Patient values informing medical treatment: a pilot community and advance care planning survey.

Medicine regards the prevention of death as an important priority. Yet patients may have a range of priorities of equal or greater importance. These other priorities are often not discussed or appreciated by treating doctors. OBJECTIVES: We sought to identify priorities of care for patients attending an advance care planning (ACP) clinic and among the general population, and to identify factors associated with priorities other than prolonging life. METHODS: We used a locally developed survey tool 'What Matters Most' to identify values. Choices presented were: maintaining dignity, avoiding pain and suffering, living as long as possible, and remaining independent. Participants rated the importance of each and then selected a main priority for their doctor. Participant groups were a purposive sample of 382 lay people from the general population and 100 attendees at an ACP clinic. RESULTS: Living as long as possible was considered to be less important than other values for ACP patients and for the general population. Only 4% of ACP patients surveyed and 2.6% of our general population sample selected 'living as long as possible' as their top priority for medical treatment. CONCLUSIONS: 'Living as long as possible' was not the most important value for ACP patients, or for a younger general population. Prioritisation of other goals appeared to be independent of extreme age or illness. When end of life treatment is being discussed with patients, priorities other than merely prolonging life should be considered.

A comparative study of tracheal diameter in Caucasian and Chinese patients.

Ethnicity may be considered a factor when considering what size endotracheal tube to insert. In particular it has been suggested that Chinese patients have a smaller tracheal diameter, justifying the selection of smaller endotracheal tubes. We systematically evaluated transverse tracheal diameters in Chinese and Caucasian patients, utilising archived computer tomography images. A convenience sample of 100 Caucasian patients from Australia was compared with 100 Chinese patients from Hong Kong. Patients over 18 years of age who had undergone a computerised tomography scan of the neck and thorax, and also had accurate body height and weight recorded, were studied. The mean transverse diameter of the trachea measured at three levels was similar between the Chinese and Caucasian patients. At the narrowest measurement point, the immediate subcricoid transverse diameter, the unadjusted mean difference between male Chinese and Caucasian patients was small (1 mm, standard deviation 0.83 mm, P=0.01), and similarly small between female Chinese and Caucasian patients (1.5 mm, standard deviation 0.8 mm, P <0.01). Multivariate analysis demonstrated only a small influence related to ethnicity (12% relative contribution to the overall variance [R2] of the model), but substantial influence of height (40%) and sex (41%). Our findings do not support the practice of routinely selecting a smaller endotracheal tube size for Chinese patients on the basis that there is a difference related to the Chinese ethnic phenotype. Considerations regarding choice of endotracheal tube size should rather focus on patient sex and height.

The utility of a Personal Values Report for medical decision-making.

Our aim was to determine if a patient's Personal Values Report (PVR) has a positive impact on a doctor's decisions regarding treatment. We conducted a prospective cohort study delivering a short, web-based hypothetical case-centred questionnaire to intensive care doctors practising in Australia and New Zealand. One hundred and twenty-four intensive care consultants and registrars agreed to participate in an online questionnaire in two routine mailings between November 2013 and February 2014. We evaluated the effect of a PVR on clinical decision-making in a case-based scenario. In addition, participants rated the utility of the PVR on their decision-making process. Participants were presented with a difficult scenario in a frail elderly man where death was almost inevitable without aggressive support but survival with severe disability was possible with significant intervention. Most doctors (52.4%) elected to continue ventilation and admit to ICU. After the PVR was made available, only 8.1% of doctors continued to choose to admit the patient to the ICU. In all cases where admission to the ICU was chosen after seeing the PVR, the admission to the ICU was stated to be to permit family to arrive before withdrawing support (an approach which was consistent with the values stated in the PVR). One hundred and twenty-one of the 124 participants (97.6%) agreed or strongly agreed that the PVR helped them get an understanding of the patient's wishes, whereas none of the participants (0%) were unsure, disagreed or strongly disagreed with this statement. The remaining 2.4% did not answer the question. It is surmised that PVRs pre-written by patients are potentially an effective and valuable tool for use in helping doctors make decisions regarding patient care.

Travel insurance.

