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drwcn · 4 years

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I was reading your post about consent for surgery and I had a question. Aren't there cases where if the patient is not of sound mind or unable to make an informed decision, then family can decide for them? That's not to say that WWX was entirely of sound mind at that point (he'd also been through insane trauma & was trying desperately to hold onto the family he had left). But JC was in a much worse state and retrospectively I agree JC would never have agreed to taking anyone else's core, but 1/2

I know I said i wasn’t going to answer asks until I’m done my exams but this one just came in and it’s a topic close and dear to my heart, so I’m going to take a couple of minutes to answer it. Thank you for the ask, but I think this brings up a lot of misconceptions of what is medical consent, capacity, competency, and substitute decision making. This is a very complicated and legally heavy topic. So it will be a long post. I apologize for that.

There are several misconceptions in the ask, and I will be addressing them in this order:

That Jiang Cheng is “not of sound mine” and cannot “make an informed decision”.

The role of family and substitute decision making

“force a life saving measure on a family member”.

Issue 1 : Jiang Cheng is not competent and has no capacity to consent.

There is no doubt that Jiang Cheng has gone through significant trauma, and that he is emotionally fragile, but this does not medically equate him to having no capacity to make surgical decisions and this certainly does not make him legally incompetent. If I may, I will define “informed decision”, “capacity” and “competency”.

The criteria of obtaining informed consent is described below.

Decision maker must:

Be aware of his/her right to withdraw consent at any time

Be free of undue influence, duress or coercion in making the consent decision (aka no one is paying them or holding a gun to their head)

Receive a proper explanation that includes but is not limited to:

diagnosis reached

advised interventions and treatments;

exact nature and anticipated benefits of the proposed examination, assessment, treatment or procedure;

common risks and significant risks;

reasonable alternative treatments available, and the associated common risks and significant risks; and

natural history of the condition and the consequences of forgoing treatment;

All of this must be explained to the patient before a procedure can be undertaken. And the patient must be able to understand what is told, and to appreciate the gravity of their choice. This brings us to the idea of “capacity”.

Capacity is not how emotionally distressed you are, or how traumatized you are. If my partner (the love of my life) and I both got into a horrible car accident, but I sustained minor injuries while he requires significant surgery, you can reasonably assume that I am in deep emotional distress. However, if I were his POA (power of attorney), I would still have the capacity to decide and consent for his surgery on his behalf if he is no longer capable (e.g.: he is unconscious).

Capacity refers to a person’s ability to make a decision that is “task specific”. As in, can he make a decision about this particular thing we’re asking him. It requires the person (Jiang Cheng) to:

Reason and deliberate - can Jiang Cheng make logical sense of the procedure and its consequences.

Hold appropriate values and goals - Jiang Cheng would want to protect his family, avenge his parents and defeat Wen Ruohan.

Appreciate one's circumstances - does Jiang Cheng know that without his surgery he will never get core back? Does he know the risks of the surgery to himself, to his brother, and its chances of success?

Understand information one is given - are Jiang Cheng’s cognitive functions intact to for him to understand and appreciate the information given?

And communicate a choice.

Can Jiang Cheng do all of that? The conclusion of the assessment for capacity ultimately lies with the attending physician. Medical capacity is a result of a physician’s assessment. Capacity wasn’t even a consideration for Jiang Cheng. Wen Qing agreed because Wei Wuxian begged, and probably because she also felt guilty. And that’s not how she should’ve done it.

From what I have seen on the show, Jiang Cheng is capable. I can say with 99% confidence that what happened to him is a gross violation of his bodily autonomy and his rights. No physician would agree to do a surgery the way Wen Qing did. In a way, she was compromised, and she should’ve seen that there was a conflict of interest between herself, Wei Wuxian, and her patient Jiang Cheng. If I were her, I would be mortified that I had done something like this.

On the other hand, competency is a legal status. It doesn’t change with activity and task. A judge needs to decide this and once you’re deemed incompetent, there’s usually no going back. This doesn’t really apply in CQL because...well they don’t have a judicial system. I can explain competency fully in another ask if you’re still interested. One thing I will say is that even “incompetent” individuals can have “capacity” for certain decisions. E.g: my grandmother with dementia while she cannot decide whether she undergoes a knee replacement or not, she can decide that she doesn’t want apple sauce with her morning meal. Again, competency is a global assessment leading to a legal status change, whereas capacity is task specific.

