Palliative care education in gynecologic oncology: a survey of the fellows.

INTRODUCTION: Gynecologic oncologists regularly care for patients at the end of life, yet little is known about their training or preparedness to deal with issues of palliative care. We sought to examine the training provided to gynecologic oncology fellows as well as their perceived preparedness to provide palliative care. METHODS: A self-administered survey was distributed to all fellows enrolled in all gynecologic oncology fellowships during the 2009 academic year. The instrument assessed attitudes, training, experience, and preparedness regarding caring for patients at the end of life. Descriptive, bivariate and multivariable analyses were performed. RESULTS: Sixty-one percent (103/168) of fellows completed the survey. Most (89%) feel that palliative care is integral to their training, but few (11%) have had any palliative care training, including either a rotation or fellowship. Using a scale of 1-10, fellows rated teaching quality on two common training opportunities, specifically managing postoperative complications (7.8) and endometrial cancer patients (8.7), as significantly higher than teaching on managing patients at the end of life (5.5; p<0.001). Fellows rated the quality of end of life teaching as significantly lower than overall teaching (55% vs. 92%; p=0.001). Their self-assessment regarding overall preparedness to deal with end of life issues was associated with higher end of life teaching quality and experience caring for more than 10 dying patients. CONCLUSIONS: The quantity and quality of training in palliative care are lower compared to other common procedural and oncological issues. Gynecologic oncology fellowship programs need to incorporate a palliative care training curriculum.

Does it matter what you call it? A randomized trial of language used to describe palliative care services.

INTRODUCTION: Integration of palliative care into oncology practice remains suboptimal. Misperceptions about the meaning of palliative care may negatively impact utilization. PURPOSE: We assessed whether the term and/or description of palliative care services affected patient views. METHODS: 2x2 between-subject randomized factorial telephone survey of 169 patients with advanced cancer. Patients were randomized into one of four groups that differed by name (supportive care vs. palliative care) and description (patient-centered vs. traditional). Main outcomes (0-10 Likert scale) were patient understanding, impressions, perceived need, and intended use of services. RESULTS: When compared to palliative care, the term supportive care was associated with better understanding (7.7 vs. 6.8; p = 0.021), more favorable impressions (8.4 vs. 7.3; p = 0.002), and higher future perceived need (8.6 vs. 7.7; p = 0.017). There was no difference in outcomes between traditional and patient-centered descriptions. In adjusted linear regression models, the term supportive care remained associated with more favorable impressions (p = 0.003) and higher future perceived need (p = 0.022) when compared to palliative care. CONCLUSIONS: Patients with advanced cancer view the name supportive care more favorably than palliative care. Future efforts to integrate principles of palliative medicine into oncology may require changing impressions of palliative care or substituting the term supportive care.

Sociodemographic differences in early access to liver transplantation services.

The question of whether health care inequities occur before patients with end-stage liver disease (ESLD) are waitlisted for transplantation has not previously been assessed. To determine the impact of gender, race and insurance on access to transplantation, we linked Pennsylvania sources of data regarding adult patients discharged from nongovernmental hospitals from 1994 to 2001. We followed the patients through 2003 and linked information to records from five centers responsible for 95% of liver transplants in Pennsylvania during this period. Using multinomial logistic regressions, we estimated probabilities that patients would undergo transplant evaluation, transplant waitlisting and transplantation itself. Of the 144,507 patients in the study, 4361 (3.0%) underwent transplant evaluation. Of those evaluated, 3071 (70.4%) were waitlisted. Of those waitlisted, 1537 (50.0%) received a transplant. Overall, 57,020 (39.5%) died during the study period. Patients were less likely to undergo evaluation, waitlisting and transplantation if they were women, black and lacked commercial insurance (p < 0.001 each). Differences were more pronounced for early stages (evaluation and listing) than for the transplantation stage (in which national oversight and review occur). For early management and treatment decisions of patients with ESLD to be better understood, more comprehensive data concerning referral and listing practices are needed.

Hospital staff attributions of the causes of physician variation in end-of-life treatment intensity.

Discrepancies between patient wishes and end-of-life treatment decisions have been documented, and the determinants of end-of-life treatment decisions are not well understood. Our objective was to understand hospital staff perceptions of the role of acute care hospital medical doctors in end-of-life treatment intensity. In 11 purposively sampled Pennsylvania hospitals, we completed 108 audiotaped semistructured interviews with key informants involved in decision making or discharge planning. Using grounded theory, we qualitatively analysed transcripts using constant comparison to identify factors affecting end-of-life treatment decisions. A predominant theme identified was that end-of-life treatment intensity depends on the doctor. Communication with patients and families and collaboration with other care team members also were reported to vary, contributing to treatment variation. Informants attributed physician variation to individual beliefs and attitudes regarding the end-of-life (religion and culture, determination of when a patient is dying, quality-of-life determination and fear of failing) and to socialization by and interaction with the healthcare system (training, role perception, experience and response to incentives). When end-of-life treatment depends on the doctor, patient and family preferences may be neglected. Targeted interventions may reduce variability and align end-of-life treatment with patient wishes.