In this article are salutory and awful stories, all based on true cases. They serve to illustrate how terrible the problems can be when travel insurance is not appropriately secured before a traveller becomes sick, or where the patient assumes the risk himself, without insurance, in the absence of a proper understanding of the consequences.

Choosing life support for suddenly severely ill elderly relatives.

OBJECTIVE: To determine whether relatives are more likely to request intensive treatment for elderly relatives than the elderly parents would wish for themselves, and to explore the reasons which drive this behaviour. METHODS: A potential end-of-life scenario was presented to 30 elderly people and also to their next generation relative who could be required to be a surrogate decision-maker for their elderly relative in the future. A semi-structured interview (which was designed to avoid the use of leading questions) was undertaken by a trained psychology researcher to ascertain the views of the subjects with regard to treatment choices and the motivation underlying these views. RESULTS: Of the potential patients, 83% reported that they would not want intensive treatment in the hypothetical situation. However, while 76% of surrogates also stated that they believed that treatment was inappropriate, all of the surrogates elected to initiate treatment. The need for time to get the family together, the need to reach family consensus and the need to be more certain of prognosis, were major influences which led the surrogates to request initiation of intensive treatment. CONCLUSIONS: Better understanding of the factors which motivate surrogate decision-makers may help the development of measures to avoid the inappropriate use of high technology treatment at the end of life and to achieve outcomes which better match the wishes of the patients whom we treat. Measures which encourage elderly, chronically ill patients to determine their treatment (e.g. by advance directives), rather than delegating the responsibility to relatives, are likely to result in less demand for inappropriate intensive care treatment.

How doctors discuss major interventions with high risk patients: an observational study.

OBJECTIVE: To investigate the difficulties doctors face in discussing treatment options with patients with acute, life threatening illness and major comorbidities. DESIGN: Observational study of doctor-patient interviews based on a standardised clinical scenario involving high risk surgery in a hypothetical patient (played by an actor) with serious comorbidities. PARTICIPANTS: 30 trainee doctors 3-5 years after graduation. MAIN OUTCOME MEASURES: Adequacy of coverage of various aspects was scored from 3 (good) to 0 (not discussed). RESULTS: The medical situation was considered to be well described (median score 2.7 (interquartile range 2.1-3.0)), whereas the patient's functional status, values, and fears were poorly or minimally addressed (scores 0.5 (0.0-1.0), 0.5 (0.0-1.0), and 0.0 (0.0-1.5), respectively; all P < 0.001 v score for describing the medical situation). Twenty nine of the doctors indicated that they wished to include the patient's family in the discussion, but none identified a preferred surrogate decision maker. Six doctors suggested that the patient alone should speak with his family to reach a decision without the doctor being present. The doctors were reluctant to give advice, despite it being directly requested: two doctors stated that a doctor could not give advice, while 17 simply restated the medical risks, without advocating any particular course. Of the 11 who did offer advice, eight advocated intervention. CONCLUSIONS: Doctors focused on technical medical issues and placed much less emphasis on patient issues such as functional status, values, wishes, and fears. This limits doctors' ability to offer suitable advice about treatment options. Doctors need to improve their communication skills in this difficult but common clinical situation.

Gastric emptying in the critically ill patient.

OBJECTIVE: To review the pathophysiology of gastroparesis and present a practical approach to the management of this disorder in the critically ill patient. DATA SOURCES: Articles and published abstracts on the mechanisms and management gastroparesis relevant to the critically ill patient. SUMMARY OF REVIEW: The importance of early enteral nutrition in the critically ill patient has been recognised for many years. However, while nasogastric tubes are easy to insert, gastric dysmotility is common, and often hinders the introduction of effective enteral nutrition. Small bowel motility problems are uncommon in the intensive care patient, and direct instillation of nutrients into the jejunum will allow enteral nutrition to begin without delay. However compared with gastric tubes, jejunal tubes are often difficult to insert, often requiring endoscopic or surgical techniques. The cause of gastric dysmotility is multifactorial. Treatment of underlying sepsis, pain, hypotension, dehydration and hyperglycaemia should occur, and opiates and dopamine should be avoided before commencing prokinetic agents. The patient's head should remain elevated, and oral or nasogastric cisapride (10 mg 6-hourly) administered. If this is not effective then erythromycin (e.g. 250 mg i.v. 8-hourly) may be included. CONCLUSIONS: Gastric dysmotility is common in the critically ill patient. However, treatment of the underlying conditions leading to gastroparesis and the introduction of prokinetic agents will allow the majority of patients to be successfully fed enterally.

