The value of disease severity in predicting patient readiness to address end-of-life issues

BACKGROUND: Although patient-physician discussion is the most important tool for end-of-life planning, less than 30% of seriously ill patients have held these discussions. While physicians use objective disease severity and recent clinical events to trigger end-of-life discussions, it is not known if such findings predict patient readiness. We evaluated the ability of disease severity measures and recent clinical events to predict patient readiness for end-of-life discussions in patients with chronic lung disease. METHODS: The desire for discussion about end-of-life care was evaluated in 100 outpatients with a diagnosis of chronic lung disease presenting for pulmonary function testing. Objective disease severity was indicated by the percentage of the predicted forced expiratory volume, use of oral corticosteroids, a functional status score, frequency of recent hospitalizations, and required use of mechanical ventilation. RESULTS: In multivariate analysis, patient desire for an end-of-life discussion with the physician was not associated with percentage of predicted forced expiratory volume in 1 second (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.96-1.03), oral corticosteroid use (OR, 1.34; 95% CI, 0.40-4.54), functional status score (OR, 1.37; 95% CI, 0.34-5.56), hospitalizations in the past year (OR, 0.33; 95% CI, 0.09-1.20), or previous mechanical ventilation (OR, 1.37; 95% CI, 0.34-5.56). CONCLUSIONS: Patients appear no more or less interested in end-of-life discussions at later stages of chronic lung disease. Physicians cannot use disease severity measures or recent clinical events to accurately predict when patients desire end-of-life discussions. Focusing on physician skill in using specific communication strategies for patients at all stages of illness may be the most promising approach to increasing end-of-life discussions.     

Physicians’ attitudes towards living wills and cardiopulmonary resuscitation

Objective:To determine whether a physician’s familiarity with the living will directly relates to an expressed willingness to discuss resuscitation issues with patients. Design:Survey of selected primary care and medical subspecialist physicians most likely to care for seriously or terminally ill patients. Setting:Private-practice clinicians practicing in an urban county. Participants:Internists, family practitioners, cardiologists, oncologists, and neurologists in private practice. Interventions:None. Results:Almost all responding physicians (97.2%) knew of the living will, although few (13.5%) had executed one for themselves. Most were willing to keep a copy of their patients’ living wills with their office records. However, only a few physicians (20%) indicated they routinely discussed extraordinary care issues with their patients. In fact, most (70%) reported they rarely or never discussed cardiopulmonary resuscitation (CPR) with their patients. With terminally ill patients, physician initiative was greater: 69% reported discussing resuscitation preferences. Comparable discussions with elderly patients were undertaken only if the physician believed they would be warranted by the clinical circumstances. When questioned about their own sentiments towards resuscitation, most physicians indicated they would not want CPR if they were terminally ill (86%) or mentally incompetent (93%). A similar number (92%) would refuse artificial feeding if permanently comatose. Conclusions:Many physicians recognize the importance of living wills as an expression of patient treatment preferences. Nevertheless, discussion of patient preferences is unlikely because of physicians’ reluctance, except in limited circumstances, to initiate a dialogue about life-sustaining measures. Because patients also are often unwilling to begin such discussions, better methods of facilitating discussion of CPR and other extraordinary health care measures must be sought. Presented at the Southern Regional Meeting of the Society of General Internal Medicine, New Orleans, Louisiana, January 19, 1990. Supported by a grant from the Charlotte-Mecklenburg Health Services Foundation, Inc.     

Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide

BACKGROUND: The practices of euthanasia and physician-assisted suicide remain controversial. OBJECTIVE: To achieve better understanding of attitudes and practices regarding euthanasia and physician-assisted suicide in the context of end-of-life care. DESIGN: Cohort study. SETTING: United States. PARTICIPANTS: 3299 oncologists who are members of the American Society of Clinical Oncology. MEASUREMENTS: Responses to survey questions on attitudes toward euthanasia and physician-assisted suicide for a terminally ill patient with prostate cancer who has unremitting pain, requests for and performance of euthanasia and physician-assisted suicide, and sociodemographic characteristics. RESULTS: Of U.S. oncologists surveyed, 22.5% supported the use of physician-assisted suicide for a terminally ill patient with unremitting pain and 6.5% supported euthanasia. Oncologists who were reluctant to increase the dose of intravenous morphine for terminally ill patients in excruciating pain (odds ratio [OR], 0.61 [95% CI, 0.48 to 0.77]) and had sufficient time to talk to dying patients about end-of-life care issues (OR, 0.79 [CI, 0.71 to 0.87]) were less likely to support euthanasia or physician-assisted suicide. During their career, 3.7% of surveyed oncologists had performed euthanasia and 10.8% had performed physician-assisted suicide. Oncologists who were reluctant to increase the morphine dose for patients in excruciating pain (OR, 0.58 [CI, 0.43 to 0.79]) and those who believed that they had received adequate training in end-of-life care (OR, 0.86 [CI, 0.79 to 0.95]) were less likely to have performed euthanasia or physician-assisted suicide. Oncologists who reported not being able to obtain all the care that a dying patient needed were more likely to have performed euthanasia (P = 0.001). CONCLUSIONS: Requests for euthanasia and physician-assisted suicide are likely to decrease as training in end-of-life care improves and the ability of physicians to provide this care to their patients is enhanced.     

Predictors for erectile dysfunction among diabetics

This study aims to examine the predictors related to erectile dysfunction (ED) among Chinese diabetics. From 1995 to 1999, 327 men with diabetes mellitus (DM) were enrolled into this study. They completed face to face interview, professional psychogenic assessment, measurements of penile hemodynamic parameters and measurements of hormone levels. Complications of diabetes were obtained from hospital medical records. One hundred and twenty nine diabetics were diagnosed as ED. The associations between individual predictor and ED were accessed using both univariate and multivariate logistic regression models. We found that the risk of ED was significantly associated with age (adjusted odd ratios (OR) = 1.16, 95% confident intervals (CI): 1.10-1.38), duration of DM (adjusted OR = 1.30, 95% CI: 1.28-1.87), lower physical activity (adjusted OR = 1.67, 95% CI: 1.15-3.03), retinopathy (adjusted OR = 1.15, 95% CI: 1.01-1.89), neuropathy (adjusted OR = 2.07, 95% CI: 1.54-3.06) and depression (adjusted OR = 1.46, 95% CI 1.32-2.56). The study shows that diabetics with ED suffer more serious complications than those patients with non-ED. ED may act as a sentinel event for underlying complications among male diabetics.     

Talking with terminally ill patients and their caregivers about death, dying, and bereavement: is it stressful? Is it helpful?

BACKGROUND: Discussing end-of-life issues with terminally ill patients is often considered distressing and harmful. This study was conducted to assess whether interviewing terminally ill patients and their caregivers about death, dying, and bereavement is stressful and/or helpful. METHODS: Patients from 6 sites in the United States who were estimated to have 6 months or less to live were interviewed in person and reinterviewed 2 to 6 months later. Their caregivers were interviewed separately. At the end of the interviews, patients and caregivers were asked how stressful and how helpful the interview had been. Of 1131 eligible patients, 988 (87.4%) were interviewed, and of 915 eligible caregivers, 893 (97.6%) were interviewed. RESULTS: At the end of the first interview, 1.9% of the patients reported having experienced a great deal of stress, 7.1% some stress, and 88.7% little or no stress from the interview. Among the caregivers, 1.5% reported a great deal of stress, 8.4% some stress, and 89.7% little or no stress. Slightly more stress was reported to have been caused by the reinterview. Overall, 16.9% of the patients reported the initial interview as very helpful, 29.6% as somewhat helpful, and 49.6% as offering little or no help. Among the caregivers, 19.1% reported the initial interview as very helpful, 34.3% as somewhat helpful, and 44.9% as offering little or no help. The reported helpfulness of the second interview was slightly less. Patients experiencing pain (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.02-1.56), more personal meaning in dying (OR, 3.05; 95% CI, 2.02-4.59), and less ease with talking about the end of life (OR, 1.32; 95% CI, 1.09-1.60) were significantly more likely to report stress. Patients who were from an ethnic minority (OR, 1.85; 95% CI, 1.31-2.63), anxious about the end of their life (OR, 1.39; 95% CI 1.16-1.67), more spiritual (OR, 1.30; 95% CI, 1.06-1.61), and serene (OR, 1.25; 95% CI, 1.08-1.45) were significantly more likely to report the interview helpful. There was no relationship between stress and helpfulness. CONCLUSIONS: Terminally ill patients and their caregivers can discuss death, dying, and bereavement in a structured interview with minimal stress and report that the interview was helpful. Institutional review boards should not preemptively restrict surveys with terminally ill patients without reliable evidence that they will be stressful or otherwise harmful.     

