Evolución del conocimiento y de la realización de instrucciones previas en los pacientes ingresados en medicina interna / Changes in knowledge and carrying out the advance directives of patients admitted to internal medicine

Antecedentes. Las instrucciones previas (IP) son documentos por los que una persona manifiesta anticipadamente su voluntad para que se cumpla cuando no pueda expresarla. Se desconoce si los pacientes ingresados en medicina interna conocen y realizan cada vez más IP. Objetivo. Estudiar la evolución del nivel de conocimiento y de realización de las IP entre los pacientes ingresados en medicina interna en un hospital público de Madrid después de haberse producido una regulación específica sobre IP. Pacientes y métodos. Estudio transversal a través de encuesta de opinión realizada a pacientes ingresados en medicina interna en 2 periodos: 2008 y 2010. Resultados. Se realizaron 206 encuestas (84 en 2008 y 122 en 2010), edad media 76,8 y mujeres el 51,5%. El 69,4% presentaba comorbilidad y 4,4% enfermedad terminal, sin diferencias estadísticas entre años. El 5,3% conocía qué son las IP, solo un paciente las ha realizado y al 46,1%, una vez informados, le gustaría realizarlas. No hubo diferencias entre 2008 y 2010 respecto al conocimiento y realización de las IP. En 2010 existió mayor interés por realizarlas («le gustaría realizarlas»: 52,5 vs 36,9%), aunque también en 2010 fueron menos los que creían que las IP cambiarían la actitud del médico («no cambiaría la actitud del médico»: 92,6 vs 69%, p < 0,001). Conclusiones. El conocimiento y la realización de las IP no varían significativamente en los años posteriores a su regulación (desde 2008 a 2010). En ambos años su conocimiento y realización son muy escasos (AU)

Backgrounds: Advance directives (ADs), are documents in which patients express in advance that their wishes are fulfilled when they are unable to communicate them. It is unknown whether patients admitted to internal medicine are more aware of and make ADs. Objective: To study the changes in the level of knowledge and implementation of AD among patients admitted to an internal medicine department of a hospital in Madrid since a specific regulation to implement them was introduced. Patients and methods: A survey was conducted among patients admitted to internal medicine in two periods: 2008 and 2010. Results: A total of 206 surveys were analysed (84 in 2008 and 122 in 2010). The mean age of the patients was 76.8 years, and 51.5% were women. More than two-thirds (69.4%) had a comorbidity. and 4.4% had a terminal illness, with no statistical differences between the periods. Only 5.3% knew what ADs are, 1 had implemented ADs, and 46.1%, once informed, would like to implement them. There were no differences between 2008 and 2010 as regards knowledge and implementation of AD. In 2010 there was a greater interest to implement them (would like to implement them: 52.5 vs 36.9%), although in 2010 less respondents believe that AD would change the attitude of the doctor (not change the attitude: 92.6 vs. 69%, P < .001). Conclusions: Knowledge and implementation of AD did not change significantly in the years following the regulation (from 2008-2010). In both periods, their knowledge and implementation are scarce (AU)

[Patients unable to give consent and without a power of attorney or legal guardian in the geriatric department]. / Der einwilligungsunfähige Patient ohne Bevollmächtigten oder Betreuer in der Akutgeriatrie.

BACKGROUND: The importance of powers of attorney and legal guardians for patients in hospitals who are unable to make decisions for themselves is growing. Without an authorized person in these cases, treatment and discharge are more difficult. The goal of this study was to describe the problem from the point of view of an acute geriatric department and discuss the problems with respect to duration and expense of hospitalization. In addition, an attempt was undertaken to improve cooperation with the legal authorities in order to reduce the time required to process the request for the appointment of a legal guardian. MATERIALS AND METHOD: A total of 24 consecutive patients appointed a legal guardian during their hospitalization were compared with 25 patients after the intervention. RESULTS: Of all patients treated in 2008, 2.1% needed an application for an appointed legal guardian (4.6% in 2009). These patients were more seriously ill and treated longer in the hospital compared to all patients. The intervention reduced the length of stay on average by 2.8 days. Independent risk factors for longer treatment were more seriously ill patients and later submission of the application after admittance to the hospital. For patients above the maximum length of stay, the move to a nursing home and the need of a professional legal guardian prolonged significantly the hospital treatment compared to those below the maximum length of stay. CONCLUSION: The data demonstrate that the German DRG system does not sufficiently consider the difficult management caused by patients without the ability to give consent to treatment and without a valid power of attorney. The time required until a professional legal guardian is appointed is too long for patients in a hospital. The necessity of a power of attorney has to be promoted more intensely to the public. Currently, the only two ways to minimize the problem is to identify the patients without, but needing a power of attorney as quickly as possible and to remain in close contact with the legal authorities.