Management In Health, MIH (National School of Public Health, Management, Romania)
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CAT DE PERFORMANT ESTE SISTEMUL DE SANATATE DIN ROMANIA? -Exista unele progrese, dar inca multe de facut -
No full textIntroduction: One of the main goals of a health system is to improve population health. In this article, we use the concept of amenable mortality to assess changes in mortality trends in the Romanian population attributable to health care over the past two decades. Methods: We used mortality data from the WHO for the period between 1996 and 2008 to calculate age-standardised mortality rates for 0-74 year olds from causes amenable to health care and assess mortality trends between 1996-2002 and 2002-2008. We compare amenable mortality rates in Romania to those for England and Wales to provide an international comparator. Results: Amenable mortality has been declining in Romania since 1996. However, detailed analysis shows that there are variations in the pace and direction of change, depending on cause and gender. Mortality rates are substantially higher in Romania compared to England and Wales for all amenable causes except for selected surgical procedures and misadventures. Conclusions: The wide gap in mortality amenable to health care in Romania compared to England and Wales points to substantial scope for improvement. However, the observation that only a modest decline has been observed since 1996 indicates that achievement of a significant improvement will be a challenge. Keywords: health system, performance, amenable mortality, RomaniaIntroducere: Unul dintre principalele obiective ale unui sistem de sanatate este imbunatatirea starii de sanatate a populatiei. In acest articol, in scopul evaluarii schimbarilor in evolutia fenomenului de mortalitate atribuibila asistentei medicale, in randul populatiei din Romania, de-a lungul ultimelor doua decenii, vom utiliza conceptul de mortalitate imputabila (amenable mortality). Metode: Pentru calculul ratelor de mortalitate standardizata pe grupe de varsta, in randul populatiei 0-74 ani, ce poate fi atribuita asistentei medicale si pentru evaluarea evolutiei in timp a mortalitatii in perioada 1996-2002 si 2002-2008, am folosit date de mortalitate OMS (Organizatia Mondiala a Sanatatii) pentru perioada 1996-2008. In scopul utilizarii unui nivel international de comparatie, am apelat la compararea ratelor mortalitatii imputabile din Romania, fata de cele din Anglia si Tara Galilor. Rezultate: In Romania, mortalitatea imputabila asistentei medicale a cunoscut un declin incepand cu anul 1996. Cu toate acestea, analiza detaliata arata ca exista variatii in ceea ce priveste ritmul si sensul schimbarii, in functie de cauza de deces si sex. Ratele de mortalitate sunt substantial mai mari in Romania, in comparatie cu Anglia si Tara Galilor, pentru toate cauzele evitabile, cu exceptia accidentelor si interventiilor chirurgicale selectate. Concluzii: Decalajul mare dintre mortalitatea imputabila asistentei medicale (Romania fata de Anglia si Tara Galilor) reliefeaza necesitatea unei imbunatatiri substantiale. Cu toate acestea, observatia ca doar o scadere modesta a fost observata incepand cu anul 1996 indica faptul ca obtinerea unei imbunatatiri semnificative va fi o provocare pentru sistemul de sanatate din Romania. Cuvinte cheie: sistem de sanatate, performanta, mortalitate imputabila, Romania
MANAGEMENTUL PROTEZELOR VASCULARE INFECTATE
No full textIntroduction: Despite routine antibiotic prophylaxis and refinements in implantation technique, microbial infection of the vascular prostehesis can occur. Infection involving a vascular graft is difficult to eradicate. If not recognized or treated promptly, implant failure will occur by producing sepsis, hemorrhage or thrombosis. Management involves graft excision alone, graft preservation within the implant wound, in/situ graft replacement, or graft excision in conjunction with extra-anatomic bypass grafting. Matherial and method: We retrospectively analysed the operative registers of our clinic as well as the regular archives, from 2000 until 2008, searching for reported graft infections which needed excisions and extraanatomical bypasses or for conservative therapy. There were 50 patients in this interval admitted and treated in Surgical Clinic No.1, out of a total of 950 vascular interventions. 