Twenty years beyond medical school: physicians' attitudes toward death and terminally ill patients.

BACKGROUND: In response to consumer demands and recent changes in health care, the American Medical Association and the Association of American Medical Colleges have expressed concern about how physicians relate to patients, especially those who are seriously ill. OBJECTIVE: To determine the impact of 20 years of medical practice on the attitudes of physicians toward terminally ill patients and their families. METHODS: Data were gathered from questionnaires mailed in 1976 and again in 1996 to physicians who graduated from medical school between 1972 and 1975. RESULTS: Responses were received from 71% and 63% of the 1664 and 1109 physicians surveyed in 1976 and 1996, respectively. Using a t test for paired variables, statistically significant differences were noted for physicians' responses to all of the 11 Likert-type attitudinal statements on death and terminally ill patients and their families. Physicians in 1996 were more willing to inform terminally ill patients of their prognosis and in general seemed more confident with dying patients than they were in 1976. CONCLUSIONS: After 2 decades of practicing medicine, physicians' attitudes toward terminally ill patients seem to have changed; physicians appear to be more open to communicating with terminally ill patients and their families on issues concerning death and dying.     

Fibromyalgia, hypermobility, and breast implants

OBJECTIVE: To examine possible relationships among fibromyalgia (FM, American College of Rheumatology 1990 criteria), hypermobility, and breast implants. METHODS: The medical records of 2,500 female patients (ages 25-65) who had been seen for the first time in a rheumatology practice in Atlanta, GA, during 1986-92 were abstracted and analyzed. In each analysis, patients whose records indicated that the patient met the full case criteria were compared with patients whose records had no indication of the disease. Patients whose medical records indicated the clinical onset of FM prior to breast implantation were identified. RESULTS: Univariate and multivariate regression analyses were performed, adjusting for age, income, and the presence of connective tissue disease or rheumatoid arthritis. Significant associations were found between hypermobility and FM (adjusted OR 2.20, 95% CI 1.73, 2.80) and between hypermobility and breast implantation (adjusted OR 1.80, 95% CI 1.19, 2.69). No association was found between breast implantation and subsequent FM (adjusted OR 0.74, 95% CI 0.42, 1.32). CONCLUSION: Hypermobility was found to be independently associated with both FM and with breast implantation, but FM and breast implantation were not found to be independently associated with each other.     

In-hospital cardiopulmonary resuscitation: prearrest morbidity and outcome

BACKGROUND: Considerations about the application of cardiopulmonary resuscitation (CPR) should include the expected probability of survival. The survival probability after CPR may be more accurately estimated by the occurrence in time of the prearrest morbidity of patients. OBJECTIVE: To identify risk factors for poor survival after CPR in relation to the dynamics of prearrest morbidity. METHODS: Medical records of CPR patients were reviewed. Prearrest morbidity was established by categorizing the medical diagnoses according to 3 functional time frames: before hospital admission, on hospital admission, and during hospital admission. Indicators of poor survival after CPR were identified through a logistic regression model. RESULTS: Included in the study were 553 CPR patients with a median age of 68 years (age range, 18-98 years); 21.7% survived to hospital discharge. Independent indicators of poor outcome were an age of 70 years or older (odds ratio [OR]=0.6, 95% confidence interval [CI]=0.4-0.9), stroke (OR=0.3, 95% CI=0.1-0.7) or renal failure (OR=0.3, 95% CI=0.1-0.8) before hospital admission, and congestive heart failure during hospital admission (OR=0.4, 95% CI=0.2-0.9). Indicators of good survival were angina pectoris before hospital admission (OR=2.1, 95% CI=1.3-.3.3) or ventricular dysrhythmia as the diagnosis on hospital admission (OR=11.0, 95% CI=4.1-33.7). Based on a logistic regression model, 17.4% of our CPR patients (n= 96) were identified as having a high risk for a poor outcome (< 10% survival). CONCLUSIONS: Time of prearrest morbidity has a prognostic value for survival after CPR. Patients at risk for poor survival can be identified on or during hospital admission, but the reliability and validity of the model needs further research. Although decisions will not be made by the model, its information can be useful for physicians in discussions about patient prognoses and to make decisions about CPR with more confidence.     

