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Chapter 2

Basic Principles

Ann-Dorthe Olsen Zwisler & Lone Schou

2.1 Introduction

The comprehensive cardiac rehabilitation programme offered by the Cardiac Rehabilitation Unit at Bispebjerg Hospital has been organized using several basic principles that are based on the current guidelines (1–3) and established by an interprofessional working group (4).

Basic principles of comprehensive cardiac rehabilitation
  • Broad concept of cardiac rehabilitation
  • Broad target group
  • Comprehensive cardiac rehabilitation services
  • Individually tailored programme
  • Involvement of family members
  • Performing tasks using an interprofessional approach
  • Patient-centred health communication
  • Systematic clinical assessment and referral

This chapter defines and explains the basic principles. The chapter concludes by outlining legislation and ethical aspects relevant to cardiac rehabilitation.

2.2 Basic Principles

2.2.1 Broad concept of cardiac rehabilitation

An international expert group appointed by the World Health Organization (5) defined cardiac rehabilitation as “the sum of activity required to ensure cardiac patients the best possible physical, mental and social conditions so that they may, by their own effort, regain as normal as possible a place in the community and lead an active life”. Efforts to prevent heart disease can be divided into primary, secondary and tertiary prevention. Primary prevention means preventing disease from arising at all. Secondary prevention means identifying patients at high risk of developing ischaemic heart disease and identifying symptoms and disease at early stages to reduce the course of disease and contribute to improving the prognosis. Tertiary prevention means preventing remission of disease and preventing chronic conditions, including reduced functioning as a result of disease (6).

Activities targeting patients with known heart disease therefore include secondary and tertiary prevention. The concept of tertiary prevention and WHO’s definition of cardiac rehabilitation are very similar.

Since both secondary and tertiary prevention are core services in cardiac rehabilitation, the comprehensive cardiac rehabilitation programme at Bispebjerg Hospital has aimed towards a concept of cardiac rehabilitation that covers both rehabilitation and disease prevention. We thus wanted to establish that the cardiac rehabilitation programme is a broadly founded rehabilitation programme that is considerably more extensive and comprehensive than previous cardiac rehabilitation programmes, which often concentrated on individual components such as physical rehabilitation (exercise training) and patient education.

2.2.2 Broad target group

The effects of cardiac rehabilitation have especially been documented among young men with myocardial infarction (7), but the results from recent studies show that these effects can be transferred to a broader target group:

Diagnostic groups
Ischaemic heart disease: Cardiac rehabilitation is recommended for all patients who have manifest ischaemic heart disease: patients with myocardial infarction, patients who have undergone percutaneous coronary intervention, patients who have undergone coronary artery bypass grafting and patients with stable ischaemic heart disease who have not yet been offered comprehensive rehabilitation (1;8–11).

Heart surgery: Patients who have undergone other heart surgery than coronary artery bypass grafting and percutaneous coronary intervention, such as the implantation of an implantable cardioverter defibrillator (12;13), heart valve surgery (14) and heart transplantation (15) also have documented benefits from cardiac rehabilitation organized based on the special conditions of the basic disease and intervention performed (11).

Congestive heart failure: Good evidence exists that physical exercise is a well-indicated treatment for patients with congestive heart failure whose symptoms are well controlled (16;17), and the clinical guidelines on cardiac rehabilitation recommend that patients with congestive heart failure be offered comprehensive cardiac rehabilitation based on the same principles as patients with ischaemic heart disease (10;11).

High-risk patients: Attention on the importance of preventing the development of heart disease among high-risk patients has increased in recent years. High-risk patients are considered a target group for cardiac rehabilitation emphasizing lifestyle intervention and risk factor management (10).

Groups unrelated to diagnosis
Women: Several studies (18–20) have shown that women obtain the same benefits from cardiac rehabilitation as men, and guidelines from Denmark (1) and elsewhere (8–10) emphasize that women should also participate in cardiac rehabilitation programmes. Despite these recommendations, studies (18;21–24) indicate that women participate half as often as men in cardiac rehabilitation programmes. One reason could be that fewer women are referred to cardiac rehabilitation (25;26) and another that women are more often older than men when they heart disease becomes manifest (27).