Issue 2: the role of family and substitute decision maker

Substitute decision makers (SDM) are brought in when the patient is deemed lacking capacity to make a certain decision, and as I have explained above, Jiang Cheng does not qualify as lacking capacity. In modern law, the role of SDM is different from country to country, even provinces/states to provinces/states.

For a lot places, pediatric patients are not able to consent for themselves and their parents are usually their SDM. This is not the case where I live. Children, as long as they are assessed by their physician to be capable of making specific decisions, will be able to make decisions in their medical treatment. This assessment is on-going throughout medical care. In many other places, parents are the SDMs. However: please note that good medical practice will still include the children in the discussion of their care as much as is appropriate for their age and ability, and that while they cannot consent, clinicians must try their best to obtain children’s ‘assent’ (aka their agreement and cooperation).

For seniors with dementia, their SDMs are their spouse or in lack that, their children. Without a specific POA - power of attorney, that is the one person the patient has written down as their legal SDM - all SDMs on the same level must come to an agreement before a procedure can be carried out. What do I mean by that? SDMs come in levels. Where I live, at the top level is the spouse. Without a specific designated POA, spouse is always SDM, their decision trumps everyone else’s. Without a spouse, the next on the list is usually children. If there are multiple children, they must all agree on what to do for mom or dad before the doctor can act. If they can’t agree, there’s usually a due process where physicians can petition the court to have a designated third-party SDM appointed. In all cases with SDMs, they should not be acting according to their own values but the values and wishes of the patient to be best of their understanding. If doctors suspect that SDMs are not following the values of their patient, there is also a process where they can petition the court to have the SDMs’ rights removed. It’s a very lengthy process and this doesn’t happen often.

For Jiang Cheng, if for example he never gained consciousness (so he is completely incompetent) and we consider Jiang Yanli and Wei Wuxian to be at the same SDM level (JC’s siblings), then they should’ve had a discussion with Jiang Cheng’s values and beliefs in mind and come to a conclusion together. Only that decision should be implemented. Of course, this didn’t happen because WWX and his martyr complex made an unilateral decision for himself based on what he thinks is right.

Issue 3: Forcing people to live against their will.

Does this happen? Tragically yes. It does. Should it happen? No. Absolutely no.

The grey areas are when a senior never wrote in legal documentation explicitly that they don’t want life sustaining measure, but that maybe in passing they’ve mentioned to their nurse or physician. When they become incompetent (coma, dementia, delirium, stroke, rapid decline in cognitive function), the children want everything to be done for dad or mom, and refuse to switch to palliative care or to end life support.

In those cases, unfortunately, many institutions will go with the families’ wishes because hospitals don’t want to be sued, and families do sue, even when all the medical team has done is respect the patient’s wishes.

There are many pediatric cases as well where parents cannot cope with their loss and can’t let go. The child could be brain-dead or in persistent vegetative state, and so even though nurses and doctors feel a lot of moral distress at continuously giving aggressive measure that they know it won’t help, they can’t stop. Because if they do, they can get sued. And sometimes it’s not even just a matter of lawsuits. These things can get crazy, media can twist the truth and people can get death threats. Feel free to google these cases.

So yeah, it happens. But it shouldn’t. Just because it happens, doesn’t mean it’s right.

And this doesn’t apply to Jiang Cheng. Because he isn’t brain dead, he isn’t in a coma, he doesn’t have frontal cortex damage, he doesn’t dementia. He is in complete control of all his faculties. So what happened to him was a crime. And if there are other examples where patients were forced into/lied to about medical procedures by their family, those are crimes too.

And yes CQL is a tv show set in fantasy china, so does it all really matter? I guess, if you don’t care that much about the drama, then no, it doesn’t matter. But keep in mind this wasn’t a historical drama, we’re not analyzing a historical figures’s actions with modern ethics. That would be misplaced. This was a fantasy drama, written by a modern girl, living in modern society. And its audiences are people living in the global community, so it should matter how it impacts the viewers who watch it.

From a modern western medical perspective, Jiang Cheng does not owe Wei Wuxian, Wen Qing, and Wen Ning anything. I liked Wen Ning up until he threw the core surgery reveal in Jiang Cheng’s face so cruelly. People cheered him on, but I was very upset.

Jiang Cheng owes these three nothing. Not a damn thing.