High rates of advance care planning in New York City's elderly population

BACKGROUND: Previous studies have demonstrated low rates of advance care planning (ACP), particularly among nonwhite populations, raising questions about the generalizability of this decision-making process. OBJECTIVE: To explore factors that may influence patients' willingness to engage in ACP. DESIGN: Survey. SETTING: Thirty-four randomly selected New York City senior centers. PARTICIPANTS: A total of 700 African American (n = 239), Hispanic (n = 237), and white (n = 224) adults 60 years and older. INTERVENTION: Participants were administered a 51-item survey that assessed attitudes, beliefs, and practices regarding ACP. MAIN OUTCOME MEASURES: Attitudes and beliefs about physicians' trustworthiness, fatalism, beliefs about surrogate decision making, and comfort discussing end-of-life medical care; factors associated with health care proxy completion; and health care proxy completion rates. RESULTS: More than one third of the participants had completed a health care proxy. There were no significant differences in completion rates across the 3 ethnic groups. Respondents who had a primary care physician (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3-3.2), were more knowledgeable about advance directives (OR, 2.0; 95% CI, 1.4-2.9), or had seen a friend or family member use a mechanical ventilator (OR, 1.5; 95% CI, 1.02-2.1) were significantly more likely to have designated a health care proxy. Respondents who were only comfortable discussing ACP if the discussion was initiated by the physician (OR, 0.6; 95% CI, 0.0-0.8) were significantly less likely to have completed a health care proxy. CONCLUSIONS: African American, Hispanic, and white community-dwelling, older adults had similarly high rates of advance directive completion. The primary predictors of advance directive completion involved modifiable factors such as established primary care physicians, personal experience with mechanical ventilation, knowledge about the process of ACP, and physicians' willingness to effectively initiate such discussions. Some of the racial/ethnic differences in desire for collective family-based decision making that were observed in this study have implications for the evolution of ACP policy that respects and operationalizes these preferences.     

Inverse relationship of serum albumin to the risk of venous thromboembolism among acutely ill hospitalized patients: Analysis from the APEX trial

Hypoalbuminemia is a common finding and independent predictor for unfavorable prognosis. The prognostic value of albumin measurement for short-term VTE prediction in hospitalized patients remains unclear. In the APEX trial ( ClinicalTrials.gov identifier: NCT01583218), medical inpatients were randomized to receive either extended-duration betrixaban or shorter-duration enoxaparin and followed for 77 days. Baseline albumin concentrations were obtained in 7266 subjects with evaluable VTE endpoints. The association of baseline albumin to VTE was assessed, with adjustment for patient characteristics, thromboprophylaxis, and biomarkers for fibrinolysis and inflammation (ie, D-dimer and C-reactive protein [CRP]). VTE risk refinement was evaluated by incorporation of albumin to well-validated risk assessment models. A stepwise increase in the risk of VTE (P < .0001) was observed with lower levels of albumin. Patients at the bottom albumin quartile (<35 g/L) had a two-fold greater odds for developing VTE compared with the top quartile (≥42 g/L) (OR = 2.119 [95% CI, 1.592-2.820]; adjusted OR = 2.079 [1.485-2.911]). The odds for VTE increased by 1.368 (95% CI, 1.240-1.509) times per SD decrement of albumin (5.24 g/L). Compared with the propensity score-matched pairs of patients with albumin ≥35 g/L, patients with albumin <35 g/L had a greater risk of VTE (OR = 1.623 [1.260-2.090]; adjusted OR = 1.658 [1.209-2.272]). Albumin measurement also refined VTE risk discrimination and reclassification after inclusion in the risk assessment models. In conclusion, acutely ill hospitalized patients with low serum albumin had an increased VTE risk through 77 days. VTE risk assessment models for medical inpatients should consider incorporation of baseline albumin measurement.     