Elderly people: Evidence (28;29) indicates that elderly patients benefit as much as younger patients from cardiac rehabilitation. Despite the existing documentation for the effectiveness of cardiac rehabilitation, studies (25;26) show that fewer older than younger cardiac patients are referred to cardiac rehabilitation programmes, and elderly people are more likely to decline cardiac rehabilitation services (22;30). Some hospital departments in Denmark have a maximum age for participating in cardiac rehabilitation, typically 70 years (31).

Ethnic minorities: Knowledge is limited on the effectiveness of cardiac rehabilitation in Denmark among patients with an ethnic background other than Danish (32). Despite this lack of knowledge, this project could not investigate this important topic because money was lacking for simultaneous interpretation.

Based on the existing evidence and the clinical guidelines, the services offered by the Cardiac Rehabilitation Unit target men and women of all ages who speak Danish and have ischaemic heart disease, congestive heart failure or a high risk of developing ischaemic heart disease.

Target groups of the comprehensive cardiac rehabilitation programme
  • Patients with ischaemic heart disease
  • Patients with congestive heart failure
  • Patients with a high risk of developing ischaemic heart disease

Patients who cannot transport themselves are offered transport to and from the Cardiac Rehabilitation Unit.

2.2.3. Comprehensive cardiac rehabilitation services

The cardiac rehabilitation programme has three phases: during admission (phase I), hospital-based outpatient cardiac rehabilitation (phase II) and the late maintenance and follow-up phase (phase III) (33). 1 In recent years attention has increasingly focused on the fact that patients are especially vulnerable during the transitions between phases because coordination may be lacking between phases, actors and efforts, with the risk of losing the health benefits achieved (34).

The Cardiac Rehabilitation Unit offers a phase II hospital-based programme. According to current guidelines (1;35;36), outpatient cardiac rehabilitation includes comprehensive cardiac rehabilitation programmes involving exercise training, patient education, lifestyle intervention, risk factor management, psychosocial support and optimizing the pharmaceutical treatment of symptoms.Nevertheless, the recommendations do not prescribe how these elements should be weighted or composed in detail. A successful phase 2 cardiac rehabilitation programme requires optimum clinical assessment and acute treatment.

Based on current evidence, the Cardiac Rehabilitation Unit has seven components and a supplementary module for patients with type 2 diabetes.

Core components of the comprehensive cardiac rehabilitation programme
  • Individually tailored rehabilitation programme
  • Patient education
  • FExercise training
  • Support for changing diet
  • Support for smoking cessation
  • Psychosocial support, including a 24-hour helpline
  • Systematic risk factor management and clinical assessment
  • A supplementary module for patients with diabetes

Cardiac rehabilitation programme

Illustration of Cardiac rehabilitation programme

Knowledge is lacking on the relationship between the length of phase II cardiac rehabilitation and the resulting effects (10). The length of phase II programmes varies greatly in Europe: from 1 to 46 weeks (33;35); the length of the programmes included in a metaanalysis of the effects varied from 1 week to 30 months (7). Although this aspect has not been sufficiently studied, the most recent European position paper (10) indicates a minimum length of 8–12 weeks.

The comprehensive cardiac rehabilitation programme offered by the Cardiac Rehabilitation Unit lasts 12 months. The programme starts with a brief period in which the individual programme is tailored followed by intensive cardiac rehabilitation for 6 weeks. When the intensive programme ends, the patient attends planned clinical follow-up assessment at the Cardiac Rehabilitation Unit after 3, 6 and 12 months.Then the patients are referred to their general practitioners or continue under the supervision of a department of cardiology if the course of disease is complicated.

The individual components and the efforts of each group of professionals need to be coordinated for the comprehensive cardiac rehabilitation programme to succeed. The Cardiac Rehabilitation Unit ensures this by organizing clinical practice, communicating with patients and exchanging information between professions.

2.2.4 Individually tailored programme

The patient is the central actor in the cardiac rehabilitation programme, since involving patients is a prerequisite for success. The Cardiac Rehabilitation Unit tailors the programme to the needs and resources of each patient based on individual discussions between the patients and health professionals.