10 of them were early graft infections(4 months).Using Szilagyi’s classification, 10 were grade I, 17 were grade II and 23 grade III.We followed antibiotic prophylaxis protocols in all of the cases, prior to first vascular intervention. Staphylococcus aureus was the most prevalent pathogen ( 95% ) found affecting our grafts. Results: We performed 20 graft excisions for infrainguinal graft infections, with the removal of the entire graft, radical debridement of infected perigraft tissues, closure of the arteriotomies with monofilament suture and the administration of systemic and topical antibiotics. We attempted graft preservation in 5 cases of infrainguinal prosthetic bypass graft infection( with serial surgical wound debridement, coupled with antibiotic therapy, early muscle flap coverage and repeated wound cultures to identify any development of bacterial resistance or change in the microbial flora). We used the staged approach in 20 cases, beginning with drainage of the perigraft abscess, followed in 2 or 3 days by graft excision and autogenous vein grafting. We performed none in-situ replacements with Rifampin-bonded prosthesis, partly because they were not available until a few years. For the patients with infection localized to only a portion of an aortofemoral graft, we preferred, for the decreased morbidity, the excision of the infected portion of the graft(partial graft excision) and after solving the inguinal infection, a staged extra-anatomical bypass- in cases.As for the gold standard regarding the aortic graft- total graft excision and ex-situ bypass, we only performed 5 of them. 3 patients died and 2 required major amputation. Conclusions: Dissatisfaction with the morbidity and the mortality of treating vascular graft infections, regardless of location, by total graft excision and remote bypass has been the impulse for the expanded application of lately performed in-situ bypasses or even for the prophylactic use of antibiotic-bonded grafts, in carefully selected cases.Introducere: In ciuda antibioprofilaxiei de rutina si a rafinarii tehnicilor de implantare, infectiile protezelor vasculare pot totusi surveni si constitui o patologie extrem de complexa si periculoasa, fiind greu de eradicat si producand esecul grafturilor prin sepsis, hemoragie sau tromboza. Tratamentul necesita justa evaluare a unor criterii specifice si individualizarea asocierii mijloacelor din arsenalul terapeutic, reprezentate de: simpla excizie a graftului, excizia in conjunctie cu revascularizatie extra-anatomica, prezervarea graftului sau excizie cu revascularizatie in-situ. Material si metoda: S-a analizat retrospectiv registrele operatorii si celelalte registre ale Clinicii Chirurgie I din cadrul Spitalului Clinic Judetean de urgenta Titgu Mures, din 2000 pana in 2008. Am inclus un numar de 50 de pacienti cu infectii depistate de graft arterial, din totalul de 950 de interventii vasculare. Conform clasificarii Syilagyi, 10 au fost infectii de grad I,17 de grad II si 23 de grad III. Alte 10 au fost infectii precoce si 40 tardive. La revascularizatia primara am folosit la toate cazurile protocoale de antibioprofilaxie. Majoritatea infectiilor (95%) au fost cu Stafilococ auriu, dar a crescut in ultimul timp proportia cazurilor infectate cu germeni gram-negativi si multirezistentí (MRSA). Rezultate: Au fost efectuate 20 de excizii de graft pentru infectii infrainghinale, cu indepartarea intregului graft, debridari radicale ale tesuturilor perigraft, inchiderea arteriotomiilor si asocierea de antibioterapie sistemica si topica. A fost realizata prezervarea graftului la 5 cazuri (cuplata cu antibioterapie si acoperire cu pedicul muscular). A fost folosita tactica seriata la 20 de cazuri, cu drenarea initiala a abcesului perigraft, urmata dupa 2-3 zile de excizie si graftare autologa. Nu a fost facuta nici o inlocuire in-situ cu proteza impregnata cu Rifampicina. Pentru pacientii cu infectie a unui by-pass aorto-femural localizata doar la nivelul triunghiului Scarpa, s-a preferat excizia partiala, iar dupa vindecarea procesului la acest nivel, o revascularizatie extra-anatomica. A fost extrasa total proteza aortica doar la 5 pacienti, dintre care 3 au murit, iar ceilalti 2 au necesitat o amputatie majora. Concluzii: Insatisfactia morbiditatii si mortalitatii mari prin aplicarea metodelor de excizie totala a fost impulsul necesar pentru cautarea unor noi solutii terapeutice pentru problema infectiei protezelor vasculare. Viitorul este reprezentat de materialele revolutionare impregnate cu antibiotice, folosite chiar profilactic, la prima revascularizatie, in cazuri selectate
OPTIUNI DE DEZVOLTARE A SERVICIILOR DE ASISTENTA MEDICALA PRIMARA