Utilization of screening for hepatocellular carcinoma in the United States

BACKGROUND: Screening for hepatocellular carcinoma (HCC) has been recommended for patients at high-risk of developing HCC. Yet, the utilization and determinants of screening remain unclear. METHODS: All patients diagnosed with HCC at 3 medical centers during 1998 to 2003 were identified. Information regarding receipt of HCC screening, demographics, risk factors, liver disease severity, number of HCC lesions, therapy, and date of death was abstracted from medical records. Multivariable logistic regression models were conducted to evaluate determinants of HCC screening and therapy. Cox proportional hazards models were developed to assess the effect of screening on risk of mortality. RESULTS: We identified 157 patients diagnosed with HCC. The majority of patients were <65 years (62%), white (59%), had a single mass (42%), and a Child-Pugh-Turcotte score B (41%). Approximately, 28% (n=44) received at least one possible screening test (36% alpha-fetoprotein only, 23% abdominal ultrasound only, 7% computed tomography only; 34% had more than one test). Screened patients were younger [odds ratio (OR)=2.70; 95% confidence interval (CI): 1.22-5.99) and were more likely to have underlying HCV (OR=2.91; 95% CI: 1.36-6.23), or alcoholic liver disease (OR=4.20; 95% CI: 1.89-9.35). The only predictors of receipt of therapy were presentation at tumor board conference (OR=2.85; 95% CI: 1.42-5.72) and documented referral to oncology (OR=2.33; 95% CI: 1.10-4.94). CONCLUSIONS: Less than one-third of patients who were diagnosed with HCC received screening before their diagnosis, and of those a large proportion received an alpha-fetoprotein test only. In this study, the use of screening was too suboptimal to be expected to affect outcomes.     

Assessing substance abuse treatment need: a statewide hospital emergency department study

STUDY OBJECTIVE: Health care providers in hospital emergency departments rarely take substance abuse histories or assess associated treatment need. This study compares documentation of psychoactive drug-related diagnoses for adult ED patients in medical records with treatment need assessed through self-report, toxicologic screening, and Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria. METHODS: A statewide, 2-stage, probability sample survey was conducted in 7 Tennessee general hospital EDs from June 1996 to January 1997. Main outcome measures were the prevalence of diagnosed substance abuse problems, positive bioassay results, denied use, and treatment need. Sensitivity and multivariate analyses were conducted by using varied case definitions of treatment need. RESULTS: Thirty-one percent (95% confidence interval [CI] 27.3% to 34.7%) of screened ED patients (n=1,330) had positive test results for substance use. Their prevalence of denial of use in the 30 days before the survey ranged from 10% for alcohol (95% CI 5.7% to 14.3%) to 100% for phencyclidine. One percent of all ED patients (n=1,502) had a recorded diagnosis of substance abuse. By contrast, as many as 27% (95% CI 23.3% to 31.8%) were assessed as needing substance abuse treatment on the basis of a comprehensive case definition that accounted for denial and positive test results. A sensitivity analysis using other case definitions is also presented. For example, 4% (95% CI 2.8% to 5.3%) of patients met the very strict definition of DSM-IV current drug dependence only. Under the comprehensive case definition, TennCare patients (adjusted odds ratio [OR] 1.63; 95% CI 1.30 to 2.05) and Medicare patients (adjusted OR 2.50; 95% CI 1.34 to 4.65) showed excess treatment need relative to the privately insured. Excess need was also exhibited by patients reporting 1 or more prior ED visits in the past year (adjusted OR 1.62; 95% CI 1.13 to 2.31) and by patients taking 2 or more hours to reach the ED after the onset of injury or illness (adjusted OR 1.54; 95% CI 1.16 to 2.04). Treatment need was inversely associated with age. Irrespective of case definition, less than 10% of ED patients who needed substance abuse treatment were receiving such treatment. CONCLUSION: EDs can be important venues for detecting persons in need of substance abuse treatment.     