2.2.5 Involvement of family members

The patient’s family members (primarily spouses) play an important role in cardiac rehabilitation at Bispebjerg Hospital and are involved as resource people in the overall rehabilitation. Studies indicate that patients with good family support are more likely to maintain participation in cardiac rehabilitation and changes in lifestyle than patients without such support (36). In addition, family members often feel powerless and anxious in connection with the illness of close family and have an independent need for support in coping with the early phase of acute illness in their family (37–41).

2.2.6 The current guidelines

(18–10) unanimously emphasize that hospital-based cardiac rehabilitation efforts should be based on an interprofessional approach. In Europe, the practitioners involved are divided into a core team comprising the practitioners with whom the patient has daily contact and a peripheral team that can be involved under special circumstances. The clinical team in the Cardiac Rehabilitation Unit comprises the staff groups that already were part of the existing rehabilitation programme in the Department of Cardiology. The composition complies with the newest recommendations for Europe, which, however, do not indicate the form of cooperation and the responsibility and role of each team member in the cardiac rehabilitation programme.

Health professionals in the Cardiac Rehabilitation Unit
Core team

Physical therapists
Clinical dietitians

Peripheral team

Social workers
Liaison psychiatrists

2.2.7 Patient-centred health communication

Studies have shown that communication between patients and health personnel can influence satisfaction, quality of life and health (42;43) and compliance (44–47). In accordance with the most recent recommendations in Denmark for communication in the health care system (48), the Cardiac Rehabilitation Unit emphasizes a patient-centred form of communication. This means that the patient’s behaviour, thoughts, feelings and general well-being are taken into account along with biological and paraclinical aspects of illness and treatment.

2.2.8 Systematic clinical assessment and referral

Although services may be available in some areas, experience in many countries (33;35) indicates that few patients who need cardiac rehabilitation are referred. The Cardiac Rehabilitation Unit emphasizes that all individual patients should be assessed systematically to determine the need for cardiac rehabilitation. This assessment is based on information from the patient records on diagnoses and the results of tests and examinations, including risk factors, and counselling the patients on their needs and resources. The Unit emphasizes to the patient that cardiac rehabilitation is a service just like all other treatment and that cardiac rehabilitation is considered and recommended as part of overall treatment.

Because of the special requirements of carrying out a randomized clinical trial,2 a nurse within the Unit (which was a project with temporary status at that time) conducted the assessment and referral from the Department of Cardiology during the project period.

2.3 Legislation

In contrast to such places as Belgium (37), Denmark has no specific legislation on cardiac rehabilitation. The Hospitals Act of 1995, the general legislation on hospitals in Denmark, describes the obligations of hospitals in disease prevention, including cardiac rehabilitation (51). The Act on Patients’ Legal Rights of 1998 stipulates that health personnel must inform patients about their state of health and treatment opportunities, including rehabilitation opportunities. Information on rehabilitation opportunities must be provided even if the hospital providing the information does not offer rehabilitation. The Hospital System Act of 2001 strengthened the obligation of hospitals to prepare rehabilitation plans. Patients have the right to have an individual rehabilitation plan prepared in connection with discharge if the physician considers that the patient needs one. The ethical rules for doctors (§ 2 on physicians’ precision and conscientiousness) say that physicians are obligated to contribute to preventing disease and promoting health. In addition, the Hippocratic oath obligates physicians to seek new knowledge to benefit patients, including knowledge on preventing disease and rehabilitation.

2.3.1 Evidence-based treatment

The Cardiac Rehabilitation Unit strongly emphasizes monitoring the continually updated clinical guidelines on the treatment of patients with heart disease and a high risk of developing heart disease, including guidelines on cardiac rehabilitation (Chapter 4). Clinical guidelines are developed to support practitioners in composing the best possible evidence-based treatment for patients based on the existing knowledge in each field. The treatment recommendations in the clinical guidelines are not legally mandated but are increasingly included in legal assessments in connection with patient complaints (50).

2.4 Ethical Considerations

Medical ethics has four traditional principles: justice, respect for patients’ autonomy, beneficence and non-maleficence (51). Cardiac rehabilitation, like all other forms of treatment, includes these ethical considerations. This section outlines the significance and the weighting of these four principles, focusing on the complexity of the basic principles for cardiac rehabilitation activities.

