A pilot study on the utility of a more informative living will.

Most written advance directives are designed to help people prescribe the care they would desire at the very end of their life. They provide little guidance for elderly patients with potentially treatable diseases who may be temporarily incapacitated and thus unable to articulate their wishes. The authors developed an alternative living will format with the intent of better documenting the care wishes of this population. A convenience survey of patients, surrogates and physicians compared the pilot version with the commonly available West Virginia Living Will to determine whether the pilot version was able to provide clearer direction for health care providers and surrogate decision makers. The majority of respondents indicated the pilot version better met their needs when compared to the commonly utilized version. This study suggests there is a need for an alternative living will that addresses the needs of those not at the very end of their life.

Visual hallucinations in a patient with adult onset acid maltase deficiency disorder.

A 66-year-old male presented with visual hallucinations. He had chronically elevated serum creatine kinase (CK) levels without muscle weakness. His hospital course was complicated by hypercapnic respiratory failure requiring mechanical ventilation. His hallucinations completely subsided on mechanical ventilation. Elevated CK levels prompted a muscle biopsy, which showed myopathy consistent with acid maltase deficiency disorder (AMDD). This is the first reported case of adult onset AMDD presenting with psychiatric symptoms. Our objective in reporting this case is to encourage early recognition of neuromuscular respiratory failure in AMDD and to reinforce that respiratory failure may develop without associated extremity muscle weakness.

Are blood gases necessary in mechanically ventilated patients who have successfully completed a spontaneous breathing trial?

BACKGROUND: The utility of routinely obtaining arterial blood gas analyses (ABGs) prior to extubation in patients who have successfully completed a spontaneous breathing trial is not known. OBJECTIVE: Review our practices and determine our extubation success rate with a policy of selective ABG utilization. METHODS: Retrospective chart review. RESULTS: We reviewed 54 extubations of 52 patients. Sixty-five percent of the extubations were performed without obtaining an ABG after the spontaneous breathing trial. The extubation success rate was 94% for the entire group and was the same regardless of whether an ABG measurement was obtained (94.7% vs 94.3%, respectively). CONCLUSION: ABG measurement does not appear to be a prerequisite to extubation following a clinically successful spontaneous breathing trial.

Stress ulcer prophylaxis.

Preview Which critically ill patients are at increased risk for gastrointestinal hemorrhage from stress ulcers? Do prophylactic agents effectively reduce the morbidity and mortality associated with stress-related hemorrhage? The author, former director of a medical intensive care unit, reviews recent literature on stress ulcer prophylaxis and outlines the risks and benefits of providing preventive therapy.