No full textPrimary health care is fundamental for medical care and for the improvement of beneficiaries’ health. For primary care, as demonstrated, the main challenge is related to how practitioners work to improve health, to develop primary and community care, to achieve a balance between the emphasis on family medicine and community health services in order to have a health system based on primary health care. If this exchange of influence can be achieved, primary health care can become the solution to improve the health of the population and to develop healthy and sustainable communities.Asistenta medicala primara este fundamentala pentru ingrijirile medicale si pentru imbunatatirea starii de sanatate a beneficiarilor. Pentru asistenta medicala primara, asa cum s-a demonstrat, principala provocare este legata de cum pot practicienii sa actioneze in vederea imbunatatirii sanatatii, dezvoltarii ingrijirilor primare si comunitare, realizarea unui echilibru intre accentul pus pe medicina de familie si serviciile de sanatate comunitare, astfel incat sa se ajunga la un sistem de sanatate bazat pe asistenta medicala primara. Daca acest schimb de influenta poate fi obtinut, asistenta medicala primara poate deveni solutia de imbunatatire a starii de sanatate a populatiei si de dezvoltare a unor comunitati sanatoase si durabile
MANAGEMENT TRAINING AND EDUCATION TO STRENGTHEN THE NURSING PROFESSION IN SERBIA
Get PDFPreambul. Rolul asistentilor medicali in Serbia este subdimensionat. Acest articol descrie situatia asistentilor medicali din sistemul sarb de sanatate, contureaza activitati de intarire a managementului si identifica politici pentru consolidarea profesiei de asistent medical in Serbia. Metode. Au fost intreprinse activitati de instruire in management pentru dezvoltarea cunostintelor si abilitatilor asistentilor medicali si pentru introducerea celor mai bune practici internationale in managementul si gestionarea activitatii asistentilor medicali. Datele obtinute din evaluari au stabilit eficacitatea instruirii si au identificat prioritati viitoare de pregatire.Rezultate. Rezultatele indica niveluri ridicate de satisfactie in privinta abordarii educatiei si instruirii in management, precum si introducerea de noi idei si concepte de management. Instruirea a conferit oportunitati pentru intarirea rolului managementului de zi cu zi la locul de munca si pentru formularea prioritatilor viitoare de pregatire a asistentilor medicali sarbi.Concluzie. Educatia si formarea in managementul de profil confera o platforma pentru dezvoltarea viitoare a directorilor de ingrijiri si profesionalizarea asistentilor medicali din Serbia. Sunt necesare alte politici si strategii pentru: imbunatatirea rolului managementului si a functiilor asistentilor medicali sarbi, inclusiv oportunitati de evolutie in cariera; sprijin legal imbunatatit; oportunitati de instruire in-service; si foarte important, o singura organizatie profesionala nationala de reprezentare a intereselor asistentilor medicali si de promovare a standardelor si a competentelor profesionale. Cuvinte cheie: Educatia asistentilor medicali sarbi, formare in management, profesionalizare, intarirea rolului asistentilor medicali.AbstractBackground: The role of nurses is underdeveloped in Serbia. This paper describes the situation of nurses in the Serbian health system; outlines activities to enhance nursing management; and identifies policies to strengthen the Serbian nursing profession. Methods: Management training activities was undertaken to develop nursing knowledge and skills and to introduce international best practice in nursing management and governance. Data based on evaluations assessed effectiveness of the training and identified future education. priorities.Results: Results indicate high levels of satisfaction with the management education and training approach, as well as the new ideas and concepts of management introduced. The training provided opportunities for enhancing the nurse management role in the everyday work setting and for articulating future education priorities for Serbian nurses.Conclusion: Management education and training of this type provides a platform for further development of nurse managers and professionalization of nurses in Serbia. Other policies and strategies are needed to improve the management role and functions of Serbian nurses, including increased career opportunities; strengthened legal support; in-service training opportunities; and importantly, a single national professional organization to represent nurses’ interests and to promote standards and competencies. Keywords: Serbian nurse education, management training, professionalization, strengthening nurse rol
MANAGEMENTUL HIPERTENSIUNII ARTERIALE LA ADULTII CU DIABET ZAHARAT SI BOALA CRONICA DE RINICHI
No full textBlood pressure (BP) level is a major determinant of cardiovascular morbidity and mortality in individuals with diabetes mellitus. Hypertension and diabetes mellitus are the most common causes of end stage renal disease. Blood pressure goals in patients with diabetic kidney disease areNivelul tensiunii arteriale este un determinant major pentru morbiditatea si mortalitatea cardiovasculara la indivizii cu diabet zaharat. Hipertensiunea si diabetul zaharat sunt cele mai frecvente cauze de boala renala in stadiul final.Tinta valorii tensiunii arteriale la pacientii diabetici cu boala renala est
