 Article 182 Rights and obligations of medical and pharmaceutical workers.  (Code of the Republic of Kazakhstan "About people's health and the health care system" 2009)

 Deontology studies the moral content of the actions and deeds of medical personnel in a specific situation.  The theoretical basis of deontology is medical ethics, and deontology, manifested in the actions of medical personnel, is the practical application of medical and ethical principles.  Aspects of medical deontology are: the relationship of physicians with the patient, relatives of the patient and physicians among themselves.  The basis of the relationship is the word that was known in antiquity: “One must heal with words, herbs and a knife,” the ancient healers believed.  A smart, tactful word can raise the patient's mood, instill in him cheerfulness and hope for recovery, and at the same time, a careless word can deeply hurt the patient, cause a sharp deterioration in his health.  It is important not only what to say, but also how, why, where to speak, how the person to whom the health worker is addressing will react: the patient, his relatives, colleagues, etc.  The same idea can be expressed in different ways.  People can understand the same word in different ways, depending on their intelligence, personal qualities, etc.  Not only words, but also intonation, facial expression, gestures are of great importance in relationships with the patient, his relatives, colleagues.

 A physician must have a special "sensitivity to a person", possess empathy - the ability to sympathize, to put oneself in the patient's place.  He must be able to understand the patient and his loved ones, be able to listen to the “soul” of the patient, calm and convince.  This is a kind of art, and not easy.  In a conversation with a patient, indifference, passivity, lethargy are unacceptable.  The patient should feel that he is correctly understood, that the medical professional treats him with a sincere interest.

 The physician must master the culture of speech.  To speak well, one must first of all think correctly.  A doctor or nurse who stumbles over every word, uses slang words and expressions, causes distrust and dislike.  Deontological requirements for the culture of the word are that a medical worker must be able to: tell the patient about the disease and its treatment;  to calm and encourage the patient, even in the most difficult situation;  use the word as an important factor in psychotherapy;  use the word so that it is evidence of general and medical culture;  convince the patient of the need for one or another treatment;  to be patiently silent when the interests of the patient require it;  do not deprive the patient of hope for recovery;  control yourself in all situations.  When communicating with a patient, one should not forget about the following communicative techniques: always listen carefully to the patient;  having asked a question, be sure to wait for an answer;  express your thoughts simply, clearly, intelligibly, do not abuse scientific terms;  respect the interlocutor, do not allow contemptuous facial expressions and gestures;  do not interrupt the patient;  encourage the desire to ask questions, answering them, demonstrate interest in the patient's opinion;  keep a cool head, be patient and tolerant.

Modern models of the relationship between doctor and patient. Nowadays there are the following types of models of the relationship between doctor and patient: informational (scientific, engineering, consumer). The physician acts as a competent expert professional, collecting and providing information about the disease to the patient himself.  At the same time, the patient has full autonomy, having the right to all information and independently choosing the type of medical care.  The patient can be biased, therefore the doctor's task is to explain and guide the patient to the choice of the right decision;  interpretive.  The doctor acts as a consultant and advisor.  He should find out the requirements of the patient and provide assistance in choosing a treatment.  For this, the physician must interpret, i.e.  interpret information about the state of health, examination and treatment so that the patient can make the only correct decision.  The physician should not condemn the patient's demands.  The goal of the doctor is to clarify the patient's requirements and help make the right choice.  This model is similar to the informational one, but it assumes closer contact between the doctor and the patient, and not just the provision of information to the patient.  Patient work with the patient is required.  Patient autonomy with this model is great;  deliberative.  The doctor knows the patient well.  Everything is decided on the basis of trust and mutual agreement.  The doctor in this model acts as a friend and teacher.  The patient's autonomy is respected, but it is based on the need for this particular treatment;  paternalistic (from Lat. pater - father).  The doctor acts as a guardian, but at the same time puts the interests of the patient above his own.  The doctor strongly recommends to the patient the chosen treatment.  If the patient does not agree, then the last word remains with the doctor.  Patient autonomy with this model is minimal (this model is most often used in the national healthcare system).