#corie replies #the untamed #cql #jiang cheng #wei wuxian #wen qing #wen ning #cql meta #medical consent: a running saga

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flupertech · 5 years

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UI/UX Mistakes That Can Ruin Your Mobile Apps

Due to the mounting competition in the mobile app development company, designing a successful mobile app has become more of a challenge these days. Mastering a pleasing mobile experience is the toughest task for the designers and app developers as the platform has various limitations to it including attention span, screen real-estate, and UI constraints. A poor Smartphone app doesn’t get another chance as already it is hard to get the users to download it the very first time. A poorly designed app can affect both performance and popularity. Perfecting UX has cut and tries ways to it and thus one tends to make so many mistakes during the process. Here are some common UI/UX mistakes that can ruin your mobile apps you must avoid to engage the customers better and give them a terrific experience-

Check out the UI/UX mistakes that can ruin your mobile apps that every mobile app developers should avoid…

Bad UI/UX Design

Poor designing is one of the biggest mistakes a designer can commit for the duration of the creation stage. Every mobile app developers who are willing to create mobile apps, they must place themselves in the user’s shoes and then decide about the design interface that will go for the mobile app. An interactive and simple UI assists to engage users better as they can easily navigate across and use all the features. Just remember one thing use the latest trends in UI design and even utilize some as inspiration from the other apps to craft an ideal product for your customers.

Bombarding with Features

Try to use required features in your mobile apps many mobile app developers implement too many features in an app which is not needed to execute and it makes mobile app sluggish and lowers the overall performance. Keep in mind one thing clearly only the right features can give a kick to your app or business and unnecessary multiple features will only consume too much money which will not be going to give you the right result. So, include only primary features which will serve the main functions to the users or visitors. Then check you app genteelly and then if you feel your app still need some more features than you can simply add or updates in a later stage.

Not Focusing or Ignoring Target Audience

Paying no attention to the target audience will definitely lead you on the path of disappointment. Target audience is equally important as an app design concept is significant to achieve success. Never exaggerate about your mobile app but explain each and every feature of your app and yes, if you have hired mobile app developer then please don’t forget to check that the information or feature they added to your mobile app are meeting the requirements of the target audience. Once, your app meets the expectations of the targeted audience then no one can stop you to achieve a goal. So focusing the target audience needs is the ultimate and vital thing to achieve the right and fruitful result.

Tiring Tutorial

A tutorial is a thing where your target audience firstly meets with your invention and your efforts. Yes, it is really important to guide your audience with proper explanation, but make this first interaction impressive and blessed not a burden. Never tell lie anything about your app to your audience, it will not give you good result and obviously, your tutorial will either give burden or freshen up your audience so this tiredness or this positive attitude of your audience will return you either thumbs-up or failure. So be there to entertain your audience with the right information about your mobile app. Therefore, each and every Mobile app development companies must work on this.

Making thing complicated

The kiss rule works extremely well for mobile app designing. Kiss means keep it Short and Simple. Don’t make things difficult as it will create mystification which will meddle in the working of the mobile app. It has been seen that many designers sometimes get overdesign and overambitious the mobile app to make it unique. Overdesigned and Over-styled visuals are a bit boring for the users as they have to learn how to use them from scratch and put in more money and efforts. Every iOS app development companies must focus to make things easy to use and obviously things must be effective and vital for your mobile app.

Breathing space

Don’t get confused with this word; I am talking about white spaces. And white space gives a breathing space to the page. It is the space that aligns images, text, and other design elements together and makes your work communicate better. Never fill everything to the brim. Fill it in a proper room to let your users absorb well. Create your design breathe. The android app developers who are designing your app should not be driven by other elements that you forget t include white space or breathing space in your mobile app design. White spaces are the best thing to be added in your design because it works to add a balance to your design and its elements.

Don’t try to copy other apps

Just keep in mind one thing each and every product is unique in its value, functionality, goals, and audience as well. No one can give you the guarantee that other’s app functionality will definitely work on your mobile app too. You can hire the best mobile app developer, or you can take online advice and learn from it, but remember one thing imitating other mobile apps straightway is where you make a big fault. In addition, instead of taking tips online it is better you apply customer feedback to make your mobile app desirable. Read reviews, do surveys and gather enough qualitative data to know the preferences and the changes they desire. Such data is useful in generating ideas that can be further verified through testing in order to accelerate the performance.

Neglecting Social Media Link

If you wish the users to be more comfortable with your app, just link it to social media. Nowadays, a big amount of people frequently found on Twitter, Instagram, and Facebook, etc. So to get more enhancements in the overall performance of the mobile app you should integrate your mobile app with social media link. As lengthy registrations test the patience of users and visitors, and ultimately makes them leave it for the toll it takes on effort and time. Provide them multiple logins through social media sites link will surely reduce the burden of the long registrations and they don’t have to bother remembering IDs and passwords separately. Almost every iOS app development companies never forget to provide social media links in their mobile apps.