MANAGEMENTUL PUBLIC - ARTA ARMONIZARII DECIZIILOR CU OBIECTIVELE PREVIZIONATE
No full textUncertain economic environment, extremely versatile and concerted action of some disturbing factors registered within the area of monetary, commercial, financial, social or public policies, have generated a severe economic crises.International financial experts and national economies confirmed that the magnitude of financial crisis has reached world wide dimensions, thus affecting the global economy.In Romania there is a wide typology of public institutions with internal architecture comprising departments, directorates, services and offices unfolding activities according to their profile, structures organically related to compartments that administrate and use public funds.TAmong relevant recommendations for Romania, resulting from our study : systemic and methodical approach of the objectives proposed, as well as stablishing program indicators to assess results to be obtained within the approved funding; monitoring objectives and results; setting agenda of priorities for judiciously selected and associated procurement, at transparent associated costs and not exceeding under any circumstances the initial prices set by contract; increasing institutional capacity and management accountability in terms of management efficiency in terms of legality and public funds administration in legal and efficient termsMediul economic incert, extrem de versatil si actiunea conjugata a unor factori perturbatori care s-au manifestat in zona politicilor monetare, comerciale, financiare, sociale sau publice au generat o criza economica severa.Expertii internationali in domeniul finantelor, precum si economiile nationale au confirmat deopotriva, ca magnitudinea crizei a atins dimensiuni de ordin planetar, afectand economia globala.In Romania exista o tipologie variata de institutii publice cu o arhitectura interna ce cuprinde departamente, directii, servicii si birouri in care se desfasoara activitati specifice profilului, structuri legate organic de compartimentele care gestioneaza, administreaza si utilizeaza resurse financiare publice.Printre recomandarile relevante pentru Romania, rezultate in urma studiului regasim: abordarea sistemica si metodica a obiectivelor propuse, precum si stabilirea unor indicatori de program care sa evalueze rezultatele ce vor fi obtinute, in limitele de finantare aprobate; monitorizarea obiectivelor urmarite si a rezultatelor obtinute; stabilirea unei agende de prioritati in care achizitiile propuse sa fie judicios selectate, iar costurile asociate sa fie transparente si, sub nicio forma, sa nu depaseasca preturile stabilite initial prin contracte; cresterea capacitatilor institutionale si responsabilizarea managementului sub aspectul administrarii in conditii de legalitate si eficienta a fondurilor publice
ACCESUL ŞI CALITATEA ÎNGRIJIRILOR MEDICALE
No full textThe aim of the study is to evaluate the access and quality of health care systems by the opinion of the patients in 10 European countries. Methods. Systematic review and comparative analysis of the data from the European surveys, published since 2007 till 2010 were used in order to compare the indicators of patient’s satisfaction with the access and quality of health care system in 10 EU countries: Austria, Germany, Denmark, Sweden, Estonia, Latvia, Lithuania, Romania, UK and Slovenia. The systematic review inclusion criteria were: systematic review has to be performed in the latest available year, but not earlier than 2007, representative sample of the public opinion survey; the study had to be performed on an international scale (i.e. in all comparative countries), target groups of the study had to be the all users of health care services. Two groups of indicators were assessed: access and quality by the variables examined in the selected studies. Overall evaluation was made by the value for money adjusted evaluation score using scatter diagram in the SPSS statistical package program. Facts and findings. The majority of the respondents in Austria and Sweden rate their healthcare system as good, but only a quarter of respondents in Romania and less than a half in Lithuania consider the quality of healthcare in their country as good or very good. It could be possible, that the financial and economic crisis has influenced those results. The access to health care is best evaluated by patients in Austria and Germany, the worst - in Latvia, Romania, Lithuania and Estonia. Sweden provides the