 The medical duty as the main ethical category.  The main ethical categories of a physician include the concept of "duty" - a certain range of professional and social obligations in the performance of their duties, formed in the process of professional relations.  Duty provides for the qualified and honest performance of each medical professional of their professional duties.  Duty is inextricably linked with the moral qualities of the individual.  The duty of a medical worker is to show humanism and always provide assistance to the patient, never participate in actions directed against the physical and mental health of people, not hasten the onset of death.

 Internal picture of the disease.  The behavior of a physician with a patient depends on the characteristics of the patient's psyche, which largely determines the so-called internal picture of the disease.  The internal picture of the disease is the patient's awareness of his disease, the patient's holistic view of his disease, his psychological assessment of the subjective manifestations of the disease.  The internal picture of the disease is influenced by the characteristics of the patient's personality (temperament, type of higher nervous activity, character, intellect, etc.).  In the internal picture of the disease, there are: the sensory level, implying painful sensations of the patient;  emotional - the patient's response to their feelings;  intellectual - knowledge about the disease and its assessment, the degree of awareness of the severity and consequences of the disease;  attitude to illness, motivation to return to health.

 The allocation of these levels is very arbitrary, but they allow doctors to more consciously develop tactics of deontological behavior with the patient.  The sensory level is very important when collecting information (anamnesis) about the manifestations of the disease, the patient's feelings, which makes it possible to more accurately diagnose the disease.  The emotional level reflects the patient's experience of his illness. Naturally, these emotions are negative.

 The physician should not be indifferent to the patient's experiences, should show sympathy, be able to raise the patient's mood, instill hope for a favorable outcome of the disease.  The intellectual level depends on the general cultural development of the patient, his intellect.  It should be borne in mind that chronic patients know a lot about their disease (popular and special literature, conversations with doctors, lectures, etc.).  This largely allows doctors to build their relationship with the patient on the principles of partnership, without rejecting the requests and information that the patient has.  In patients with acute diseases, the intellectual level of the internal picture of the disease is lower.  Patients, as a rule, know very little about their acute illness, and this knowledge is very superficial.  The task of a medical worker in relation to such a patient is to, within the limits of the necessary and taking into account the patient's condition, make up for the lack of knowledge about the disease, explain the essence of the disease, tell about the upcoming examination and treatment, that is, involve the patient in a joint fight against the disease, aim  him to get well.

 Knowledge of the intellectual level of the internal picture of the disease allows you to choose the right treatment tactics, psychotherapy, etc.  Therefore, clear ideas about the intellectual level of the internal picture of the disease must be obtained from the first minutes of communication with the patient.  The nature of the attitude towards the disease plays a very important role.  Even the doctors of antiquity knew about this: “There are three of us - you, the disease and me.  If you are sick, there will be two of you, but I will remain alone - you will overcome me.  If you will be with me, there will be two of us, the disease will remain one, we will overcome it ”(Abul Faraja, Syrian doctor, 13th century).  This ancient wisdom shows that in the fight against illness, much depends on the patient himself, on his assessment of his own illness, the ability of doctors to attract the patient to their side.

 The patient's attitude to the disease is sometimes adequate and inadequate.  Adequate attitude to illness is distinguished by awareness of one's illness and recognition of the need to take measures to restore health.  Such a patient shows active partner participation in the treatment, which contributes to a speedy recovery.  An inadequate attitude towards the disease often manifests itself in several types: anxious - continuous anxiety and suspiciousness;  hypochondriacal - focused on subjective sensations;  melancholic - dejection, disbelief in recovery;  neurasthenic - a reaction of the type of irritable weakness;  aggressive-phobic - suspiciousness based on unlikely fears;  sensitive - preoccupation with the impression that the patient makes on others;  egocentric - “withdrawal” into illness;  euphoric - feigned mood;  anosognostic - discarding thoughts about the disease;  ergopathic - avoiding illness for work;  paranoid - the belief that the disease is someone's malicious intent;  dismissive - underestimation of one's condition and corresponding behavior (violation of the prescribed regimen, physical and mental stress, ignoring the prescribed treatment, etc.);  utilitarian - the desire to extract material and moral benefits from the disease (without serious grounds they seek release from military service, mitigation of punishment for a crime, etc.).