Wrong Estimates of Updates

Making changes on the web is simple as the developers can make adjustments effortlessly and apply them instantly. However, on mobile, making changes is a chore in itself. As an app is hosted on a client’s device or phone so updates have to undergo a long process before they finally appear. Changes after development are tough and involve lengthy app store review cycle. Also, updates require a manual confirmation from unwilling users and that adds to the challenge. So, it is very important that whatever you change is properly tested to enhance the interactive experience rather pull it down. Correcting mistakes on mobile is difficult, but if you use testing as a part of the development process you can save yourself from the trouble later.

Final Thoughts

Your small and simple mistake can mount up to big losses and sooner or later take you away from your target. UI/UX design can’t be improved in a single night. It is an ongoing process that needs you to learn from each mistake and come up with something awesome We at Fluper provides the number of android developers which can give a kick to your business, so why wait to contact us if you are looking for the best mobile app developers and have a conversation with our experts to achieve your goals.

#mobile apps #buisness #news #technology #company #development #ios #android phone #MobileAppDevelopment #industrial

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bountyofbeads · 5 years

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https://www.latimes.com/politics/story/2019-09-19/border-patrol-interview-migrant-families-credible-fear?_amp=true&__twitter_impression=true

🚨🚨NEWSFLASH: "Border Patrol agents are beginning to screen migrant families for 'credible fear' instead of highly trained asylum officers". It's creating chaos at the border and asylum seekers are getting the help they need. This is a look from the perspective of those agents, judges and asylum seekers on the front lines.

Border Patrol agents, rather than asylum officers, interviewing families for ‘credible fear’

By MOLLY O’TOOLE | Published September 19, 2019 5:50 AM ET | Los Angeles Times | Posted September 19, 2019 12:32 PM ET |

WASHINGTON —

Border Patrol agents are beginning to screen migrant families for “credible fear” instead of highly trained asylum officers who are charged with determining whether applicants qualify for U.S. protection, the Los Angeles Times has learned.

The first Border Patrol agents arrived last week to start training at the South Texas Family Residential Center in Dilley, the nation’s largest immigrant family detention center, according to lawyers working there and several employees at U.S. Citizenship and Immigration Services.

The move expands the Trump administration’s push for Border Patrol agents to take over the interviews that mark the first step in the lengthy asylum process. Border Patrol agents began training to conduct asylum interviews in late April, but agents have now deployed to family detention facilities for the first time.

As a result, Border Patrol agents — law enforcement personnel who detain migrant families at the border — will also have authority to decide whether those families have a “credible fear” of being persecuted in their home countries.

Customs and Border Protection has provided few details about the Border Patrol asylum training and has not publicly acknowledged whether agents have yielded significantly lower approval rates than federal asylum officers, but internal communications and other official documents obtained by The Times indicate early problems with the program.

The Citizenship and Immigration Services personnel requested anonymity for fear of retaliation. Neither the agency nor Customs and Border Protection, the Border Patrol’s parent agency, immediately responded to requests for comment by deadline.

Agents at Dilley are not wearing the Border Patrol’s well-known olive-green uniforms, and are identifying themselves to migrant families and children as asylum officers, said Shay Fluharty, an attorney with the Dilley Pro Bono Project, who has been in interviews conducted by the agents.

“It’s creating significant strain for our clients — not just because they’re unprepared and untrained,” Fluharty told The Times. “We understand that the intention is to significantly limit asylum officers who are conducting these interviews and have them be primarily conducted by Border Patrol.”

The Trump administration’s ultimate goal with the Border Patrol training program is to make it more difficult for migrants to win asylum, asylum officers, officials, and lawyers say, because White House officials believe that agents will be more adversarial and less likely to approve asylum seekers. By contrast, asylum officers work under Citizenship and Immigration Services, the Homeland Security agency that administers the legal immigration system and benefits.

Under Homeland Security regulations, the credible-fear interview must be conducted in a “non-adversarial manner.”

Michael Knowles, special representative for the federal asylum officers’ union, said many members are concerned about the use of law enforcement personnel for crucial interviews with people seeking refuge. Neither the union nor its officers have been given official notice of or explanation for the shift, Knowles said.

“I don’t mean to denigrate the proper and legitimate role of Border Patrol, but it’s different,” Knowles said. “They’re not trained and geared toward refugee protection, any more than I’m trained to go look for tracks in the desert and chase people.”