worst access to family doctors, Estonia - to the hospitals among the all evaluated countries.Conclusion. The overall assessment of quality and access in ten selected European countries considering value for money-adjusted evaluation shows that the leading countries in terms of health care quality are Austria, Denmark and Germany, whereas the worst quality is evaluated in Latvia, Romania, Lithuania and Estonia. In terms of health care access the leading three countries are still the same - Germany Austria and Denmark, while Lithuania, Latvia and Romania are estimated as most lagging behind.Scopul acestui studiu este de a evalua accesul şi calitatea îngrijirilor de sănătate prin opinia pacienţilor din 10 ţări europene.Metode. În scopul comparării indicatorilor privind satisfacţia pacienţilor din 10 ţări europene (Austria, Germania, Danemarca, Suedia, Estonia, Letonia, Lituania, România, Marea Britanie şi Slovenia) faţă de accesul şi calitatea îngrijirilor, s-a utilizat revizia sistematică şi analiza comparativă a datelor existente la nivel European, publicate în perioada 2007-2010. Criteriile de includere în revizia sistematică au fost: revizia sistematică să fie din ultimul an disponibil, dar nu mai devreme de anul 2007; eşantionul reprezentativ din sondaj de opinie publică; studiul trebuia să fie realizat pe o scară internaţională (de exemplu, comparaţii între toate ţările), grupurile ţintă ale studiului trebuiau să fie reprezentate de toţi utilizatorii de servicii de îngrijiri de sănătate. Au fost evaluate două grupe de indicatori: de acces şi de calitate prin variabilele analizate în cadrul studiilor selectate. Evaluarea globală a fost realizată pe baza unui scor de evaluare ajustat în funcţie de valoarea monetară, folosindu-se diagrama de împrăştiere din programul statistic SPSS.Rezultate şi concluziiMajoritatea respondenţilor din Austria şi Suedia au considerat că sistemul lor de sănătate este bun, dar numai un sfert dintre respondenţii din România şi mai puţin de jumătate din Lituania consideră calitatea asistenţei medicale din ţara lor ca fiind bună sau foarte bună. Este posibil ca rezultatele respective să fi fost influenţate de criza financiară şi economică. Accesul la asistenţă medicală este considerat a fi cel mai bun de către pacienţii din Austria şi Germania şi cel mai scăzut de către cei din Letonia, România, Lituania şi Estonia. În Suedia, cel mai dificil este considerat accesul la medicii de familie, iar în Estonia cel mai rău este considerat accesul la spitale, comparativ cu toate celelalte ţări evaluate. Concluzie. Evaluarea generală a calităţii şi a accesului la îngrijiri medicale în zece ţări europene selectate, folosind scorul de evaluare ajustat în funcţie de valoarea monetară, evidenţiază faptul că ţările lider în termeni de calitate a îngrijirilor medicale sunt: Austria, Danemarca şi Germania, în timp ce evaluarea cea mai rea a calităţii este în Letonia, România, Lituania şi Estonia. În ceea ce priveşte accesul la îngrijirile de sănătate, lidere au rămas aceleaşi trei ţări - Germania Austria şi Danemarca, în timp ce Lituania, Letonia şi România sunt considerate ca fiind cele rămase în urmă
MEDIEREA TRANSFORMATIVA IN ORGANIZATIILE DE SANATATE: O RESURSA
No full textIntroduction In recent years, conflicts between patients (or their family) and healthcare professionals and monetary compensations requested for an effective or presumed adverse event are continuously increasing. Conflicts are destructive, as both disputants are suffering: the doctor for the accusations he/she perceives as “unjust”, the patient (or their relatives) for the “harm” he/she attributes to low performance of the healthcare organization. Besides, they stop any communication with each other. The transformative mediation approach allows parties to meet and express those values, points of view and feelings which nourish their conflict, without any involvement of the judicial authority. This paper aims to describe the transformative mediation approach and to illustrate its potential in healthcare organizations, through selected case studies. Methods Transformative mediation is based on empowerment (parties are enabled to define their own issues and to seek solutions on their own) and mutual recognition (each party listens to and understands the other party’s point of view). The steps for the mediation process are: the individual meetings with the parties, the mediation meeting, and the follow-up post-mediation. During the individual and mediation meetings, mediators act as a “mirror” for the parties’ feelings (affective dimension of the conflict) and do not assess medical or technical details of the conflict (rational dimension of the conflict). Case studies Three conflicting situations between