Health care and medication costs and use among older adults with heart failure

BACKGROUND: Heart failure disproportionately affects older adults for whom multiple medications are prescribed to prevent exacerbations and hospitalization. To target interventions effectively, it is important to understand the association of medication acquisition with health care utilization and costs. METHODS: We used electronic medical records from an urban public health care system to identify patients aged >/=50 years who had a diagnosis of heart failure. We assessed the association between inappropriate or appropriate medication supplies and hospitalization and costs using multivariable analyses that adjusted for demographic characteristics, prior health care use, health status, and insurance status. RESULTS: Total health care costs for treating 1554 patients with heart failure from 1996 to 2000 were 36.6 million dollars (in 2000 dollars). Less than a third of patients received appropriate medication supplies (between 90% and 110% of the supplies needed) annually. Compared with patients with appropriate supplies, the odds of hospitalization were greater among those with undersupplies (odds ratio [OR] = 3.1; 95% confidence interval [CI]: 2.3 to 4.2; P <0.0001) or oversupplies (OR = 2.0; 95% CI: 1.7 to 2.4; P <0.0001). Total costs were 25% higher for patients with undersupplies (95% CI: 8% to 46%; P = 0.004) and 18% higher for those with oversupplies (95% CI: 7% to 30%; P = 0.0009) than for those with appropriate supplies. CONCLUSION: Among adults with heart failure, inappropriate medication supplies were associated with increased hospitalization and higher costs. Monitoring medication supplies from electronic medical records may be a useful component of programs aiming to improve care while managing costs.     

Heart to Heart Discussions: Characterizing Goals of Care Conversations for Advanced Heart Failure Patients Initiating Palliative Inotropes

BackgroundGuidelines recommend goals of care conversations (GOCC) and specialty palliative care at the time of initiation of palliative inotropes for patients with advanced heart failure. The extent to which GOCC are occurring, the content of the GOCC, and the frequency of palliative care involvement is unknown.Methods and ResultsWe conducted a retrospective chart review of all patients discharged from a tertiary medical center between October 2015 and April 2020 initiated on continuous palliative inotropes. We identified 53 patients who were discharged on continuous palliative inotropes. Most patients (46/53 [87%]) had a documented GOCC, including discussions around preferences for life-sustaining treatments, hospice, and/or prognosis. However, just more than one-half of the patients (55% [15/27]) with an ICD had a documented discussion regarding preferences for ICD deactivation. Patients seen by palliative care were more likely to have a documented discussion about ICD deactivation (68% vs 0%, P = .0098). The frequency of palliative care consultation and documented GOCC conversations increased over time.ConclusionsAlthough we observed overall high rates of documented GOCC, there is room for improving the rate of discussions with patients about whether they wish to have their ICD deactivated. Future research should test interventions to improve the frequency of ICD discussions.     

Fresh-frozen plasma and platelet transfusions are associated with development of acute lung injury in critically ill medical patients