The Cardiac Rehabilitation Unit maintains the basic principles of the Department of Cardiology for social justice in treatment: age, gender and social status do not influence treatment. The Unit also emphasizes tailoring the treatment to the needs and resources of each patient.

The patients’ motivation and own efforts are decisive in achieving the treatment goals, and respect for the patients’ self-determination is very important in cardiac rehabilitation. On the other hand, cardiac rehabilitation activities are based on the obligation of health professionals to disseminate and use knowledge on the relationships between disease, lifestyles, level of functioning and treatment opportunities. The programme strongly emphasizes the fact that patients are ultimately responsible for their own health.

Cardiac rehabilitation at Bispebjerg Hospital gives high priority to the safety of patients, similar to the rest of Denmark’s health care system. Nevertheless, in efforts to prevent disease, situations may arise in which health services inadvertently cause people to feel more ill than they are. This applies especially to high-risk patients, but patients who have been told that they are healthy after an invasive intervention may also experience an inadvertent feeling of being ill in connection with cardiac rehabilitation.


(1) Danish Heart Foundation and Danish Society of Cardiology. Rehabilitering af hjertepatienter. Retningslinjer [Cardiac rehabilitation. Guidelines]. Copenhagen, Danish Heart Foundation, 1997.

(2) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(3) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(4) Olsen AD, Degn L, Sigurd B. Hjerterehabilitering og -forebyggelse på Bispebjerg Hospital [Cardiac rehabilitation and prevention of heart disease at Bispebjerg Hospital]. Copenhagen, Bispebjerg Hospital, 1997.

(5) Needs and action priorities in cardiac rehabilitation and secondary prevention in patients with CHD: report on two WHO consultations, Udine, Italy, 28–30 April 1992, Tours, France, 9 July 1992. Copenhagen, WHO Regional Offfice for Europe, 1993 (http://whqlibdoc.who.int/euro/-1993/ EUR_ICP_CVD_125.pdf, accessed 22 March 2004).

(6) Kamper Jørgensen F, Almind G. Det forebyggende sundhedsarbejde. Forebyggelsesbegreber og forebyggelsesprogrammer [Disease-preventive health activities. Concepts and programmes within disease prevention]. In: Kamper Jørgensen F, Almind G, ed. Forebyggende sundhedsarbejde [Disease-preventive health activities]. 4th edn. Copenhagen, Munksgaard Danmark, 2003: 17–51.

(7) Jolliffe JA, Rees K,Taylor RS,Thompson D, Oldridge N, Ebrahim S. Exercise-based rehabilitation for coronary heart disease (Cochrane review). The Cochrane Library. Issue 1, 2004. Chichester: John Wiley & Sons.

(8) Wood D, De Backer G, Faergeman O, Graham I, Mancia G, Pyorala K. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on Coronary Prevention. Atherosclerosis 1998; 140(2): 199–270.

(9) Wenger NK, Froelicher ES, Smith LK, Ades PA, Berra K, Blumenthal JA et al. Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute. Clin Pract Guidel Quick Ref Guide Clin 1995; (17): 1–23.

(10) Giannuzzi P, Saner H, Bjornstad H, Fioretti P, Mendes M, Cohen-Solal A et al. Secondary prevention through cardiac rehabilitation: position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. Eur Heart J 2003; 24(13): 1273–1278.

(11) Stewart KJ, Badenhop D, Brubaker PH, Keteyian SJ, King M. Cardiac rehabilitation following percutaneous revascularization, heart transplant, heart valve surgery, and for chronic heart failure. Chest 2003; 123(6): 2104–2111.

(12) Lewin RJ, Frizelle DJ, Kaye GC. A rehabilitative approach to patients with internal cardioverterdefibrillators. Heart 2001; 85(4): 371–372.

(13) Sears SF Jr, Conti JB. Quality of life and psychological functioning of icd patients. Heart 2002; 87(5): 488–493.

(14) Miller HS. Exercise training in special populations: valvular heart disease. In: Wenger NK, Smith LK, Froelicher ES, Comoss PM, editors. Cardiac rehabilitation. A guide to practice in the 21st century. New York, Dekker, 1999.