patient’s family and professionals from different healthcare organizations in northern Italy, in which a transformative mediation approach was proposed, are illustrated and analysed. Conclusions Successful mediation allows healthcare organizations build-up citizens’ trust and to preserve their good reputation and may reduce costs, when a damage request is expressed. Neutrality is a big challenge for mediators. Besides, there is always a lot of uncertainty in transformative mediation, as mediators have to cope with human subjectivity. Unfortunately, a number of disputants do not accept mediation, because they fear or dislike confrontation. Keywords: healthcare organizations, conflict, empowerment, mutual recognition, transformative mediationIntroducere In ultimii ani, conflictele dintre pacienti (sau familiile lor) si personalul din sistemul sanitar, precum si cererile de despagubiri monetare pentru evenimente adverse reale sau presupuse, sunt in continua crestere. Conflictele sunt distructive, pentru ca ambele parti sufera: medicul pentru acuzatiile pe care le considera „nedrepte”, iar pacientul (sau rudele sale) pentru „daunele” pe care le atribuie slabei performante a organizatiei de sanatate. Mai mult, orice comunicare intre ei inceteaza. Medierea transformativa le permite partilor sa se intalneasca si sa exprime acele valori, puncte de vedere si sentimente care alimenteaza conflictul, fara implicarea autoritatii judiciare. Acest articol descrie modul de abordare pe care se bazeaza medierea transformativa si ilustreaza potentialul acesteia in organizatiile de sanatate, prin intermediul unor cazuri de studiu selectionate. Metoda Medierea transformativa se bazeaza pe cresterea potentialului personal (partilor le este conferita forta si increderea necesare pentru a putea sa defineasca propriile probleme la care sa caute ele insele solutii) si pe recunoasterea reciproca (fiecare parte asculta si intelege punctul de vedere al celeilalte parti). Etapele procesului de mediere sunt: sesiunile individuale, sesiunile de mediere (comuna) si urmarirea rezultatelor post-mediere. In timpul sesiunilor, mediatorii sunt o „oglinda” care reflecta sentimente (dimensiunea afectiva a conflictului) si nu intra in aspecte medicale sau tehnice (dimensiunea rationala a conflictului). Cazurile de studiu Sunt relatate si analizate trei situatii conflictuale dintre familia pacientului si medici din diferite organizatii de sanatate din nordul Italiei, in care a fost propusa medierea transformativa. Concluzii Medierea reusita permite organizatiilor de sanatate sa recupereze increderea cetatenilor si sa-si pastreze buna reputatie. Poate reduce costurile, atunci cand exista o cerere de despagubiri. O importanta provocare pentru mediatori ramane insa impartialitatea. De asemenea, exista si multa incertitudine privind medierea transformativa, intrucat mediatorii au de-a face cu subiectivismul uman. Din pacate, numeroase persoane nu accepta medierea, pentru ca se tem sau nu le place confruntarea. Cuvinte cheie: organizatii de sanatate, conflict, empowerment, recunoastere reciproca, mediere transformativ
Problema alegerii in dilemele majore ale obstetricii- actori, roluri, argumente etice si influente
No full textThe article discusses the principle of autonomy of patients’s choice in a highly sensitive area, the obstetrics, regarding two issues which arise many dilemmas and debates, the induced abortion and the elective cesarean section..It brings up many pro and cons ethical arguments, reviews the various points of view and historical, legal, religious and humanist influences.Article stresses the need to adapt the old ethic principles to the realities of the actual complex society and the necessity of fully respect for the fundamental rights of the patient, including autonomy. Article leaves still open the problem of the influence of various factors on patient’s choice, and the need for the physician to assure the observance of this right.Articolul isi propune sa trateze principiul autonomiei alegerii pacientilor intr-un domeniu extrem de sensibil, cel al obstetricii, privitor la cele doua aspecte care nasc atatea dileme si dezbateri, avortul provocat si cezariana electiva.Se aduc in lumina argumentele etice pro si contra, se trec in revista diversele puncte de vedere si influente istorice, legislative, religioase si umaniste.Articolul subliniaza necesitatea adaptarii vechilor principii etice la realitatile complexe ale societatii de astazi si respectarea pe deplin a drepturilor fundamentale ale pacientului, inclusiv pe cel de autonomie. Articolul lasa, totusi, deschisa problema influentarii alegerii exercitate de pacient, de catre diversi factori si necesitatea ca medicul sa devina garantul respectarii acestui drept