Legal and ethical guidelines for physicians in geriatric terminal care

In the American legal system, the right to refuse treatment--the right, in other words, to be "let alone"--is an important aspect of autonomy and individuality. In health care decision making, people rarely choose to have no treatment at all, but usually choose from among various forms of medical treatment. Even when aggressive technological options are rejected, patients will often elect to have intensive nursing and pain control. Sometimes they choose to forego treatment and risk hastening death. Particularly among the elderly, a series of small decisions may have to be made as health status worsens over time. No matter what the decision, in observing patients' wishes, physicians will find support in current ethical and legal concepts.     

Women’s preferences for specialists who provide cancer screening and general medical care

In order to determine what types of specialists women prefer for medical care, we examined responses from a cross-sectional survey of adult female patients in a health plan of the independent practice association model in the Minneapolis–St. Paul metropolitan area ( n = 1,204). The response rate for the survey was 90%. The women expressing a preference (60% of responders) overwhelmingly preferred to see obstetrician-gynecologists for their breast examinations and Pap smears and strongly preferred family physicians or internists for the remainder of their cancer screening and general medical care. Thus, the majority of women expressed preferences for physicians of different specialties to provide their medical care.     

Types of information physicians provide when prescribing antidepressants

BACKGROUND: Providing antidepressant information to patients may foster greater adherence to therapy. OBJECTIVE: To assess physician information-giving while prescribing antidepressants, and to identify factors that influence the provision of information. DESIGN: Randomized experiment using standardized patients (SPs). Standardized patients roles were generated by crossing 2 clinical conditions (major depression or adjustment disorder) with 3 medication request types (brand-specific, general, or none). PARTICIPANTS: One hundred and fifty-two general internists and family physicians recruited from solo and group practices and health maintenance organizations; cooperation rates ranged from 53% to 61%. MEASUREMENTS: We assessed physician information-giving by analyzing audio-recordings of interactions between physicians and SPs, and collected physician background information by survey. Generalized estimating equations were used to examine the influence of patient and physician factors on physicians' provision of information. RESULTS: One hundred and one physicians prescribed antidepressants, accounting for 131 interactions. The mean age of physicians was 46.3 years; 69% were males. Physicians mentioned an average of 5.7 specific topics of antidepressant-related information (of a possible maximum of 11). The most frequently mentioned topic was purpose (96.1%). Physicians infrequently provided information about the duration of therapy (34.9%) and costs (21.4%). Standardized patients who presented with major depression received less information than those with adjustment disorder, and older and solo/private practice physicians provided significantly less information to SPs. CONCLUSIONS: Physicians provide limited information to patients while prescribing antidepressants, often omitting critical information that may promote adherence. Mechanisms are needed to ensure that patients receive pertinent antidepressant information.     

Emergency physicians and physician-assisted suicide, Part II: emergency care for patients who have attempted physician-assisted suicide.

Part I of this article reviewed key terms, events, and arguments in the heated national debate regarding physician-assisted suicide (PAS). Part II of the article examines the role of emergency physicians in caring for patients who present to the emergency department after an incomplete or unsuccessful attempt at PAS. The article considers the analogous cases of emergency care for other patients who have attempted suicide and care for terminally ill patients who refuse life-sustaining treatment. Morally relevant features of these situations are identified, including the decisionmaking capacity and the choices of the patient, the opinions of the patient's family or other surrogate decisionmakers, the presenting condition and medical history of the patient, the nature of the patient's suicide attempt, and the physician's own moral convictions. The article evaluates the 3 management options: aggressive intervention to preserve life, palliative care only, and assistance in completing the suicide. It concludes with several general recommendations for addressing these situations.     

The role of physicians in home health care.

Physician involvement in home care has declined markedly over the past 50 years. By contrast, the renaissance in home care in the US over the last decade has created a pressing need for greater physician participation and new roles for physicians as members of the home care team. This article reviews these developments and identifies the need for improved medical education and physician reimbursement if the desired physician involvement in home care is to become a reality.     

Diagnosing dementia: perspectives of primary care physicians.