 Knowledge of the internal picture of the disease helps in establishing deontologically competent communication with the patient, in the formation of an adequate attitude of the patient to his disease, which increases the effectiveness of the treatment.

 Basic ethical principles in medicine.  The main ethical principle in medicine is “do no harm”.  This principle was followed by the doctors of the Ancient World.  So, Hippocrates in his work "The Oath" directly points out: "I will send the regime of the sick to their benefit, in accordance with my strength, I will refrain from causing any harm and injustice.  I will not give anyone the lethal remedy I ask for, and I will not show the way for such a plan".  Not causing harm, damage to the patient's health is the primary duty of every medical worker.  Neglect of this obligation, depending on the degree of damage to the patient's health, may become the basis for bringing the medical worker to justice.  This principle is required, but it allows for a certain degree of risk.  Some treatments are risky for the health of the patient, but this harm is not done deliberately and is justified by the hope of success in the fight against a disease, especially a fatal one.  For all peoples, the principle of preserving medical secrecy has always been of great importance.

 Article 95 Medical secrecy (Code of the Republic of Kazakhstan "About people's health and the health care system" 2009)

 Information about the fact of seeking medical help, the state of health of a citizen, the diagnosis of his illness and other information obtained during examination and (or) treatment constitutes the MEDICAL CONFIDENTIALITY.

It is not allowed in the interests of the disclosure of information constituting a medical secret by persons to whom they became known during training, performance of professional, official and other duties.

 With the consent of the patient or his legal representative, it is allowed to transfer information constituting a medical secret to other individuals and (or) legal entities in the interests of examining and treating a patient, for conducting scientific research, using this information in the scientific process and other purposes.

 Submission of information constituting a medical secret without the consent of a citizen or his legal representative is allowed in the following cases:

 

 1) for the purpose of examining and treating a citizen who, due to his condition, is unable to express his will;

 2) with the threat of the spread of diseases that pose a danger to others;

 3) at the request of the bodies of inquiry and preliminary investigation, a prosecutor, a lawyer and (or) a court in connection with an investigation or trial;

 4) when providing medical assistance to a minor or an incapacitated person to inform his legal representatives;

 5) if there are grounds to believe that harm to the health of a citizen was caused as a result of unlawful acts.

 

 It is not allowed to include and use in automatic databases without the patient's permission information of a personalized nature concerning his private life.

 It is not allowed to connect automated databases of a personalized nature to networks connecting them with other databases without the permission of patients when using information of a personalized nature concerning their private life.

 The purpose of preserving medical secrecy is to prevent possible moral or material damage to the patient.  Medical confidentiality should be kept not only by doctors, but also by other medical professionals.

 For the disclosure of professional secrets, the physician bears personal moral and sometimes legal responsibility

 The preservation of medical confidentiality is not only the most important manifestation of a moral duty, but also the first duty of a medical worker.  An equally important principle in modern healthcare is the principle of informed consent.

 Article 88 Rights of Citizens (Code of the Republic of Kazakhstan "About People's Health and the Healthcare System" 2009)

 Article 91 The rights of patients (Code of the Republic of Kazakhstan "About people's health and the health care system" 2009)

 The information is necessary so that on its basis the patient can decide, for example, whether to agree to an operation or to prefer conservative treatment, etc. The principle of respect for patient autonomy (close to the principle of informed consent) means that the patient himself, regardless of the doctors, must  make a decision on treatment, examination, etc. At the same time, the patient does not have the right to require doctors to make a decision for him (unless the patient is unconscious (Article 94 "Provision of medical care without the consent of citizens" Code of the Republic of Kazakhstan "On the health of the people and  system of health care "2009), so as not to hold doctors accountable for inappropriate treatment.