BACKGROUND: Transfusion has long been identified as a risk factor for acute lung injury (ALI)/ARDS. No study has formally evaluated the transfusion of specific blood products as a risk factor for ALI/ARDS in critically ill medical patients. METHOD: In this single-center retrospective cohort study, 841 consecutive critically ill patients were studied for the development of ALI/ARDS. Patients who received blood product transfusions were compared with those who did not, in univariate and multivariate propensity analyses. RESULTS: Two hundred ninety-eight patients (35%) received blood transfusions. Transfused patients were older (mean [+/- SD] age, 67 +/- 17 years vs 62 +/- 19 years; p < 0.001) and had higher acute physiologic and chronic health evaluation (APACHE) III scores (74 +/- 32 vs 58 +/- 23; p < 0.001) than those who had not received transfusions. ALI/ARDS developed more commonly (25% vs 18%; p = 0.025) in patients exposed to transfusion. Seventeen patients received massive RBC transfusions (ie, > 10 U of blood transfused within 24 h), of whom 13 also received fresh-frozen plasma (FFP) and 11 received platelet transfusions. When adjusted for the probability of transfusion and other ALI/ARDS risk factors, any transfusion was associated with the development of ALI/ARDS (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.24 to 3.75). Among those patients receiving individual blood products, ALI/ARDS was more likely to develop in patients who received FFP transfusions (OR, 2.48; 95% CI, 1.29 to 4.74) and platelet transfusions (OR, 3.89; 95% CI, 1.36 to 11.52) than in those who received only RBC transfusions (OR, 1.39; 95% CI, 0.79 to 2.43). CONCLUSION: Transfusion is associated with an increased risk of the development of ALI/ARDS in critically ill medical patients. The risk is higher with transfusions of plasma-rich blood products, FFP, and platelets, than with RBCs.     

Opinions of doctors and nurses about appropriate medical treatment for terminally ill geriatric patients

We investigated the opinions of medical doctors and nursing staff about desirable medical treatment for terminally ill geriatric patients. The purpose of the present study is: 1) to examine the recent opinion of doctors and nurses, 2) to examine discrepancies of opinions between doctors and nurses on treatment for terminal geriatric patients. Doctors and nurses working in long-term care wards in four hospitals were enrolled. They were asked to fill in a questionnaire which asked about desirable medical treatments for a typical bedridden terminally ill geriatric patient. The difference of answers between doctors and nurses were analyzed. The most common opinion of the 18 doctors and 84 nurses were as follows: 1) for the treatment of relapsing pneumonia, they would perform oxygenation, antibiotic injections, and continuous intravenous infusion during the period of discontinuation of enteral nutrition, 2) for the treatment of relapsing urinary tract infection, they would catheterize patients for a brief period and would irrigate the bladder, and would perform antibiotics injection, 3) for chronic anemia, they would perform iron replacement, 4) for decubitus ulcer, they would treat conventionally, and 5) at the final stage just before death, they would avoid special therapy for shock after obtaining informed consent from patient's family. To most questions, the proportion of each answer was almost identical between doctors and nurses; however, there were discrepancies concerning "way of nutrition in patients with relapsing pneumonia" and "irrigation of the urinary bladder" (p = 0.0544 and 0.0531, respectively). We expect that the present study will activate a discussion of what constitutes appropriate medical treatment for terminally ill geriatric patients.     

Factors influencing the prevalence of gallstones in liver disease: the beneficial and harmful influences of alcohol

OBJECTIVE: The Patient Treatment File of the Department of Veterans Affairs comprises the computerized records of all inpatients treated in all Veterans Affairs hospitals distributed throughout the United States. This database was used to study the association between liver disease and clinically manifest cholelithiasis. METHODS: The computerized medical records of 38,459 patients with various forms of liver disease and 69,336 controls without the diagnosis were extracted from the annual files between 1990 and 1993. In a multiple logistic regression analysis, the occurrence of cholelithiasis served as the outcome variable, whereas different forms of liver disease and demographic characteristics, such as age, gender, and ethnicity, served as predictor variables. RESULTS: Among the control population, cholelithiasis was reported in 5.2% (3,571 of 69,336) of subjects. Cholelithiasis occurred in 7.5% (2,898 of 38,459) of patients with all liver disease, 9.5% (1,642 of 17,287) of patients with alcoholic liver cirrhosis, 13.7% (981 of 7,149) of patients with nonalcoholic liver cirrhosis, and 9.1% (66 of 728) of patients with alcoholic fatty liver (chi2 = 1059, df = 4, p < 0.001). In the logistic regression, the odds ratios (ORs) for cholelithiasis associated with various forms of liver disease were: in all liver diseases combined (OR = 1.31, 95% CI = 1.25-1.38), in alcoholic liver cirrhosis (OR = 1.62, 95% CI = 1.54-1.72), in nonalcoholic liver cirrhosis (OR = 2.07, 95% CI = 1.94-2.21), and in alcoholic fatty liver (OR = 1.40, 95% CI = 1.11-1.75). Other risk factors for cholelithiasis besides liver disease were: female gender (OR = 1.43, 95% CI = 1.25-1.63), older age (OR = 1.28 per age decade, 95% CI = 1.26-1.30), Native American (OR = 1.38, 95% CI = 1.12-1.72) or Hispanic ethnicity (OR = 1.25, 95% CI = 1.15-1.35), and presence of diabetes mellitus (OR = 1.43, 95% CI = 1.35-1.52). A history of alcoholism exerted a protective influence (OR = 0.92, 95% CI = 0.87-0.97). CONCLUSION: Gallstone disease occurs frequently in hospitalized patients with chronic liver disease or liver cirrhosis and contributes to the burden of the disease.     