Communicating prognosis with parents of critically ill infants: direct observation of clinician behaviors.

OBJECTIVE: Delivering prognostic information to families requires clinicians to forecast an infant's illness course and future. We lack robust empirical data about how prognosis is shared and how that affects clinician-family concordance regarding infant outcomes. STUDY DESIGN: Prospective audiorecording of neonatal intensive care unit family conferences, immediately followed by parent/clinician surveys. Existing qualitative analysis frameworks were applied. RESULTS: We analyzed 19 conferences. Most prognostic discussion targeted predicted infant functional needs, for example, medications or feeding. There was little discussion of how infant prognosis would affect infant/family quality of life. Prognostic framing was typically optimistic. Most parents left the conference believing their infant's prognosis to be more optimistic than did clinicians. CONCLUSIONS: Clinician approach to prognostic disclosure in these audiotaped family conferences tended to be broad and optimistic, without detail regarding implications of infant health for infant/family quality of life. Families and clinicians left these conversations with little consensus about infant prognosis.

The unbearable rightness of bedside rationing. Physician duties in a climate of cost containment.

A local internist is in the process of ordering an intravenous pyelogram for a patient she suspects of having kidney problems, when a medical student shadowing her in clinic interrupts. The student wants to know why the physician is not ordering a low-osmolality contrast agent for the patient, having read that they are less likely to cause serious side effects than high-osmolality contrast agents. The physician realizes that the medical student is correct, but rejects the suggestion, telling the student that "low-osmolality contrast agents are the standard of care for low-risk patients."

Experts practice what they preach: A descriptive study of best and normative practices in end-of-life discussions.

BACKGROUND: Advance directives (ADs) are widely regarded as the best available mechanism to ensure that patients' wishes about medical treatment at the end of life are respected. However, observational studies suggest that these discussions often fail to meet their stated goals. OBJECTIVES: To explore best practices by describing what physicians who are considered expert in the area of end of-life bioethics or medical communication do when discussing ADs with their patients and to explore the ways in which best practices of the expert group might differ in content or style from normative practice derived from primary care physicians' discussions of ADs with their patients collected as part of an earlier study. DESIGN: Nonexperimental, descriptive study of audiotaped discussions. SETTING: Outpatient primary care practices in the United States. PARTICIPANTS: Eighteen internists who have published articles in the areas of bioethics or communication and 48 of their patients. Fifty-six academic internists and 56 of their established patients in 5 practice sites in 2 locations-Durham, NC, and Pittsburgh, Pa. Eligible patients were at least 65 years old or suffered from serious medical illness and had not previously discussed ADs with their physician. Expert clinicians had discretion regarding patient selection, while the internists chose patients according to a predetermined protocol. MEASUREMENTS: Coders applied the Roter Interaction Analysis System (RIAS) to audiotapes of the medical visits to describe communication dynamics. In addition, the audiotapes were scored on 21 items reflecting physician performance in specific skills related to AD discussions. RESULTS: Experts spent close to twice as much time (14.7 vs 8.1 minutes, P<.001) and were less verbally dominant (P<.05) than other physicians during AD discussions. When length of visit was controlled statistically, the expert physicians gave less information about treatment procedures and biomedical issues (P<.05) and asked fewer related questions (P<. 05) but tended toward more psychosocial and lifestyle discussion and questions. Experts engaged in more partnership building (P<.05) with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion (P<.001), and more positive talk (P<.05) than patients of community physicians. Expert physicians scored higher on the 21 items reflecting AD-specific skills (P<.001). CONCLUSIONS: Best practices as reflected in the performance of expert physicians reflect differences in measures of communication style and in specific AD-related proficiencies. Physician training in ADs must be broad enough to include both of these domains. Arch Intern Med. 2000;160:3477-3485.

Lying to each other: when internal medicine residents use deception with their colleagues.

