Anticoagulants in cerebrovascular disease. A critical review of studies.

Anticoagulant therapy in the treatment of cerebral thromboembolism remains controversial despite 20 years of statistical studies. Among the unresolved questions are (1) the relative value of aspirin vs coumarin derivatives for long-term therapy; (2) the relative benefits of long-term therapy vs short-term therapy; (3) the complications of anticoagulant therapy vs their therapeutic benefits; and (4) the optimal therapy of the various types of cerebral thromboembolic events, eg, transient ischemic attacks, strokes in evolution, and completed strokes. Much of this controversy derives from the same problems that have plagued the question of anticoagulation for acute myocardial infarction, namely that "the existing statistics were obtained without adequate attention to fundamental principles of clinical science". We have examined the available clinical studies bearing on this issue and are reporting our analysis of these studies.

Relationship of advance directives to physician-patient communication.

BACKGROUND: Although advance medical directives, such as living wills and durable powers of attorney for health care, are by themselves imperfect instruments for expressing patients' treatment preferences, a possible benefit of these documents is that they will enhance patient-physician communication, especially when end-of-life treatment decisions have to be made. METHOD: Structured interviews were completed for 115 seriously ill cancer patients and 22 of their physicians. The questions dealt with various aspects of advance directives, including communications between the two parties regarding general and specific treatment wishes. Responses were compared in 37 physician-patient pairs for patients who had executed advance directives and in 31 physician-patient pairs for patients who had not executed advance directives. RESULTS: Physicians were frequently unaware of their patients' advance directives. Although patients with advance directives were marginally more likely than patients without advance directives to report discussions about end-of-life treatment decisions, only 34 (30%) out of the total of 115 patients claimed that they had any discussion of treatment decisions with their physicians. Such discussions tended to be about general life attitudes and feelings rather than specific treatments, such as use of artificial nutrition or ventilation. CONCLUSION: Despite public enthusiasm for the use of advance directives and great efforts to promote them, we found little evidence that these documents are associated with enhanced communication between patients and physicians about end-of-life treatment decisions.

Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness.

OBJECTIVE: To determine whether brief general instructions in a typical proxy-instruction advance directive (California Durable Power of Attorney for Health Care [DPAHC]) provide interpretable information about patient requests to limit life-saving treatments, and to determine whether patient treatment preferences are stable over time. DESIGN: Prospective structured interviews. SETTING: University of California, San Diego Medical Center and Veterans Affairs Medical Center, La Jolla. PATIENTS: One hundred four patients (from a randomly chosen sample of 185) with a 5-year life expectancy of no better than 50% as judged by their physicians. MAIN OUTCOME MEASURES: Patients completed the California DPAHC, a proxy-instruction advance directive, at entry and at 1 year. The patients also completed a questionnaire at entry, after 6 months, and after 1 year, indicating their preferences on a five-point Likert-format comparative rating scale for cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition, and hospitalization for pneumonia. RESULTS: Sixty-eight percent of the subjects executed the DPAHC. Most patients wished treatments to be limited or withheld under certain conditions of reduced quality of life. Although general instructions noted on the DPAHC and preferences regarding specific procedures were stable over the course of a year, the advance directive's general instructions were often inconsistent with, and poor predictors of, specific procedure preferences. CONCLUSIONS: The brief general instruction component of the California DPAHC is not helpful in communicating patient wishes regarding specific life-saving procedures.

Enhancing comprehension of consent for research in older patients with psychosis: a randomized study of a novel consent procedure.

OBJECTIVE: The ability of individuals with schizophrenia to provide informed consent for research has become the focus of public debate. The authors examined whether a novel consent procedure improved the comprehension of consent for older patients with psychosis. METHOD: Fifty outpatients with schizophrenia or other psychotic disorders and 19 normal comparison subjects aged 40-80 were randomly assigned to groups given either a routine or an enhanced consent procedure. The latter utilized a computerized presentation that included sequential bullet points and summaries of key information. A posttest measured comprehension of consent-relevant information. RESULTS: A significantly greater proportion of patients who received the enhanced consent procedure scored 100% on first and second trials of the posttest, compared to those receiving the routine procedure (trial 1: 42.3% versus 8.3%; trial 2: 80.8% versus 45.8%, respectively). CONCLUSIONS: The enhanced consent method improved comprehension of information relevant for consent in older patients with psychosis.