As few as 50% of dementia cases are diagnosed by physicians. This study investigated how primary care physicians assess patients for dementia and identified barriers to dementia diagnosis in the primary care setting. Seventy-eight physicians in three geographic areas participated in 18 focus groups. Barriers identified included: (a) the failure to recognize and respond to symptoms of dementia; (b) a perceived lack of need to determine a specific diagnosis; (c) limited time; and (d) negative attitudes toward the importance of assessment and diagnosis. These barriers keep physicians from diagnosing dementia and, consequently, from offering concrete help for patients experiencing symptoms of dementia or for the families who care for them.     

Provision of care to the terminal ill in the home: Community experiences in Japan

An analysis of the costs of terminal care in Japan revealed that the last month of life accounted for almost one-third of the costs incurred by patients during the entire preceding 10 months. In order to reduce the costs of terminal care and raise the level of care provided in the community two groups, an urban group led by Dr. Sato and a rural group led by Dr. Asai, developed innovative approaches for providing community care to terminal cancer (and other) patients. Three case studies illustrate the way the terminal stages of illness are managed under these new approaches. The authors conclude by proposing several reforms to improve the delivery of care to the terminally ill.     

Prognostic factors in patients in the terminal phase of haematological malignancies who are receiving home medical care

Although there are many prognostic models for patients in the terminal phase of solid tumours, a reliable prognostic scoring system in patients in the terminal phase of haematological malignancies (HM) has not been established. We retrospectively evaluated 180 patients in the terminal phase of HM who were receiving home medical care (HMC). Multivariate analyses revealed that clinician's estimate, consciousness, loss of appetite, dyspnoea, neutrophil count, lymphocyte count, and lactate dehydrogenase were associated with overall survival (OS). Based on this result, we developed a novel prognostic scoring system, the Japan palliative haematological oncology prognostic estimates, in which four risk groups were shown to clearly differ in survival (p < 0.001): a low-risk group (n = 41, median OS of 434 days), an intermediate-low-risk group (n = 80, median OS of 112 days), an intermediate-high-risk group (n = 38, median OS of 31.5 days), and a high-risk group (n = 21, median OS of 10 days). This is the first investigation of prognostic factors that influence the OS of patients in the terminal phase of HM who are receiving HMC. Providing patients with reliable information about their prognosis is important for them to consider how to spend their remaining life.     

Preventive geriatrics: basic principles for primary care physicians.

The goal of preventive geriatrics is to nurture a state of health that allows maximal active life expectancy while maintaining high levels of function. The physician's role in promoting such a state of health is disease prevention and the control of chronic diseases of aging. Barriers such as insufficient time and/or staff resources and insufficient third-party reimbursement restrict the delivery of multiple risk factor intervention and healthy aging counseling in the office setting. A systematic approach to preventive geriatrics proposed by the U.S. Prevention Services Task Force is discussed.     

Older persons' preferences for site of terminal care.

BACKGROUND: Little is known about patients' preferences for site of terminal care. OBJECTIVE: To describe older persons' preferences for home or hospital as the site of terminal care and to explore potential reasons for their preferences. DESIGN: Cross-sectional quantitative and qualitative interviews. SETTING: Participants' homes. PATIENTS: Community-dwelling persons 65 years of age or older who were recently hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were not selected according to life expectancy; 246 patients participated in quantitative interviews and 29 participated in qualitative interviews. MEASUREMENTS: Preference for site of terminal care and the reasons for that preference. RESULTS: In quantitative interviews, 118 patients (48%) preferred terminal care in the hospital, 106 (43%) preferred home, and 22 (9%) did not know. One third changed their preference when asked about their preference in the event of a nonterminal illness. Reasons for preference identified during qualitative interviews included the desire to be with family members and concerns about burden to family members and their ability to provide necessary care. Concern about long-term care needs resulted in preference for a nursing home when choice was not constrained to home and hospital. CONCLUSIONS: Preference for home as the site of care for terminal illness exceeds existing practice. However, the current debate about home versus hospital as the ideal site for end-of-life care may ignore an important issue to older persons--namely, the care of disabilities that precede death.