Family member satisfaction with end-of-life decision making in the ICU

RATIONALE: Families of ICU patients may be at risk for increased psychological morbidity due to end-of-life decision making. The identification of chart-based quality indicators of palliative care that predict family satisfaction with decision making may help to guide interventions to improve decision making and family outcomes. OBJECTIVE: To determine patient and family characteristics and chart the documentation of processes of care that are associated with increased family satisfaction with end-of-life decision making for ICU patients. METHODS: We conducted a cohort study of ICU patients dying in 10 medical centers in the Seattle-Tacoma area. Measurement: Outcomes from family surveys included summary scores for family satisfaction with decision making and a single-item score that indicated feeling supported during decision making. Predictor variables were obtained from surveys and chart abstraction. Main results: The survey response rate was 41% (442 of 1,074 families responded). Analyses were conducted of 356 families with questionnaire and chart abstraction data. Family satisfaction with decision making was associated with the withdrawal of life support, and chart documentation of physician recommendations to withdraw life support, discussions of patients' wishes, and discussions of families' spiritual needs. Feeling supported during decision making was associated with the withdrawal of life support, spiritual care involvement, and chart documentation of physician recommendations to withdraw life support, expressions of families' wishes to withdraw life support, and discussions of families' spiritual needs. CONCLUSIONS: Increased family satisfaction with decision making is associated with withdrawing life support and the documentation of palliative care indicators including the following: physician recommendations to withdraw life support; expressions of patients' wishes; and discussions of families' spiritual needs. These findings provide direction for future studies to investigate approaches to improving family satisfaction in end-of-life decision making. In addition, because there were few nonwhites in this study, these results may not be generalizable to more diverse populations. Future studies should target diverse populations in order to test whether similar factors are similarly important for end-of-life decision making.     

INAUGURAL ARTICLE by a Recently Elected Academy Member:The Lucretian swerve: The biological basis of human behavior and the criminal justice system

It is widely believed, at least in scientific circles, that living systems, including mankind, obey the natural physical laws. However, it is also commonly accepted that man has the capacity to make “free” conscious decisions that do not simply reflect the chemical makeup of the individual at the time of decision—this chemical makeup reflecting both the genetic and environmental history and a degree of stochasticism. Whereas philosophers have discussed for centuries the apparent lack of a causal component for free will, many biologists still seem to be remarkably at ease with this notion of free will; and furthermore, our judicial system is based on such a belief. It is the author’s contention that a belief in free will is nothing other than a continuing belief in vitalism—something biologists proudly believe they discarded well over 100 years ago.     

Infectivity of HBV DNA positive donations identified in look-back studies in Hyogo-Prefecture, Japan

Aims/Objectives: To clarify transfusion incidence of hepatitis B virus (HBV) infected blood negative for mini pool‐nucleic acid amplification testing (MP‐NAT). Background: Japanese Red Cross (JRC) blood centres screen donated blood to avoid contamination with HBV. However, a low copy number of HBV may be overlooked. Methods/Materials: In Hyogo‐Prefecture, JRC blood centres screened 787 695 donations for HBV from April 2005 to March 2009. Of these, 685 844 were donations from the repeat donors. To detect the donors with HBV, serological tests, MP‐NAT and/or individual donation (ID)‐NAT were performed. To detect the recipients with transfusion‐transmitted HBV infection (TTHBI), serological analysis and/or ID‐NAT were performed. Results: In this study, 265 of the 685 844 repeat donations were serologically and/or MP‐NAT positive for HBV. Their repository samples from the previous donation were examined in a look‐back study; 13 of the 265 repository samples proved ID‐NAT positive. Twelve recipients were transfused with HBV‐infected blood components derived from 10 of the 13 HBV‐infected donors. Only 1 of the 12 recipients was identified as TTHBI case. Seven of the 12 recipients escaped from our follow‐up study and 4 recipients were negative for HBV during the observation period. Conclusion: On the basis of the look‐back study among the repeat donors in Hyogo‐Prefecture, Japan, donations with HBV‐infected blood negative for MP‐NAT occurred with a frequency of 13 in 685 844 donations (～1/53 000 donations). However, more than half of the recipients transfused with HBV‐infected blood negative for MP‐NAT could not be followed up. It is necessary to establish a more cautious follow‐up system.     

Life-sustaining treatments during terminal illness

Objective: To determine patient characteristics associated with the desire for life-sustaining treatments in the event of terminal illness. Design: In-person survey from October 1986 to June 1988. Setting: 13 internal medicine and family practices in North Carolina. Patients: 2,536 patients (46% of those eligible) aged 65 years and older who were continuing care patients of participating practices, enrolled in Medicare. The patients were slightly older than the 65+ general population, 61% female, and 69% white, and most had one or more chronic illnesses. Measurements and main results: The authors asked the patients whether they would want each of six different treatments (hospitalization, intensive care, cardiopulmonary resuscitation, surgery, artificial ventilation, or tube feeding) if they were to have a terminal illness. The authors combined responses into three categories ranging from the desire for more treatment to the desire for less treatment. After adjustment for other factors, 53% of women chose less treatment compared with 43% of men; 35%ofblacksvs 15% of whites and 23% of the less well educated vs 15% of the better educated expressed the desire for more treatment. High depression scores also were associated with the desire for more treatment (26% for depressed vs 18% for others). Conclusion: Patients’ choices for care in the event of terminal illness relate to an intricate set of demographic, educational, and cultural factors. These results should not be used as a shortcut to determine patient preferences for care, but may provide new insights into the basis for patients’ preferences. In discussing choices for future life-sustaining care, physicians need to explore with each individual the basis for his or her choices. Supported in part by a cooperative research agreement (95-C-98516/4) between the Health Care Financing Administration and the Department of Social Medicine, School of Medicine, in collaboration with the Cecil G. Sheps Center for Health Services Research, at the University of North Carolina at Chapel Hill (Joseph P. Morrissey, PhD, principal investigator). The views expressed are those of the authors and do not necessarily reflect the opinions of HCFA.     

香白芷的生药学研究

目的 研究香白芷的生药鉴定特征。方法 应用来源、性状、显微及理化鉴别方法。结果 香白芷为伞形科植物白亮独活Heracleum candicans Wall.ex DC.的干燥根,详细描述了其生药鉴别特征。结论 实验结果为该药的鉴别、开发利用及质量标准的制订提供依据。