Futility and rationing.

It seems more than coincidental that at a time of great concern over rising health care costs and fears of rampant technology, debates are suddenly taking place about medical futility and health care rationing. This article examines the economic, historical, and demographic factors that have motivated increased attention to both these concepts, explores differences and similarities in the meaning of these terms, and discusses their ethical implications. Specifically, we identify four common sources of current debates on futility and rationing: the rise in health care costs; the development of high-technology medicine; the aging of society; and the effort to limit the scope of patient autonomy. We propose that when rationing criteria refer to medical benefit, the meanings of futility and rationing share certain common features. Futility and rationing differ, however, in important ways. Futility refers to treatment and outcome relationships not in a general population but in a specific patient. Rationing criteria usually are supported by reference to theories of justice, whereas the definition of futility, if achieved, will probably be arrived at by empirical community agreement. Rationing always occurs against a backdrop of resource scarcity, but futility need not. Toward the end of the paper, we clarify how the various connotations and contexts we associate with each term enhance or frustrate ethical debate.

Beyond futility to an ethic of care.

The medical futility debate is usually framed as a conflict between physician and patient (or surrogate) over the right to decide whether a particular life-saving treatment is futile and should not be attempted. Arguments on behalf of physician-determined futility emphasize the limits of physicians' obligations; arguments on behalf of patient-determined futility reflect concerns over the potential erosion of recent gains in patient autonomy against medical paternalism. Underlying the arguments of those pressing for "value-free" definitions of medical futility and unlimited obligations of physicians to patients may be fears of covert rationing and patient abandonment. Often overlooked in this debate, both at the bedside and in public commentary, is the ethical duty of the physician to redirect efforts from life-saving treatments toward the conscientious pursuit of treatments that maximize comfort and dignity for the patient and the grieving family. To supplement the limited terms of the futility debate with an ethic of care, physicians should lead in advocating greater awareness of the ethics of care in doctor-nurse interactions, institutional facilities, insurance policies, and public education.

Effects of offering advance directives on quality adjusted life expectancy and psychological well-being among ill adults.

Two hundred and four patients from various clinical services at the San Diego Veterans' Administration Medical Center and the University of California, San Diego Medical Center were randomly assigned to either experimental (offered the opportunity to execute an Advance Directive regarding the level of care they wanted to receive if incapacitated) or control (no Advance Directive offered) conditions. Patients were given a baseline interview and re-interviewed at specific intervals (3 months, 6 months, 1 year and 2 years after baseline, and every 6 months thereafter). Outcome measures included the Qualitty of Well-being Scale, a measure of health status, and the General Well-being Index, a measure of psychological well-being. All differences between the health status and psychological well-being of experimental and control groups 3.5 years after the randomization were non-significant. Methodological implications of including mortality as part of the outcomes are discussed.

Comparison of the Quality of Well-being Scale and the SF-36 results among two samples of ill adults: AIDS and other illnesses.

PURPOSE: To compare results of using the SF-36 Short Form 36 (SF-36) and the Quality of Well-being Scale (QWB) in characterizing health outcomes over time in patients having serious illnesses, including cancer and AIDS. BACKGROUND: The SF-36 and the QWB are alternative measures of health-related quality of life. The SF-36 is a morbidity measure that features a profile of nine dimensions. The QWB is a preference-based measure that combines morbidity and mortality into a single number. However, the QWB can also be scored and used as a profile. We compare SF-36 and QWB scores with different scoring methods to assess validity and sensitivity to change over time in health outcomes for adult patients with HIV infection, cancer, and other serious illnesses. SUBJECTS: 201 adults with serious illnesses, including 99 with AIDS and 102 with cancer or other illnesses. PROCEDURE: All subjects received both measures at baseline and at 6-month intervals thereafter, over a period of 21/2 years. RESULTS: In the profile mode, the QWB captured outcomes that characterize the AIDS syndrome. The SF-36 differentiated between the AIDS and other illnesses patients on some scales, but without consistent direction. However, the overall QWB showed a decrease in quality of life over time for both the AIDS and other illnesses patients while the SF-36 did not. This is because many patients died and these were counted as outcomes by the QWB and as missing data by the SF-36. CONCLUSIONS: The QWB appears to be better able to capture outcomes of serious illness over time than does the SF-36.