BACKGROUND: While lying is morally problematic, physicians have been known to use deception with their patients and with third parties. Little is known, however, about the use of deception between physicians. OBJECTIVES: To determine the likelihood that resident physicians say they would deceive other physicians in various circumstances and to examine how variations in circumstances affect the likelihood of using deception. METHODS: Two versions of a confidential survey using vignettes were randomly distributed to all internal medicine residents at 4 teaching hospitals in 1998. Survey versions differed by introducing slight variations to each vignette in ways we hypothesized would influence respondents' willingness to deceive. The likelihood that residents say they would use deception in response to each vignette was compared between versions. RESULTS: Three hundred thirty surveys were distributed (response rate, 67%). Of those who responded, 36% indicated they were likely to use deception to avoid exchanging call, 15% would misrepresent a diagnosis in a medical record to protect patient privacy, 14% would fabricate a laboratory value to an attending physician, 6% would substitute their own urine in a drug test to protect a colleague, and 5% would lie about checking a patient's stool for blood to cover up a medical mistake. For some of the scenarios, the likelihood of deceiving was influenced by variations in the vignettes. CONCLUSIONS: A substantial percentage of internal medicine residents report they would deceive a colleague in various circumstances, and the likelihood of using deception depends on the context. While lying about clinical issues is not common, it is troubling when it occurs at any time. Medical educators should be aware of circumstances in which residents are likely to deceive, and discuss ways to eliminate incentives to lie.

Palliative care and the hospitalist: an opportunity for cross-fertilization.

Most US citizens die in acute care hospitals, often in physical pain, without attention to emotional and spiritual suffering. This represents an ethical failure of our current health-care system. The field of palliative medicine aims to address the physical, emotional, and spiritual needs of patients with advanced disease. At the same time, a new specialty of hospitalists is emerging, providing care for acutely ill hospitalized patients, many of whom will die. Thus, the hospitalist may become the primary deliverer of palliative care. This presents many potential opportunities for dying patients and their families, including increased time and attention from a physician; enhanced knowledge and skills around the physical symptoms, and emotional and spiritual distress; perhaps more detached and therefore more accurate prognostication; and increased efficiency, leading to a more rapid discharge to home. Hospitalists could enhance the quality of care for the dying by emphasizing interdisciplinary communication and involvement of hospital-based health professionals to address emotional and spiritual distress and bereavement issues, as well as through specific quality-improvement efforts. Finally, hospitalists can provide strong role modeling of optimal care for dying patients and their families. When hospitalists are not selected and trained effectively around palliative care issues, the risks are great. Discontinuity of physicians can lead to miscommunication and misunderstanding (by professionals, patient, and family); disagreement about treatment focus (especially as it relates to a shift from curative to palliative); inappropriate deferring of advance care planning to the hospital setting; and, most worrisome, a lack of expertise in symptom control, communication skills, and attention to patient and family distress and the provision of emotional and spiritual support. This article evaluates the convergence of the 2 fields of palliative medicine and hospitalist medicine and reviews the opportunities for mutual education and improved patient care.

Absolutely relative: how research results are summarized can affect treatment decisions.

PURPOSE: To determine whether alternative methods of presenting a contrast between the same two quantities in descriptions of research results could lead to different treatment decisions by physicians. SUBJECTS AND METHODS: We conducted a survey of practicing physicians and of faculty and fellows in training programs in clinical epidemiology and social science research methods. Each questionnaire presented results from a published study of either hypertension or hypercholesterolemia in two different ways: once as the relative change in the outcome rate and once as the absolute change in the outcome rate. We asked respondents to read each summary and indicate how the information contained in the summary would influence decisions about treatment. RESULTS: Of the 235 physicians who completed the questionnaire, 108 (46%) gave different responses to the same results presented in different ways. Of these, 97 (89.8%) indicated a stronger inclination to treat patients after reading of the relative change in the outcome rate (p less than 0.0001). CONCLUSION: The manner of presentation of results can influence physicians' judgments about the treatment of patients.

Elevator talk: observational study of inappropriate comments in a public space.

OBJECTIVES: We conducted a study to determine the type and frequency of inappropriate comments made by hospital employees while riding hospital elevators. METHODS: Four observers rode in elevators at five hospitals, listening for any comments made by hospital employees that might be deemed inappropriate. All potentially inappropriate comments were reviewed by the research team and were classified as inappropriate if they met at least one of the following criteria: violated patient confidentiality, raised concerns about the speaker's ability or desire to provide high-quality patient care, raised concerns about poor quality of care in the hospital (by persons other than the speaker), or contained derogatory remarks about patients or their families. RESULTS: We observed 259 one-way elevator trips offering opportunity for conversation. We overheard a total of 39 inappropriate comments, which took place on 36 rides (13.9% of the trips). The most frequent comments (18) were violations of patients confidentiality. Next most frequent (10 comments) were unprofessional remarks in which clinicians talked about themselves in ways that raised questions about their ability or desire to provide high-quality patient care. Other comments included derogatory statements about the general quality of hospital care (8) and derogatory remarks about patients (5). Physicians were involved in 15 of the comments, nurses in 10, and other hospital employees in the remainder. CONCLUSION: Inappropriate comments took place with disturbing frequency in the elevator rides we sampled. These comments did not exclusively involve violations of patient confidentiality, but encompassed a range of discussions that health care employees must be careful to avoid.