Severity of illness in patients with systemic lupus erythematosus hospitalized at academic medical centers

OBJECTIVE: To compare the severity of illness of patients with systemic lupus erythematosus (SLE) between those hospitalized at academic medical centers and those hospitalized at community hospitals. METHODS: In this population based cross-sectional survey, data on all hospitalizations of patients with SLE in California, New York, and Pennsylvania in 2000 were obtained from discharge abstracts submitted by acute care hospitals to state health planning agencies. Patients hospitalized at one of 36 academic medical centers in these states (N = 2072) were compared to patients hospitalized at community hospitals (N = 9373). The primary measures of severity of illness were the SLE Comorbidity Index, a weighted index of SLE manifestations and comorbid medical conditions based on discharge diagnoses, and long lengths of stay, defined as stays that exceeded the 90th percentile of hospital stays in the same diagnosis-related group in the United States. RESULTS: Compared to patients at community hospitals, patients at academic medical centers had substantially higher scores on the SLE Comorbidity Index (odds ratio for each 1-point increase 1.27, 95% confidence interval 1.15-1.40, p < 0.0001) and were more likely to have long lengths of stay (OR 1.65, 95% CI 1.42-1.91, p < 0.0001). Patients at academic medical centers also had higher scores on the SLE Comorbidity Index (OR for each 1-point increase 1.16, 95% CI 1.07-1.27, p = 0.0002) and were more likely to have long lengths of stay (OR 1.27, 95% CI 1.08-1.49, p = 0.004) compared to patients at large (> or = 300 beds) community hospitals in the same metropolitan areas. Results for the SLE Comorbidity Index were similar in the subset of patients with SLE as the primary discharge diagnosis. CONCLUSION: Patients with SLE hospitalized at academic medical centers are generally more severely ill than those hospitalized at community hospitals, including large community hospitals in the same area.     

Managing end-of-life care: comparing the experiences of terminally Ill patients in managed care and fee for service

There have been no published empirical studies comparing the experiences of terminally ill patients in managed care organizations (MCOs) and those in fee for service (FFS). This investigation represents the first empirical study to systematically compare substantive outcomes between populations of terminally ill patients enrolled in MCO and FFS healthcare delivery systems. The investigators interviewed 988 patients whose physicians judged them to be terminally ill and 893 of their caregivers. Outcomes assessments were made in six domains: patient-physician relationship; access to care and use of health care; prevalence of symptoms; and planning for end-of-life care, care needs, and economic burdens. Overall, the two populations of terminally ill patients were found to have comparable outcomes, but several significant differences were present. MCO patients were more likely than their FFS counterparts to use an inconvenient hospital (P =.02), spend more than 10% of their income on medical care (P =.02), and have been bedridden more than 50% of the time during the last 4 weeks of life (P =.03). Caregivers of MCO patients were as likely as the caregivers of FFS patients to report a substantial caregiving burden (P =.59). Despite concerns about the threats of MCOs to the physician-patient relationship, few differences in the quality of the relationship between the two cohorts were found. Finally, terminally ill patients in MCOs did not show better experiences than those in FFS on any outcome measure. Additional research is required to explore how MCOs may improve upon the care available to dying patients.