Healthcare resource consumption in terminal care.

Recent developments in healthcare have raised important ethical challenges. One of the trends is the increasing attention to patient autonomy for medical decision making. Patients are exercising greater authority to refuse medical treatment and to seek medical treatment that may end life. Another important trend is that end of life medical care has become increasingly expensive. Further, changes in reimbursement for medical care may create incentives for providers to deny heroic treatment. This article reviews issues relevant to these developments. We consider the issue of medical futility, the role of advance directives, and the international movement toward the legalisation of euthanasia. We suggest that futile medical treatment should not be offered and that advance directives should he used. However, review of the literature suggests that advance directives may not reduce medical costs. The effect of managed care upon advance directives, denial of heroic care and euthanasia is not known at this time.

Is dying young worse than dying old?

In contemporary Western society, people experience the deaths of older and younger persons differently. We are disposed to feel that the death of a small child is a greater injustice than the death of an older adult, and we experience correspondingly greater sorrow, anger, regret or bitterness when a very young person dies. This article examines these responses critically to determine whether they are backed by ethical considerations that reason can discern and defend. We contrast contemporary attitudes with those of ancient Greece and show the relevance that different attitudes toward death have for health care decision making.

Impact of pediatric ethics consultations on patients, families, social workers, and physicians.

OBJECTIVE: To evaluate whether health providers and families find ethics consultations helpful in identifying, analyzing, and resolving ethical problems. STUDY DESIGN: Forty consecutive pediatric ethics consultations at the San Diego Children's Hospital and Health Center were evaluated retrospectively through chart reviews and structured interviews with physicians, social workers, and family members. RESULTS: In 23 of 40 cases, physicians or social workers were successfully interviewed. Of these 23 cases, four family interviews were completed. Over 90% of physicians and social workers found the ethics consultation to be helpful and would recommend an ethics consultation to others in the same circumstances. Two of the four families were strongly dissatisfied with the consultation and identified miscommunication of the ethics consultant's role as a major problem. CONCLUSION: The disparity observed in this study between satisfaction levels of health providers and families raises concerns. More studies that evaluate ethics consultations are needed, especially those that are designed prospectively and explore both these perspectives.

Medical futility.

The debate on medical futility can lead to a fresh revisiting of the doctor-patient relationship and with it a restoration of common sense and reality to society's grasp of the powers and limits of medicine. In my view, the duty of the physician is to attempt that which is of therapeutic benefit to the patient. Nothing less and nothing more.

Having babies at home: is it safe? Is it ethical?

Home births entail a definite small risk, of unknown magnitude. Hospital births entail a wider range of risks, whose magnitude may be large but is also unknown. The morality of home births should be decided on a case-by-case basis, according to these priorities: safety of the mother, safety of the fetus, benefit to the fetus, potential benefit to the mother.

KIE: While both home and hospital births entail risks to the pregnant woman and fetus, no evidence of significantly greater risk of home birth is currently available that would clearly tilt the scales in favor of requiring babies to be born in hospitals. Parents, the state, and physicians have an interest in deciding about home birth, but for low-risk mothers with well-trained birth attendants, home birth can be considered in the best interest of both woman and fetus cannot be considered neglectful or abusive. Since home birth does not represent a clear and present danger to the common good, it does not warrant legal prohibition; physicians, however, are not required to participate but can legitimately offer backup support. The morality of home birth should be decided on a case-by-case basis, according to the priority of safety of the mother, safety of the fetus, benefit to the fetus, and potential benefit to the mother.

Cost-effectiveness analysis in health care.

PIP: With the skyrocketing costs of modern health care, many health policy planners turn to cost effective analysis (CEA) or cost benefit analysis (CBA) to get quantitative answers for appropriateness of health procedures. This article analyzes how well approaches like CEA or CBA handle the hidden ethical judgements for such problems as: alternative treatments for an identical goal, the most effective utilization of funds earmarked for a particular goal, empirical support for the adoption of previously underfunded medical programs, and exposing noncostworthy care. Areas of analysis that involve human capital methodologies, whereby human value is often defined by economic worth, was shown to discriminate against low wage earners. The quandary of how to determine the value of human life and health is an essential problem but is certainly not straight forward. A particular criticism of CEA where there exist ethical shortcomings is the analysis of health care for the elderly (e.g. the elderly have a worse expenditure of dollars for lifespan extension). If CEA or CBA is applied in an appropriate manner, CEA can encompass many of our democratic society's values, and therefore philosophers, historians, and students of the humanities are encouraged to provide input in this domain of analysts and economics.^ieng

Ethical issues in managing the noncompliant child.