Double connections in total anomalous pulmonary venous connection.

Three infants who underwent operation for total anomalous pulmonary venous connection had unobstructed drainage of all the pulmonary veins to both the coronary sinus and left vertical vein. In one patient the anatomy was demonstrated preoperatively and complete correction accomplished without difficulty, but in two patients the second connection was discovered only at postoperative reinvestigation. Arbitrary classification of total anomalous pulmonary venous connection into cardiac, supracardiac, infracardiac, and mixed types does not lend itself to description of such lesions and may obscure their clinical importance. For these less common variants of total anomalous pulmonary venous connection, a more detailed and precise definition of morphology facilitates accurate surgical repair.

Symptomatic upper extremity venous thrombosis associated with permanent transvenous pacemaker electrodes.

Symptomatic arm vein thrombosis secondary to permanent transvenous cardiac pacing electrodes is an uncommon occurrence with an incidence of 1 to 3 percent. Two patients with this problem are presented who were treated with streptokinase followed by conventional anticoagulation therapy with heparin and warfarin. Near total resolution of the thromboses was accomplished in both patients. In follow-up periods of nine and 20 months, the patients have remained asymptomatic. An aggressive approach to this problem may decrease the current high morbidity.

Discussions about limiting treatment in a geriatric clinic.

OBJECTIVE: Obtain detailed information about the frequency and content of discussions about withholding treatment between doctors and elderly outpatients. DESIGN: Survey. SETTING: Primary care geriatric clinic at an urban university. PARTICIPANTS: Twelve physicians and one nurse practitioner completed questionnaires for 185/198 (93.4%) patient visits. MEASUREMENTS: Questionnaires were completed by physicians after each patient visit during August 1989. Interviews were conducted with physicians who had discussed limiting life-sustaining treatment with patients. RESULTS: Ten percent (n = 19) of patients seen had had discussions with their physicians about life-sustaining treatment. These patients were older and had worse prognoses as estimated by their physicians. Physicians usually raised the issue with the families of demented patients and mentioned dementia, quality of life, prognosis, and the need to make other clinical decisions as motivation for initiating discussions. The majority of patients with poor prognoses, however, had not had discussions about life support. CONCLUSIONS: Despite increasing attention given to end-of-life decisions in the medical and lay press, discussions with elderly outpatients about limiting treatment occur rarely. They are more likely when patients are older or have worse prognoses, but age, prognosis, and poor quality of life do not consistently lead physicians to raise the issue.

Tricuspid valve replacement using an unstented pulmonary homograft.

In consideration of the limitations of mechanical and stent-mounted tissue valves, a technique was developed for tricuspid valve replacement using an inverted pulmonary homograft. It was used successfully in a 4-year-old patient operated on for pulmonary atresia with intact ventricular septum and in a 3 1/2-year-old girl with Ebstein's anomaly.

Medical ethics education: past, present, and future.

This paper examines undergraduate medical ethics education in the United States during its 25-year history. Included is a brief description of early efforts in medical ethics education and a discussion of the traditional model of ethics teaching, which emphasizes the knowledge and cognitive skills necessary for ethical decision making. The authors also discuss alternatives to the traditional model that focus more directly on students' personal values, attitudes, and behavior. Current areas of consensus in the field are then explored. Finally, the authors identify three incipient trends in medical ethics education--toward increased emphasis on everyday ethics, student ethics, and macroethics. Throughout the paper, examples of specific courses and curricula are used to illustrate the modes and trends described.

The role of partners in selecting a residency.

To study the influence of medical students' partners (that is, those to whom they are married or engaged, or with whom they are living as "significant others") on students' selections of their residency programs, the authors surveyed fourth-year medical students and their partners at 20 medical schools in 1986. Forty-six percent of 770 eligible couples responded to the questionnaire; data from 314 couples were used in this study. Sixty-five percent of the medical students were men. Eighty-five percent of the partners were employed outside the home. The partner was the most influential person in the students' choice of a residency. Twenty-six percent (81) of the couples mutually made the decision and over 50% (186) tried to satisfy equally both partners' needs. However, the women medical students had less influence over the decision and were more apt to sacrifice their needs for their partners' (p less than .05). The women students were also significantly less satisfied with their role in the decision-making process (p less than .05). Attention to these issues by both medical students and residency programs could help couples deal with the stresses involved in choosing a residency location.

