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Others may wish the clinician to insomnia verb best unisom 25 mg take a more primary role in information provision sleep aid without antihistamine safe 25mg unisom. Some women may have made their decision to sleep aid headphones safe unisom 25 mg participate in prenatal screening before they arrive at the first prenatal visit; others may require the chance to think it over, talk with their partners, friends, or family members or to ask questions of the clinician at a later date. There are many demands on clinician time and the suggestions for facilitating informed choice in prenatal screening exacerbate these demands. With acknowledgement of the additional time resources that counseling about prenatal screening may require, clinicians may wish to consider creative approaches to imparting information, such as directing women to online or other educational resources, having electronic information available at the office, offering group information sessions before individual counseling, employing non-physician health care providers for counseling purposes, or providing written information before the counseling session, so that clinician counseling time is used for particular questions and discussion rather than informing women of the basic information. The integration of counseling about prenatal screening into the existing time allotted for the first prenatal visit, without extra remuneration or educational resources, does not support clinicians in helping women make informed choices. The original clinical practice guideline universalizing the offer of prenatal screening (Summers et al, 2007) was issued by a professional college that does not control the fee-for-service payment structure of the Canadian health care system. As genetic testing services become increasingly prevalent in primary care, prenatal screening will become one of a variety of tests that primary care physicians will be responsible for offering, or for identifying appropriate referrals to genetic counseling resources (Greendale & Pyeritz, 2001). Other work has shown that additional educational resources are needed to provide appropriate primary care for other types of genetic testing (Burke & Emery, 2002; Carroll et al. This study focused on prenatal screening, but the findings about counseling, written materials, and information-seeking and decision-making are relevant to many other types of genetic screening. Genetic testing asks people to consider complex scientific information and mathematical probabilities in turn with their personal values and beliefs. The profession of genetic counseling has been established to aid in this consideration, but genetic testing has expanded into primary care; professional and funding policy needs to respond to this evolution by providing educational and resource support for primary care providers asked to assume this additional responsibility. The ideas about informed decision-making and possible solutions outlined in this work are not able to be wrapped up in a neat paragraph or two. As described earlier in this chapter, I think current conceptions of informed decision-making are deeply problematic for several reasons, but I have yet to arrive at a better alternative. Sherwin writes that feminists are often conflicted about the idea of autonomy because this concept provides protection and agency to vulnerable people, but also "hides the workings of privilege and masks the barriers of oppression" (Sherwin, 1998, p. I think informed decision making is the best option we have right now, and in my work I have tried to suggest ways in which it could be improved, including acknowledgement of embedded values and assumptions, appreciation of the individualized requirements for information, and understanding that the information-seeking and decision-making processes start before and continue after a visit with the clinician. After working on this project for five years, my own take-home message is that we should afford people who have atypical needs the same support to reach their potential as we afford those who have typical needs (Wendell, 1996). If we spent as much money supporting the lives of people with disabilities as we do on research and clinical services designed to prevent those lives (Lippman, 1991), we might stand on firmer ground when espousing the importance of autonomous and informed choices. While undertaking this research I have identified several tensions between individuals and society. The premise of expanding the offer of prenatal screening is based on individual rights; as evidenced in the Clinical Practice Guidelines (Chitayat et al, 2011; Summers et al, 2007) through the emphasis on informed decision-making and autonomous choices, women should be able to make their own choices about how much information they want to know about their pregnancy, and what to do with that information. At the same time, social forces may act in many different ways (through language, available resources for child raising, social ideas of normality, accommodations of people with different needs) to shape and constrain the choices that are available to women. Future research may explore these tensions and their implications for informed decision-making. This thesis addresses a particular type of prenatal screening that can identify particular conditions through specific mechanisms. As medical science progresses, more conditions are able to be identified prenatally, and different therapies become available, the offer and consideration of prenatal screening will become more complex. This technology, known as non invasive prenatal diagnosis, will enable women to obtain diagnostic information early in pregnancy without any physical risk to the mother or fetus. Family physicians are a famously overburdened group, who juggle challenging patients, a high workload and time limitations while also trying to participate in continuing education, improve relationships with their patients, cope with limited health resources, imposed rules and regulations, and a lack of support from specialists (Lee, Brown, & Stewart, 2009). Counseling about prenatal screening takes time, and the strategies I have proposed in this thesis increase the amount of time required by the family physician. There has been significant research into innovative ways to impart information about prenatal screening without one-on-one physician-patient interaction (Baldwin, 2006; Browner, Preloran, & Press, 1996; Griffith, Sorenson, Bowling, & Jennings-Grant, 2005; Kaiser et al. For instance, information may be provided prior to a visit with the physician, so that counseling time can be used to clarify understanding, deliberate, and discuss implications of different decisions rather than impart basic information.

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