Brandon Judd, president of the National Border Patrol Council union, confirmed that agents are undergoing training in which they conduct credible-fear interviews with family units. But he pushed back against the idea that Border Patrol agents would be “tougher” against asylum seekers.

“I’ve personally had conversations with both President Trump and Stephen Miller,” Judd said. “It’s always been my understanding that the reason to have Border Patrol agents do the credible-fear interviews is to ensure the asylum process begins at the earliest practicable moment. ... The narrative being painted that Border Patrol agents will deport more persons doesn’t hold water.”

According to a Customs and Border Protection training timeline obtained by The Times, 10 Border Patrol agents from the El Centro sector in California began training to do credible-fear interviews in April, and by August, a total of 60 agents were due to conduct their first credible-fear interviews. A new group started trainingin early September, according to Citizenship and Immigration Services personnel.

The agents are all “non-bargaining employees,” meaning they are not members of a union.

The timeline states three times that “additional training will be required” if the Border Patrol role in asylum interviews expands to family units. Homeland Security officials also assured congressional staffers in August that the Border Patrol was not going to cover family units because of that requirement, a Senate Homeland Security and Governmental Affairs committee aide told The Times. Department officials did not inform the committee they’d be deploying agents to family detention centers.

It’s unclear whether the agents sent to the detention center in Dilley received additional training, or whether Citizenship and Immigration Services asylum officers will remain at the facility after they finish instructing the agents. Several officers have already been reassigned.

According to separate records obtained by The Times, as of last month, Border Patrol agents had completed 178 credible-fear screenings with asylum seekers from more than 15 countries — all of whom were single adults. They determined 54% met the credible-fear standard and 35% did not. Agents closed 11% of cases without making a determination.

While the newly trained Border Patrol agents have yet to complete many screenings, that’s a far lower approval rate than is typical for the initial interviews. Congress deliberately set a low standard for “credible fear” in order to ensure that the U.S. government did not return people to potential harm, and roughly 80% of asylum seekers pass the first interview.

Ultimately, only about 1 in 5 asylum seekers wins a case, according to the Justice Department. The Trump administration cites that disparity to argue that most asylum seekers have fraudulent cases, and President Trump frequently disparages asylum as a “hoax.” He also has lamented that Border Patrol and military personnel are restricted from getting “rough” with migrants.

Advocates argue that the disparity only shows how difficult it is to win the right to stay in the United States. With the backlog of immigration cases now surpassing 1 million, a final decision can take years.

The asylum division at Citizenship and Immigration Services has faced heavy pressure from the White House and from Ken Cuccinelli, who was named acting director of the agency in June. John L. Lafferty, asylum division chief for six years, recently was reassigned to a service center and replaced on an acting basis by Andrew Davidson, who oversaw fraud detection.

Lafferty was outspoken about his directorate being forced to implement dramatic changes to U.S. immigration policy with what he said was little to no advance notice or consultation. Knowles, the union representative, called Lafferty’s reassignment “diplomatic exile.”

All decisions made so far by Border Patrol agents at the “credible fear” stage have been reviewed by a supervisory asylum officer before they were issued, according to the records obtained by The Times.

But critics of the training program worry that the administration will use it to get around requirements for asylum officers and supervisors to have special training and extensive experience — with comparatively inexperienced and less-trained Border Patrol agents in effect policing themselves rather than having their decisions reviewed by a Citizenship and Immigration Services supervisory officer.

Internal communications obtained by The Times indicate Border Patrol agents appear to have already stepped outside their allowed roles.

Last Thursday, Ashley Caudill-Mirillo, deputy chief of the asylum division at Citizenship and Immigration Services, wrote to leaders in the field stressing that agents could only screen credible-fear claims from the Northern Triangle countries of El Salvador, Honduras and Guatemala and “under no circumstances” should they interview Cubans.

“There are no exceptions to this rule,” she said, adding that officials “may follow up with you if it is found these assignments occurred in the event we are asked to explain.”

Fluharty said she and her colleagues have witnessed a range of issues. The handful of Border Patrol agents deployed to Dilley are all male, effectively preventing clients who’ve suffered from severe sexual or gender-based violence from requesting a female asylum officer. Some agents are conducting interviews over the phone — a first at Dilley, where all screenings had previously been in-person — and with children as young as 6 years old. Other screenings are lasting far longer than normal, more than six hours. And agents are consistently asking irrelevant questions, while leaving out the most critical ones, she said.

“It’s most difficult for families who have to share really traumatic experiences under really stressful circumstances,” she said, “And now with someone without the appropriate knowledge or training.”

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