 Responsibility of healthcare professionals and institutions.

 The Criminal Code of the Republic of Kazakhstan stipulates responsibility for causing harm to the health of citizens. Unfortunately, when providing medical care to a patient, there are often cases of adverse effects of treatment.  These cases are subdivided into medical errors, accidents, professional offenses.  Professional offenses (crimes) - negligent or deliberate actions of a medical worker, resulting in harm to the life and health of the patient.  Occupational misconduct arises from the bad faith of a medical professional;  illegal medicine, including the use of inappropriate methods of treatment, medicine in a specialty for which the doctor does not have a certificate;  negligence in professional duties (negligence - failure to fulfill their professional, official duties or perform them improperly, carelessly) In the event of professional offenses, it is possible to bring a medical worker to administrative, disciplinary, criminal and civil (property) liability (Article 114 Improper performance of professional  duties by medical and pharmaceutical workers).

 The issues of medical deontology occupy a special place in oncological practice.  This is due to the fact that in case of oncological diseases, there is practically no self-healing and the patient's recovery depends entirely on the competence of the doctor;  the public's fear of malignant tumors is especially great, and there is a widespread belief that treatment is futile.  The relevance of deontological issues in oncology is also due to the fact that in most cases, even at the initial stages of the disease, the doctor cannot be sure that the patient is completely cured.

 According to N.A. Semashko, medical ethics includes three groups of issues: firstly, the attitude of the doctor to the patient, secondly, the attitude of the doctor to the team, and thirdly, the attitude of doctors among themselves.

 The issues of deontology also include proper communication with patients' relatives, organization of the work of the medical team, the correct choice of optimal treatment methods, protection of the patient from unscientific methods of healing that distract from the necessary treatment and sometimes cause irreparable harm.

 At the heart of the successful solution of this problem, the leading role belongs to the oncologist, his personality, and professional awareness.  In the oncology clinic, there are mainly patients with a serious illness.  Working with them and paying tribute to the methods of diagnosis and treatment, the oncologist has no right to forget the humane essence of the medical profession.  The word of the doctor who enjoys the authority of the patient is very significant.  At the same time, doubt expressed in the presence of the patient, uncertainty of intonation, confusion can damage his relationship with the attending physician.

 The doctor's task is to calm down the patient and psychologically prepare for the upcoming treatment, instilling belief in the curability of the disease.  The ability to achieve the desired contact with the patient requires some experience, but often depends on the personal qualities of the doctor.  Cancer patients experience severe emotional stress associated with a suspicion of the possibility of a malignant neoplasm, the need for a long examination, hospital stay, surgery and waiting for the result of histological examination, radiation and chemotherapy.  Emotional stress triggers a chain of neuroendocrine reactions leading to psychosomatic disorders.  The physician's task is to reduce or neutralize the stress response when communicating with the patient.  This has a positive meaning for the general condition of the patient, the course of the disease, and subsequent labor and social rehabilitation.

 Of particular importance is the correct psychological approach to the patient, this is a kind of psychotherapy already at the first stage of contact between the doctor and the patient. Changes in the psyche of patients go through the following stages of adaptation:

 • stage of shock after receiving information about the disease;

 • stage of denial, displacement of information;

 • stage of aggression, search for the cause of the disease;

 • stage of depression, lack of faith in treatment and help from others;

 • the stage of an attempt at collusion with fate (turning to non-traditional methods of treatment, to religion, diet, starvation, gymnastics);

 • the stage of accepting the disease, rethinking life, the emergence of new values.

 

 The listed stages do not always follow in the described order, each patient has different durations, they can all exist at the same time.  Psychological correction should correspond to the stages of adaptation, the patient's condition, his psychological characteristics and smoothly prepare him for the transition to the next stage of adaptation.