The influence of diethyl-dithiocarbamate ('Imuthiol') on mononuclear cells in vitro.

Diethyl-dithiocarbamate ('Imuthiol') has been shown to enhance various immune functions in vivo but is toxic in vitro. Macrophages were observed to show evidence of toxicity when exposed to lower concentrations of Imuthiol than inhibited thymidine incorporation by the Raji lymphoid cell line. Inhibition of the mitogenic response of human mononuclear cells to phytohaemaglutinin (PHA) occurred after preincubation of adherent or non-adherent mononuclear cells with Imuthiol. This finding contrasts with the results with gold salts where preincubation of adherent cells inhibits the response to mitogens, while preincubation of non-adherent cells has no effect. The specific toxicity of gold on monocyte/macrophages in vitro is not a feature of Imuthiol.

A Seldinger technique for minitracheostomy insertion.

Minitracheostomy is a valuable technique in patients with sputum retention. However, insertion of a minitracheostomy tube over a dilator passed through an incision through the cricothyroid membrane (the suggested method of insertion of the 'Mini-trach II', [Portex]), can prove difficult. A Seldinger method is described which results in easier and more reliable placement in difficult cases.

Monitoring intestinal ischaemia.

OBJECTIVE: To review the clinical and experimental methods of detecting intestinal ischaemia and to assess their value in current clinical practice. DATA SOURCES: Relevant articles and published reviews on intestinal ischaemia and/or infarction. SUMMARY OF REVIEW: The incidence of acute mesenteric ischaemia has increased substantially over the last few decades. Death rates of 70% to 90% have been reported for this condition. Improved management depends upon prompt diagnosis and early aggressive management. Despite mounting evidence that ischaemic intestinal injury may be frequent and may be a cause of multi-organ failure, accurate monitor-ing of the intestinal circulation in critically ill patients continues to be a distant goal. The need for a reliable, specific test of intestinal ischaemia has been recognised for many years. Numerous potential monitors have been evaluated including intraluminal pCO2, abdominal CT, abdominal MRI and specific plasma enzymes, but few have shown potential to be clinically useful. At present no specific test for intestinal ischaemia and/or infarction is in routine clinical use. Development of a specific test to monitor for intestinal injury would be of great clinical value. Further work will inevitably lead to the development of useful markers. CONCLUSIONS: Accurate detection of intestinal ischaemia in the critically ill patient is often difficult. While numerous tests have been examined to diagnose and monitor intestinal ischaemia and/or infarction most exhibit an unacceptably low specificity and sensitivity.

Respiratory depression complicating epidural diamorphine. Two case reports of administration after dural puncture.

Two cases of severe respiratory depression complicating epidural diamorphine administration are reported. In both cases, the dura had been punctured. The risk of epidural opiate administration in association with a breach in the dura is reiterated.

Adsorption, desorption, and activity of glucose oxidase on selected clay species.

The adsorption of the enzyme glucose oxidase (EC 1.1.3.4) to clays followed the pattern described for other proteins as being pH dependent. Maximum adsorption occurred at or below the isoelectric point of the enzyme. The amount of enzyme adsorbed to clay was influenced by the type of clay used, and also the saturating cations. Initially adsorbed enzyme showed low specific activities, and as amounts of enzyme adsorbed approached maximum stauration of clay, specific activities increased approaching that determined for free enzyme. The adsorption of glucose oxidase involved a temperature-independent cation-exchange mechanism, and enzyme adsorbed to surfaces of clay could be desorbed in active form by elevation of pH of suspending solution. This was followed by a slower temperature-dependent fixation, probably by hydrogen bonding, which resulted in protein being irreversibly adsorbed to clay surfaces. It is proposed that on adsorption of glucose oxidase to clay surfaces unravelling of the protein structure occurred, which allowed penetration of protein into the interlamellar spaces of montmorillonite. This proposal was based on the observed expansion of montmorillonite to 23 A, and the decreases in amount of a second-protein lysozyme adsorbed with extended incubation times of glucose oxidase - clay complexes at pH 4.5.