Children who refuse treatment present a particularly difficult ethical problem in the practice of dentistry. Five areas should be considered when a patient refuses treatment. First, the urgency of the dental needs should be assessed to determine if treatment can be delayed or avoided with no lasting ill effects. Second, the capacity of the child to participate in decision making should be considered, and the child involved to the extent of that capacity. Next, the potential harm of management techniques should be weighed against the benefits of treatment. Then, the informed permission of parents should be obtained. Finally, pediatric dentists have a responsibility to attempt to shape policy to make care more available on the basis of need as part of an overall system of justly distributed health care.

Three approaches to problem solving in medicine and some problems they create.

Three general approaches to problem solving in medicine are examined: Basic Science Problem Solving, Clinical Medicine Problem Solving, and Human Values Problem Solving. These three approaches employ different--indeed contradictory--search strategies. Not infrequently, students of medicine become versed in one or another problem solving approach only to flounder when they try to apply it inappropriately. Recognition of this problem may help to solve it.

Effect of topical corticosteroids on symptoms of clinical sunburn.

Topical corticosteroids have been advocated in the treatment of sunburn. This therapy was evaluated by means of a random, double-blind study in which subjects who had acquired acute natural sunburn served as their own controls. Subjects applied fluocinolone cream to an acutely exposed area of their body and the inert carrier base to a symmetrical, similarly exposed area twice a day for five days while avoiding further exposure. The subjects recorded by means of a rating scale the progression, at both sites, of redness, pain, blistering, swelling, and peeling. The natural course of mild to moderate sunburn to symptomatic resolution was observed to be about three to five days. There was no significant difference in response between the steroid-treated area and the inert-base-treated area.

Attitudes of patients toward family care in a family practice group.

There is little information documenting the extent to which the ideal of whole family care is represented in the real world of family practice. A previous study of a suburban family practice group revealed that only 28 percent of families obtained whole family care from a single physician. Interviews were conducted on a sample of 97 of these patients in an effort to gain insights into the factors influencing the choice of a single physician or more than one physician providing their health care. There were no significant differences between same-physician and different-physician families with respect to demographic factors or attitudes toward physician characteristics and family care. Most families had no insights into the potential value of having a single physician for the whole family; indeed, only one family specifically selected a single physician with the belief that it would thereby gain better care. If the observations reported here are representative of the situation at large in the country, family physicians have an important task ahead in patient education.

A clinical study of the use of human chorionic gonadotrophin in weight reduction.

Treatment of obesity with human chorionic gonadotrophin was shown to be of no better value than saline in a double-blind crossover study of weight reduction in obese subjects. There was also no significant difference in mood, hunger, or missed injections, and no apparent difference in adherence to diet when the two agents were compared. In contrast, a significant difference was found in the ability of subjects to lose weight in the first four weeks of the study in contrast with the second four weeks, no matter which agent was used. Thus, the initiation of a new therapeutic program, even using an inert agent, has a temporary benefit--a manifestation both of placebo effect and the Hawthorne effect.

Contribution of unexpected serum thyroxine (T4) abnormality to detection of thyroid disease.

The screening serum thyroxine (T4) was compared to the history and physical examination as a means of detecting new cases of thyroid disease in a university hospital outpatient population. Of 13 new cases of hyperthyroidism diagnosed during the study period, 10 were suspected on the basis of history and physical examination, and 3 as a result of an elevated screening T4. Of 32 new cases of hypothyroidism, 23 were discovered on the basis of history and physical examination, and 9 as a result of a low screening T4. Thus approximately one quarter of new diagnoses of thyroid disease were made not by history and physical examination but by the unexpected appearance of a deviant T4 on the screening laboratory panel. Since approximately 40 percent of the deviant T4 values were not followed up by physicians, it is possible that an even higher yield of new cases would have resulted by laboratory detection alone. These results suggest that a significant number of new cases of thyroid disease are missed by the clinician and are uncovered only as a result of screening laboratory procedures.