 Cancer is a powerful stress for the patient himself and his family, the consequence of which is mental trauma, which is not always associated with the physical well-being of the sick person.  A cancer patient finds himself in a difficult life situation: treatment requires the mobilization of physical and mental strength, while illness, treatment and related experiences lead to significant psychological, physical and biochemical changes that deplete the patient's body.

 Psychological assistance to an oncological patient, including psychotherapy, provided during treatment in a hospital and after discharge from it, contributes to a better adaptation to the disease and overcoming the consequences of treatment.

 The question of rationally informing the patient about the true diagnosis should be approached individually.  In each case, the doctor chooses the only correct line of behavior.  This is determined by the nature and stage of the disease, the psychological characteristics of the patient, his age, profession, attitude to the proposed methods of research and treatment, the social environment and socio-cultural belonging of the patient, the country and the prevailing norms, traditions and attitudes of the medical institution, as well as the level of professional knowledge of the doctor.  In most cases, the patient is not informed of the presence of cancer or other malignant tumor, as this causes a lot of psychological trauma.  When a doctor talks with a patient, for example, with stomach cancer, when asked about the diagnosis, one can say about an ulcer or a polyp of the stomach with proliferative cell changes, about a type of tumor or precancerous disease.

The patient should not get into the hands of the medical documentation and data confirming the diagnosis of a malignant tumor.  In the presence of the patient, care is taken when analyzing radiographs and the results of special studies.  In the documents (certificates, extracts from case histories), which are given to the patient with a malignant neoplasm upon discharge from the hospital or when sent for examination and treatment, the diagnosis of an "organic disease" of the stomach, skin, breast, etc. is usually indicated.  The same terms are used when examining patients with students and on rounds, avoiding words such as "cancer", "sarcoma", "metastasis", "advanced form of the disease", "III and IV stages of the disease", "inoperability  ".  So, when collecting anamnesis, clarifying the hereditary predisposition, the question "were there any malignant tumors in the closest relatives?"  one may prefer the option “what did the parents and other relatives die of or what disease did they have?”.

 An exception can be made only if the patient underestimates the seriousness of the situation and refuses examination and treatment.  If the patient refuses radical treatment with a good prognosis, there is talk about the possible malignancy of the process.

 Communicating the true diagnosis is the task of only very experienced doctors who are well versed in people, who are able to monitor their reactions and find expressions that carry a minimum emotional load and do not hurt the patient.  The main thing in a truthful diagnosis is the desire of the doctor to maintain hope in the patient.  To accomplish this task, a conversation about the prognosis of the disease is useful.  The doctor outlines the prospect of a cure, based on the results of scientific research or based on examples of successful outcomes of the same disease in specific people known to the patient.  The diagnosis can be communicated only when the patient is prepared for this, when there is a real possibility of his healing or significant prolongation of life.

 Many oncologists, foreign and a number of domestic ones, in their relations with cancer patients adhere to truth-oriented tactics.  This is due to the legal aspects of this problem (a person must be correctly oriented in his state of health and has the right to independently choose a method of treatment).

 However, no matter what point of view the doctor adheres to, the main thing is his desire to maintain in the patient the hope of recovery, as far as possible. Regarding, from the standpoint of medical deontology, preventive examinations of the population, clinical examination and observation of groups of people at high risk for the purpose of early detection of tumors, it should be remembered  about the mental trauma that can be caused by an accidentally dropped word, and be careful in your statements.  It can be quite difficult to convince a patient of the advisability of a complete clinical examination in an oncological institution, and only a careful approach, attentive attitude can reduce the feeling of fear, reduce anxiety, and create favorable conditions for examination and subsequent treatment.  dubious.

