Lessons learned from autopsies at a pediatric teaching hospital.

Twenty-six percent of pediatric patients had discrepant major diagnoses revealed at autopsy. A printed form used to document permission for autopsies improved the autopsy rate. No variables were found to predict the success rate for obtaining autopsies.

Attitudes of pediatricians and pediatric residents toward obtaining permission for autopsy.

OBJECTIVE: To investigate attending physician and resident attitudes and factors affecting autopsy consent. METHODS: A validated, self-report, multiple-choice questionnaire was administered to 158 physicians. RESULTS: The overall response rate was 113 (72%), with 57 (85%) of 67 pediatric residents and 51 (56%) of 91 attending physicians responding. The status of five respondents was unknown. Most respondents (98%) believed autopsies provide valuable information; physicians who had graduated before 1980 were more likely to believe that the benefits of autopsy should be taught (P < or = .002). Autopsy was considered unnecessary by 20% (22/112) when the disease was known before death and by 11% (12/112) when the patient was designated "do not resuscitate." Physicians who did not attend an autopsy while in training were less likely to believe in the benefits of autopsy (P < or = .02). Factors that influenced the failure to obtain consent for an autopsy were physician belief that the family felt the body would be desecrated (30/81 [37%]); physician belief that the family would be upset (36/104 [35%]); and physician belief that little information would be obtained (19/104 [18%]). Fourteen (17%) of 81 physicians indicated that they do not ask permission for autopsy if the family is upset. CONCLUSION: Most physicians believe autopsies have benefit. If the autopsy rate is to improve, physicians in training will require increased exposure to autopsies, education regarding the potential benefits, and enhancement of interpersonal skills for successful communication with families in crisis.

Do not resuscitate policies of New Jersey hospitals.

The do not resuscitate (DNR) policies of 100 New Jersey hospitals were investigated using a questionnaire to evaluate hospital characteristics, DNR documentation, decisionmaking, consent, satisfaction with present policies, and revision plans. Among responding hospitals, 78% indicated they had a policy, with--61% being established between 1984 and 1987. Twenty-two percent of hospitals with a DNR policy accepted oral orders, 39% accepted telephone orders, and 36% required written consent from a competent patient. Forty-nine percent of hospitals with a policy accepted qualified orders such as, "do not intubate." Sixty-two percent of responding hospitals were satisfied with their current policy. For 22 hospitals without a policy, 80% indicated dissatisfaction with their current practice. When hospitals with a DNR policy were compared to those without a policy, government supported hospitals were less likely to have a DNR policy than non-governmental hospitals (P = .04). Hospitals without a policy were more likely to perform "slow codes" than those with a policy (P = .007). A two-year follow-up survey found seven hospitals without DNR policies.

Evaluation of patient, physician, nurse, and family attitudes toward do not resuscitate orders.

We investigated attitudes toward resuscitation by interviewing 97 competent patients classified as do not resuscitate, 60 physicians, 80 family members, and 84 nurses. In addition, 58 family members of incompetent do not resuscitate patients were interviewed. Interview patients were generally elderly, female widows with a diagnosis of malignancy. The majority (66%) preferred that their medical decision making be shared with the physician and/or family. Only 38 patients (39%) could correctly define a "living will." After hearing the definition, 59 patients (61%) thought it was a good idea to ask noncritically ill patients at the time of hospital admission, if they had a living will. Fifty-six patients (58%) said they had discussed resuscitation with their physician, whereas 44 physicians (73%) said they had discussed it with the patient. Only 53 patients (55%) said that they thought their physician understood their wishes. Sixty-five patients (67%) wanted involvement in resuscitation decisions. Forty-eight patients (49%) offered "quality of life" reasons for not wanting to be resuscitated. Sixty-four patients (66%) did not think discussing resuscitation was cruel and insensitive. Eighteen physicians (30%) said they were uncomfortable discussing resuscitation with patients. We recommend introducing the topic of resuscitation early in the patient-physician relationship before diminished competency occurs.

Evaluation of the do not resuscitate orders at a community hospital.

Demographic, medical, and outcome characteristics for 821 do not resuscitate (DNR) patients were compared with 300 age- and sex-matched control patients, and with 230 patients for whom cardiopulmonary resuscitation had been performed. Do not resuscitate patients were more likely to be female and older than cardiopulmonary resuscitation patients and to have a child as next of kin. Although DNR patients in intensive care units had comparable illness levels before and at the time of the order, treatment levels were reduced when the order was written. In general, DNR patients received more nursing care than other patients. Hospital mortality was 59.8% for DNR, 83.9% for CPR, and 1.7% for control patients. We identified diagnosis, prior activity, hospital unit, and employment status as predictors of DNR. According to documentation, 20% of patients participated in the DNR decision. Introduction of a DNR progress note form significantly improved documentation of the DNR process, but further efforts to improve DNR practice and patient participation are recommended.

Limitations in testing for attitudes toward cancer.

A Cancer Attitude And Knowledge Questionnaire was administered to two groups of incoming first year medical students and to one of these groups at the end of their second year. The same questionnaire, except for the questions dealing with cognitive knowledge, was also used to assess the attitudes of practicing oncologists. There was a wide variation in the responses to the attitudinal items in all groups. In view of many inconsistencies in the results, a rigorous analysis of the instrument was carried out. The subscales derived from the Cancer Attitude Survey were found to lack adequate reliability. The only part of the attitudinal test found to be reliable and discriminatory was the semantic differential developed by the authors. It is, therefore, concluded that the currently used techniques are inadequate, and there is a need for a new multidimensional approach to the assessment of attitudes toward cancer.

Development and validation of a test instrument for assessing value preferences in medical ethics.

A test instrument for assessing the preferences medical students display for six value categories--aesthetic, economic, political, religious, social, and theoretical--was developed using a case study approach. The major validation procedures involved the relationship of medical ethics values to general and the differences of medical ethics values as expressed by six "known groups" of non-medical students. Data from 151 medical students and 274 students representing six groups were analyzed to provide information concerning social desirability, internal consistency, and test-retest reliability. The dominance of the social value category was supportive of research previously reported that physicians consider the social dimension of medical decision-making to be of primary importance. However, because of the dominance of the social value category with all respondents and the weak known group relationships, further study is recommended to define the components of the social value category within the medical ethics domain.