Circulating secretory phospholipase A2 in critical illness--the importance of the intestine.

OBJECTIVE: To review the role of secretory phospholipase A2 in the pathogenesis of multiple organ failure in the critically ill patient. DATA SOURCES: Relevant articles and published reviews on secretory phospholipase A2 in critical illness. SUMMARY OF REVIEW: Secretory phospholipase A2 (sPLA2) has an important role in inflammation and in antimicrobial defence. However, excessive activity of sPLA2 has been shown to result in tissue damage and has been implicated as a mediator of organ failure associated with critical illness. Gastrointestinal release of secretory phospholipase A2 from Paneth cells increases during intestinal ischaemia and may be an important factor in the pathogenesis of the multiple organ dysfunction syndrome. In experimental models, specific PLA2 inhibitors reduce organ failure associated with sPLA infusion and may play an important role in reducing organ failure in the management of the critically ill patient. CONCLUSIONS: Intestinal ischaemia may play an important role in the pathogenesis of the multiple organ dysfunction syndrome in the critically ill patient. In patients with sepsis, specific PLA2 inhibitors have the potential to reduce organ failure and improve morbidity and mortality.

Extracorporeal circulation in the management of massive propranolol overdose.

A case of refractory hypotension following propranolol overdose is reported. Management included isoprenaline, glucagon and extracorporeal circulatory support using femoral vein-femoral artery bypass. The unreliability of neurological observations, especially unreactive pupils, in the presence of drug overdose is reiterated.

The effect of nickel on the growth, photosynthesis, and nitrogenase activity of Anabaena inaequalis.

Anabaena inaequalis was sensitive to nickel ion in the order of decreasing sensitivity of growth, photosynthesis, and acetylene reduction. At a culture density of 9 x 10(4) cells per millilitre, growth after 12 days was completely inhibited by 0.125 ppm (microgram/mL) Ni2+. Nickel caused the increase of both the lag phase of growth and the culture doubling time, and caused the retardation phase to be sooner. Photosynthesis and acetylene reduction were completely inhibited by 10 and 20 ppm Ni2+, respectively, at a cell concentration of 1.3 x 10(6) cells per millilitre. Preincubation for 24 h in the presence of nickel ion significantly increased the sensitivity of photosynthesis and acetylene reduction. Under these conditions acetylene reduction was more sensitive than photosynthesis. Nickel ion reduced culture growth by 35% at a level of 0.05 ppm and inhibited that culture's acetylene-reducing ability by 29% while leaving photosynthesis unaffected. Nickel caused some damage to filament apical cells and induced pigment bleaching in aged cultures. Nickel toxicity was proposed to be due to poisoning of intracellular enzyme systems by nickel ions.

Factors affecting the development of penicillamine side-effects.

Characteristics of patients on penicillamine therapy for rheumatoid arthritis were correlated with the occurrence of different side-effects. Patients developing proteinuria tended to have lower sheep-cell agglutination test titres prior to therapy, but no other correlations were found. It is postulated that rheumatoid factor reacts with immune complexes, causing their precipitation and reducing renal glomerular deposition and therefore the incidence of proteinuria. Penicillamine would surely be the first choice of anti-rheumatic therapy if it were not for its side-effects. It is capable of controlling the disease, but in many cases treatment must be interrupted because of some potentially serious side-effects, such as thrombocytopenia, rash or nephropathy. Understanding the mode of action of a drug may lead to the development of new and better compounds. Similarly, understanding the mechanism of the side-effects may lead to their elimination. This survey was designed to identify factors which influenced the development of particular side-effects in patients receiving penicillamine for rheumatoid arthritis.

Effect of acetone on the toxicity of atrazine towards photosynthesis in Anabaena.

The effect of acetone on the toxicity of atrazine towards photosynthesis in the blue-green algae Anabaena inaequalis, A. variabilis and A. cylindrica was investigated. The order of sensitivity to atrazine was A. inaequalis greater than A. variabilis greater than A. cylindrica. Acetone and atrazine interacted additively, antagonistically, and synergistically, depending upon the concentrations of acetone and atrazine used. The EC50 of atrazine towards photosynthesis was dependent upon the type of solvent-pesticide interaction.