 Refusal of therapy can also be associated with the patient's well-being, when the tumor is detected by chance against the background of complete health.  This is due to the fact that malignant neoplasms often, especially in the early stages, are asymptomatic or asymptomatic, general well-being does not suffer, and sometimes patients inadequately assess their condition.  In such a situation, the patient hopes for a mistake in the diagnosis and does not believe in the need for treatment (denial reaction).  Such patients are explained the seriousness of the situation, speaking about the tumor in the form of an assumption, and only in an extreme situation about the presence of a tumor detected at an early, curable stage.

 The refusal of a patient from treatment is considered as one of the indicators of the organization of the work of a medical institution. Patients who have been cured of cancer often have increased suspiciousness, anxiety, depression;  any violation of well-being is interpreted by them as a relapse of the disease.  The doctor is obliged to carefully consider the complaints, make a thorough examination, if necessary, use instrumental research methods so as not to miss a relapse of the disease or the appearance of metastases and to reassure the patient.  A favorable family environment is of great help in this regard.  The doctor should explain to the patient's relatives that both overprotection and accusations of suspiciousness should be avoided.  Permission to the patient to perform certain types of work has a positive effect, this convinces him of the reality of recovery. There are no incurable cancer patients.  Patients with advanced forms of malignant tumors are subject to symptomatic or palliative treatment carried out by doctors at the patient's place of residence in consultation with oncologists.  Severely ill patients who are obviously not subject to special anticancer treatment are not referred for consultation.  The patient perceives the need for such a consultation as confirmation of the diagnosis of a malignant tumor, and the impossibility of treatment in a specialized institution as a sign of the incurability of the disease. If the neglect of the process is established after examination and trial treatment in the hospital, then the patient is informed about the presence of any non-oncological disease, which is either cured.  or is subject to further treatment at the place of residence.  In the case of a relapse or metastasis after radical treatment, the deontologically justified version of the explanation is chosen by the oncologist who observed the patient.  The district doctor and the district oncologist should know which version the patient is oriented to and adhere to it.

 The relationship of a doctor with relatives and colleagues of the patient is a subject of special discussion.  Both psychological aspects and property, material and a number of other factors play a role here, which sometimes cannot be weighed at once.  In this case, the interests of the patient come to the fore.  No matter how busy the attending physician is, he must find time to talk with the patient's relatives, especially with a far-reaching process.  The question is about the life of a loved one, for them it is a serious mental trauma.  Perhaps the manifestation of anxiety, excessive care for the patient, less often - an inadequate reaction, some alienation, intemperance.  The next of kin should be correctly informed about the true diagnosis and the version that should be adhered to in conversation with the patient, as well as the risk of surgery and the prognosis.

 However, there are exceptions to this rule, especially when talking with a husband or wife, and sometimes with the children of patients.  For example, a number of women agreeing to an oophorectomy do not want their husbands to be informed about the details of the operation.  Such interference is considered medical secrecy.  In some cases, patients are asked not to talk about the severity of their condition to their relatives, trying to protect the elderly or sick family members from the worries.  Thus, this issue is resolved only after a thorough analysis of the patient's relationship with the people around him.

 If the patient is diagnosed with a malignant tumor for the first time, relatives should help convince him of the need for treatment.  The attention of relatives is drawn to the creation of a benevolent sparing microclimate in the family, including in the long term after radical operations, emphasizing that stressful situations, experiences, severe mental trauma, even in the long term after treatment, can contribute to the appearance of distant metastases or the appearance of other tumors.  localizations.  The task of relatives is to instill in a patient who has been cured of cancer or suffering from advanced forms of a malignant tumor, hope for a favorable outcome of the disease, and maintain his psychological balance.

 Relatives often ask questions about the possible life expectancy of the patient, especially in the presence of distant metastases.  Specific dates are undesirable.  The exact answer in such a situation is hardly perceived by the family, and a natural mistake in one direction or another lowers the authority of the doctor.  The doctor should be ready to answer questions about the scope of the operation, the possible infectiousness of cancer.

 With the exception of relatives and people closest to the patient, the doctor has no right to disclose information about the cancer patient.  Notifying friends and colleagues of the patient about everything that concerns him violates the law on medical secrecy.  You should be careful about phone calls with relatives, as the doctor does not know who is on the other end of the line.  In such cases, they offer a personal meeting.