(15) Kobashigawa JA, Leaf DA, Lee N, Gleeson MP, Liu H, Hamilton MA et al. A controlled trial of exercise rehabilitation after heart transplantation. N Engl J Med 1999; 340(4): 272–277.

(16) Belardinelli R, Georgiou D, Cianci G, Purcaro A. Randomized, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, quality of life, and clinical outcome. Circulation 1999; 99(9): 1173–1182.

(17) Recommendations for exercise training in chronic heart failure patients. Eur Heart J 2001; 22(2): 125–135.

(18) Limacher MC. Exercise and cardiac rehabilitation in women. Cardiol Rev 1998; 6(4): 240–248.

(19) Lavie CJ, Milani RV. Benefits of cardiac rehabilitation and exercise training in elderly women.Am J Cardiol 1997; 79(5): 664–666.

(20) Cannistra LB, O’Malley CJ, Balady GJ. Comparison of outcome of cardiac rehabilitation in black women and white women. Am J Cardiol 1995; 75(14): 890–893.

(21) O’Callaghan WG, Teo KK, O’Riordan J, Webb H, Dolphin T, Horgan JH. Comparative response of male and female patients with coronary artery disease to exercise rehabilitation. Eur Heart J 1984; 5(8): 649–651.

(22) McGee HM, Horgan JH. Cardiac rehabilitation programmes: are women less likely to attend? BMJ 1992; 305(6848): 283–284.

(23) Hamilton GA, Seidman RN. A comparison of the recovery period for women and men after an acute myocardial infarction. Heart Lung 1993; 22(4): 308–315.

(24) Halm M, Penque S, Doll N, Beahrs M.Women and cardiac rehabilitation: referral and compliance patterns. J Cardiovasc Nurs 1999; 13(3): 83–92.

(25) Ades PA, Waldmann ML, Polk DM, Coflesky JT. Referral patterns and exercise response in the rehabilitation of female coronary patients aged greater than or equal to 62 years. Am J Cardiol 1992; 69(17): 1422–1425.

(26) Bowker TJ, Clayton TC, Ingham J, McLennan NR, Hobson HL, Pyke SD et al. A British Cardiac Society survey of the potential for the secondary prevention of coronary disease: ASPIRE (Action on Secondary Prevention through Intervention to Reduce Events). Heart 1996; 75(4): 334–342.

(27) Madsen M, Kjøller M, Rasmussen S. Kvinder og hjertesundhed – en rapport om sundhedsadfærd og hjertesygdom blandt kvinder [Women and heart health – a report on health behaviour and heart disease among women]. Copenhagen, National Institute of Public Health and Danish Heart Foundation, 2003.

(28) Balady GJ, Jette D, Scheer J, Downing J. Changes in exercise capacity following cardiac rehabilitation in patients stratified according to age and gender. Results of the Massachusetts Association of Cardiovascular and Pulmonary Rehabilitation Multicenter Database. J Cardiopulm Rehabil 1996; 16(1): 38–46.

(29) Ades PA, Waldmann ML, Gillespie C. A controlled trial of exercise training in older coronary patients. J Gerontol A Biol Sci Med Sci 1995; 50A(1): M7–M11.

(30) Ades PA,Waldmann ML, McCann WJ,Weaver SO. Predictors of cardiac rehabilitation participation in older coronary patients. Arch Intern Med 1992; 152(5): 1033–1035.

(31) Ischiel Træden U, Olsen Zwisler AD, Møller L, Tønnesen H. Forebyggelse på danske sygehuse. En kortlægning [Disease prevention and health promotion at hospitals in Denmark. A survey]. Copenhagen, Unit of Preventive Medicine and Health Promotion, Bispebjerg Hospital and National Network of Health Promoting Hospitals in Denmark, 2003.

(32) Wenger NK, Smith LK, Froelicher ES, Comoss PM. Needs and directions for research. In: Wenger NK, Smith LK, Froelicher ES, Comoss PM, editors. Cardiac rehabilitation. A guide to practice in the 21st century. New York, Dekker, 1999: 467–470.