Ethical issues in organ procurement: a review for intensivists.

The current state of organ procurement and the ethical issues raised by the procurement process are reviewed in this article. After an examination of the legislative framework governing organ procurement, the intensivist's role in donation is discussed, including (1) donor identification, (2) asking the family to donate, and (3) obtaining consent. Recent proposals for changing the organ procurement system are analyzed, including increasing family donation or increasing the donor pool.

Clinical evaluation of demineralized-unicortical-ilium-strips for guided tissue regeneration.

This study compared demineralized-unicortical-ilium-strips (DUIS) and an expanded polytetrafluoroethylene (ePTFE) physical barrier in combination with decalcified freeze-dried bone allograft (DFDBA) for treatment of Class II mandibular furcations. Twenty patients with adult periodontitis and at least 2 furcation invasions participated in this study. Probing depth (PD), clinical attachment level (CAL), and bone fill were measured at 6 and 12 months. Standardized radiographs were analyzed using computer assisted densitometric image analysis (CADIA). Fifteen of 20 patients completed the 12-month evaluation. At 6 months both control and test groups showed significant reductions in PD from baseline (P < 0.01). PD reduction for the ePTFE + DFDBA sites was 2.13 mm +/- 1.25, and the DUIS + DFDBA, 1.77 mm +/- 1.21. CAL at 6 months was sustained to 12 months when the net gains in CAL for ePTFE + DFDBA being 1.30 mm +/- 1.45 (P < 0.01) and for DUIS + DFDBA sites 1.13 mm +/- 1.68 (P < 0.02). The horizontal furcation PD decreased 2.87 mm +/- 1.68 (P < 0.01) in the ePTFE + DFDBA and 1.70 mm +/- 1.69 (P < 0.01) for DUIS + DFDBA sites over 12 months. The evaluation of the hard tissue response at the 12-month re-entry demonstrated a bone fill of 2.37 mm (75%) +/- 2.04 (P < 0.01) with ePTFE + DFDBA and 1.83 mm (79%) +/- 1.57 (P < 0.01) with DUIS + DFDBA. DUIS material and ePTFE showed significant improvements in clinical parameters and neither material proved to be significantly better. However, a larger sample size may have permitted us to demonstrate statistically significant differences between the materials. The positive results from the utilization of DUIS for GTR and the advantage of its bioresorbability warrant further investigation. The study found limitations in the use of CADIA for evaluation of guided tissue regeneration in furcations.

Pathologic migration of anterior teeth in patients with moderate to severe periodontitis.

The purpose of this study was to determine the prevalence of pathologic migration of anterior teeth in patients with moderate to severe periodontitis. The correlation between pathologic migration of anterior teeth and attachment loss (AL) was investigated, and an attempt was made to identify the most common early form of pathologic migration. Prevalence of tooth migration was studied in a group of 343 patients with moderate to severe periodontitis before treatment. The presence of pathologic migration was determined from the chief complaint and patient awareness o tooth movement in the last 5 years. Forty-four patients (age range 18 to 69; mean = 48.75) with 75 pairs of migrated and non-migrated teeth were studied further to determine if there is a correlation between severity of periodontal AL and pathologic migration. Migrated teeth were compared to control contralateral teeth that did not have migration. In addition, tooth mobility of the anterior teeth on 36 of the 44 patients was measured using the mobility meter. It was anticipated that tooth mobility would follow the same pattern as AL in relation to pathologic migration. The type and severity of displacement was recorded for each tooth affected by migration. The types of pathologic migration recorded were diastema, extrusion, rotation, facial flaring, and drifting into edentulous spaces. Pathologic migration prevalence was 30.03% +/- 2.5 (103/343 subjects). The mean AL of migrated teeth (4.79 +/- 0.28 mm) was significantly greater (P < 0.0001) than control teeth (3.21 +/- 0.18 mm). The numeric values (called PTV) of migrated teeth (17.6 +/- 1.5) were significantly greater (P < 0.0001) than control teeth (9.4 +/- 1.1). It was difficult to identify a primary form of displacement, as most patients demonstrated a combination of movements. The percentage of the 44 patients who presented with a specific type of movement was: facial flaring (90.9 +/- 4.4%), diastema (88.6 +/- 4.8%), rotation (72.7 +/- 6.8%), extrusion (68.2 +/- 7.1%), and tipping (13.6 +/- 5.2%). The results of this study confirms clinical impressions that periodontal disease destruction of the attachment apparatus plays a major role in the etiology of pathologic migration.