 Patients with cancer phobia also require attention of oncologists.  Carcinophobia is an obsessive condition, expressed in an unreasonable belief in the presence of a malignant tumor.  It occurs in persons whose relatives or friends have suffered from malignant neoplasms, as well as if the patient has pathological sensations or objective symptoms similar to signs of malignant neoplasms.  Such patients, as a rule, are depressed, distrustful, the doctor's statement about the absence of cancer is regarded as a sign of insufficient medical competence or as a result of inattention.  The diagnosis of "carcinophobia" can be made only after a comprehensive examination, since the patient's complaints are sometimes really caused by a malignant tumor.

 The problem of unscientific healing in oncology is urgent.  Often one has to deal with various kinds of "healers" who promise cancer patients or their relatives a cure for malignant tumors with the help of herbs or other "folk" remedies.  Most of these "healers" are people far from medicine, making money out of someone else's misfortune and striving to acquire a scientific name.  By their own means, they distract patients from real treatment, and sometimes they do harm, using toxic substances (arsenic, aconite, kerosene, etc.) without reason.

 In this situation, the oncologist must take a principled position, since the permission of this practice can lead to the fact that such "healers" will be approached by patients who can be helped by modern scientific methods.  The attending physician can make informed recommendations regarding the use of treatment fees, which produces a positive psychological effect.  This question is especially relevant now, when the unlimited advertising campaigns have led to the use of drugs (sometimes expensive) that have not passed the appropriate clinical trials and are not approved for medical use, which is especially dangerous in the presence of a tumor process.  Inadequate use of such agents can accelerate tumor growth and death of the patient.

 Oncology is a complex specialty that brings together the efforts of surgeons, radiologists, therapists, and anesthesiologists.  Their close interaction and cooperation are the most important conditions for the successful treatment of an oncological patient.  To create an optimal environment for the patient, clarity and coherence must be observed in the work of the team.

 If it is decided to inform the patient of certain information about his condition, then all members of the team are informed about what exactly the patient knows and in what form they should talk to him.  The contradiction in the information received from different doctors, inconsistent actions lead him to the idea that they are hiding the truth from him.  Thus, instead of calming down, the patient receives mental trauma.  To avoid such situations, all conversations about the patient with himself and his close relatives are usually conducted by the attending physician.

 Clinical rounds in oncological clinics have their own characteristics.  In the ward, they talk with each patient, touching upon the disease within the limits that are permissible in his presence, without telling the patient about the details of the treatment, which he may not understand or understand correctly.  For each patient, words of encouragement should be found to maintain hope and good mood, it is necessary to talk calmly, with an even mood, avoiding haste, distraction, condescension or impatience when listening to complaints.  A medical bypass should support the patient's confidence in a successful outcome of the disease.  The patient's condition is discussed in detail in the internship at the end of the round.  The analysis of the most complex clinical cases is carried out at councils and conferences.

 Before the operation, the patient is informed about its volume, possible removal of an organ, limb, imposition of an unnatural anus, esophagostomy, gastrostomy, etc.  In the process of presenting information about the state of health, one should not embellish the possibilities of treatment and hide possible complications of therapy.  As a result, the patient gives informed voluntary consent to medical intervention.

 If the operation is performed under local anesthesia, remember that the patient hears all the conversations that take place during the operation.  This situation is also possible if the surgery was performed under anesthesia (during the period of awakening, the patient can hear and remember conversations in the operating room or recovery room).

 In the postoperative period, the doctor warns the patient about the possible consequences of the operation, methods of correction.  For all the severity of the patient's condition, it must be supported morally.

 Students should also remember this when working in the clinic.  Before answering the patient's question about the nature of his disease, the version offered to the patient should be clarified with the teacher or the attending physician.  Nursing and nursing staff are also informed about the extent to which it is possible to talk with the patient about his illness.