(33) Vanhees L, McGee HM, Dugmore LD, Schepers D, van Daele P. A representative study of cardiac rehabilitation activities in European Union Member States: the Carinex survey. J Cardiopulm Rehabil 2002; 22(4): 264–272.

(34) Comoss PM. The new infrastructure for cardiac rehabilitation practice. In: Wenger NK, Smith LK, Froelicher ES, Comoss PM, editors. Cardiac rehabilitation. A guide to practice in the 21st century. New York, Dekker, 1999.

(35) Hildebrandt P, Gøtzsche CO. Akut koronart syndrom. Retningslinjer for diagnostik og behandling [Acute coronary syndrome. Guidelines for diagnosis and treatment]. Copenhagen, Danish Society of Cardiology, 2001 (www.dadlnet.dk/klaringsrapporter/2001-03/2001-03.HTM, accessed 22 March 2004): 1–28.

(36) Working Group of the Danish Secretariat for Clinical Guidelines. Referenceprogram for behandling af patienter med akut koronart syndrom uden ledsagende ST-segmentelevation i ekg’et [Clinical guidelines for the treatment of patients with acute coronary syndrome without accompanying ST-segment elevation in electrocardiogram]. Copenhagen, Danish Secretariat for Clinical Guidelines, 2002.

(37) Vanhees L, Mc Gee HM, Dugmore LD, Vuori I, Pentilla UR. The Carinex survey. Current guidelines and practices in cardiac rehabilitation within Europe. 1st edn. Leuven, Acco, 1999.

(38) Pell J. Cardiac rehabilitation: a review of its effectiveness. Coronary Health Care 1997; 1: 8–17.

(39) Bedsworth JA, Molen MT. Psychological stress in spouses of patients with myocardial infarction. Heart Lung 1982; 11(5): 82–92.

(40) Skelton M, Dominian J. Psychological stress in wives of patients with myocardial infarction. Br Med J 1973; 2(5858): 101–103.

(41) Stern MJ, Pascale L. Psychosocial adaptation post-myocardial infarction: the spouse’s dilemma. J Psychiatry 1979; 23(1): 83–87.

(42) Taylor CB, Bandura A, Ewart CK, Miller NH, DeBusk RF. Exercise testing to enhance wives’ confidence in their husbands’ cardiac capability soon after clinically uncomplicated acute myocardial infarction. Am J Cardiol 1985; 55(6): 635–638.

(43) Dracup K, Meleis A, Baker K, Edlefsen P. Family-focused cardiac rehabilitation. A role supplementation program for cardiac patients and spouses. Nurs Clin North Am 1984; 19(1): 113–124.

(44) Stewart MA. Effective physician-patient communication and health outcomes: a review. Can Med Assoc J 1995; 152(9): 1423–1433.

(45) Ong LM, de Haes JC, Hoos AM, Lammes FB. Doctor-patient communication: a review of the literature. Soc Sci Med 1995; 40(7): 903–918.

(46) Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther 2001; 26(5): 331–342.

(47) Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care 1998; 26: 657–675.

(48) Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988; 3(5): 448–457.

(49) Orth JE, Stiles WB, Scherwitz L, Hennrikus D, Vallbona C. Patient exposition and provider explanation in routine interviews and hypertensive patients’ blood pressure control. Health Psychol 1987; 6(1): 29–42.

(50) Danish Regions and Quality Assurance Division, Aarhus County. Patientens møde med sundhedsvæsenet [The interaction of patients and the health care system]. Copenhagen, Danish Regions.

(51) Fugleholm AM, Tønnesen H. [Lifestyle and disease prevention in hospitals. The power of experts or patients’ rights.] Ugeskr Laeger 2003; 165(11): 1121–1123.

(52) Schwartz PJ, Breithardt G, Howard AJ, Julian DG, Rehnqvist AN. Task Force Report: the legal implications of medical guidelines.A Task Force of the European Society of Cardiology. Eur Heart J 1999; 20(16): 1152–1157.

(53) Andersen S. Forebyggelse og etik [Disease prevention and ethics]. In: Kamper Jørgensen F, Almind G, ed. Forebyggende sundhedsarbejde [Disease-preventive health activities]. 4th edn. Copenhagen, Munksgaard Danmark, 2003: 228–232.

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