 Cancer patients are often difficult to diagnose and choose a treatment method.  Diagnostic errors can be associated with low qualifications and insufficient attention of the doctor, lack of oncological literacy, insufficient equipment of the medical institution, and often the actual difficulty of making a diagnosis.  At the slightest doubt about the diagnosis, they resort to consultation.  Deontology dictates the need for analysis and broad discussion in medical teams of mistakes made in the diagnosis and treatment of patients, as this helps to avoid this in the future.  Errors made in other institutions that sent a patient to an oncological dispensary are reported to these institutions.

 Choosing a specific amount of diagnostic and therapeutic measures, the doctor is guided by the following principle: "Optimum diagnostic procedures and medical care with the maximum sparing of the patient's psyche."  The importance of modern technical means (endoscopy, ultrasound diagnostics, computed tomography, etc.) in medicine is great: they have significantly reduced the examination time and made treatment more timely.  It should be borne in mind that such examinations are alarming for patients.  This psychological background requires tact and an individual approach from the doctor.  It is necessary to be able to prepare patients for research, paying attention to their mental state during the procedure.  In the question of who should inform the patient of the results of apparatus and laboratory tests, it is advisable to give preference to the attending physician, because only he, comparing the clinical data and the results of special research methods, can draw a final conclusion and inform the patient about the absence of pathological changes, about the dynamics of the disease,  on the removal of suspicions of cancer, etc.

 As in any medical institution, a friendly working psychological climate must be created in an oncological clinic, which is one of the factors of success in work.  This is especially important when analyzing the protocols of neglect, conducting clinical and anatomical conferences, in consultation with patients referred from other medical institutions.  It is unacceptable to point out to the patient the shortcomings of examination and treatment at the previous stages, thereby creating his own false authority.  This additionally traumatizes patients, causes unnecessary anxiety, and sometimes contributes to the appearance of complaints.  It is necessary to proceed from the fact that the doctors who observed the patient at the previous stages made inaccuracies in the examination and treatment unconsciously, unconsciously, but due to other circumstances.  Losing the authority of your colleague before a patient is unworthy of either a doctor or a person.  At the same time, it is necessary to indicate to the doctor in the correct form the shortcomings in the examination and treatment of the patient.  Авторитет, построенный на нарушении этических норм взаимоотношений с коллегами в своем же коллективе, временный, это рано или поздно становится достоянием других врачей, что создает нездоровую обстановку.  According to the famous arab doctor Isaac El Israeli: “Never speak negative about other doctors, for everyone has his own happy and unlucky hour. Let your deeds glorify you, not your tongue.”

In modern medical institutions, including oncological ones, research work is widely carried out.  Practitioners and students take an active part in it, which contributes to the growth of their professional skills, improvement of knowledge;  scientific research helps to analyze the causes of morbidity and mortality, to make constructive proposals on the diagnosis, treatment and prevention of malignant neoplasms.  Research work is organized in such a way as not to worsen the quality of the diagnostic and treatment process, not to violate the patient's regimen.

 The work of an oncologist is always associated with the patient's experiences.  The path of knowledge not only of the medical side of the disease, honestly traversed next to the patient, gives the doctor a great experience of mental work.  But it is just as important for a doctor to have the ability to cope with his own stress arising in the process of treating a patient in order to avoid the "burnout syndrome" and more effectively realize himself in work.

 Compliance with the rules of deontology largely depends not only on the professional training of the doctor, but also on his upbringing, the degree of culture, education, delicacy and attention to a person.  Complete dedication, optimism, faith in the enormous capabilities of the human body allow the oncologist not to succumb to difficulties and achieve the desired result.  Any medical worker should develop and improve these qualities throughout his life, remembering that the pinnacle of deontology of an oncologist is the patients' trust in him.

 

 PRIMUM NON NOCERE (lat.)FIRST, DO NO HARMthis statement is the main ethical principle in medicine.

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