Euthanasia, assisted suicide and end-of-life care: attitudes of students, residents and attending physicians

BACKGROUND: Attitudes in regard to end-of life issues are evolving in Western societies. We have sought to trace this evolution in the relatively homogeneous cultural setting of Puerto Rico. METHODS: One hundred fifty-two medical students, 62 medical residents and 84 members of three medical faculties were asked whether in terminally ill patients they: 1) would support a request for euthanasia(E); 2) if legalized, would engage in, would oppose or would not be opposed to others engaging physician-assisted suicide(PAS); 3) would consider ethical to prescribe full doses of drugs needed to alleviate pain, even if they knew it would hasten death; 4) would agree to limit certain resources for the terminally ill. Gender and religious affiliation were also requested. RESULTS: Twenty-eight percent of the students, 26of the residents and 31of the faculty supported E. Only 13of the students, 18of the residents and 11of the faculty would engage in PAS. Men were more willing than women to acquiesce to a request for E or PAS. Religious affiliation or its absence did not influence the support or opposition to E and PAS. If it would hasten death, 86of the residents, but only 65of the faculty considered ethical to prescribe the dose of drugs needed to alleviate pain. More than 2/3 of the students, residents and faculty favored the limiting of certain resources for the terminally ill. CONCLUSIONS: In our cultural and medical environment, men are more willing than women to engage in E or PAS. The attitude towards E and PAS is not influenced by religious affiliation. If it hastens death, some still consider unethical to prescribe full doses of drugs needed to alleviate pain in the dying patient.

Polymyositis: rare complication of hepatitis B vaccination. An unusual cause of toxic shock syndrome

Transient weakness of the legs developed in a 17 year-old male high school student three weeks after the initial injection of a hepatitis B vaccine. Seventeen days after the second injection of the vaccine, low-grade fever, a pruritic maculopapular rash appeared and weakness of the legs recurred. This was associated with elevation of the creatinine kinase to 2,406 U/L. The day after admission he became afebrile and in the subsequent four days the rash improved but leg weakness persisted. One-month later, muscle strength had returned; and the creatinine kinase had returned to normal levels. The only case of dermatomyositis associated with hepatitis B vaccination and the findings in the six reported cases of surface antigen-positive hepatitis associated with polyomyositis or dermatomyositis are briefly reviewed. Hepatitis B vaccination should be encouraged, but it is important to be aware that, rarely, dermatomyositis, polymyositis or neurovascular complications may occur. Polymyositis associated with the administration of the hepatitis B vaccine or with hepatitis B virus infection is a rare occurrence. A Medline Search performed from 1960 to January 2002 associating hepatitis B vaccine or hepatitis B virus with myopathy, myositis, polymyositis and dermatomyositis, showed only one case of dermatomyositis related to the hepatitis B vaccine, and six case reports relating polymyositis to hepatitis B virus infection. We present a case where a causal relationship between polymyositis and hepatitis B vaccination appears quite likely

ST. segment elevation: is it a possible infarct?

In patients with acute substernal pain seen at Emergency Departments, ST segment elevations are considered the hallmark of an acute myocardial infarct. Acute substernal pain associated with ST segment elevations is the inclusion criteria for thrombolytic therapy. However, there are other conditions, which may present with ST segment elevation in which thrombolytic therapy is not indicated. Acute pericarditis and ECG variants of normal must also be considered in the differential diagnosis. Three cases are presented that illustrate this ECG presentation. It is of paramount importance, that the Emergency Department physician who does the triage for these patients be able to identify the various causes of ST segment elevation

ST. segment elevation: is it a possible infarct?

In patients with acute substernal pain seen at Emergency Departments, ST segment elevations are considered the hallmark of an acute myocardial infarct. Acute substernal pain associated with ST segment elevations is the inclusion criteria for thrombolytic therapy. However, there are other conditions, which may present with ST segment elevation in which thrombolytic therapy is not indicated. Acute pericarditis and ECG variants of normal must also be considered in the differential diagnosis. Three cases are presented that illustrate this ECG presentation. It is of paramount importance, that the Emergency Department physician who does the triage for these patients be able to identify the various causes of ST segment elevation.

Cerebral thrombosis and vasculitis: an uncommon complication of ulcerative colitis.

Cerebral thrombotic disease is a rare and nearly always fatal complication of ulcerative colitis. It is associated with a necrotizing vasculitis. We report a fatal case with a confusing neurologic picture arising from this complication. Autopsy revealed necrosis and hemorrhages affecting both cortical grey and white matter. Microscopic examination showed thrombosis of small and medium size vessels associated with hemorrhages and a necrotizing angiitis. Ulcerations, hemorrhages, pseudopolyps, and cryptic abscesses were found in the rectosigmoid region of the colon compatible with active ulcerative colitis. A sudden neurologic deficit in a patient with ulcerative colitis should direct attention to the consideration of a cerebral thrombotic event and the possibility of an associated cerebral vasculitis. Diagnosis may be strongly suggested by MRI or arteriography, but it may require confirmation by biopsy of the brain parenchyma and leptomeninges. A hypercoagulable state has been associated with the thrombosis. Anticoagulation has yielded successful results in some patients with cerebral thrombosis but the risk of massive intracranial and gastrointestinal bleeding preclude to establish clear indications. Neurologic improvement has been obtained with the use of steroids and cyclophosphamide.

Cerebral thrombosis and vasculitis: an uncommon complication of ulcerative colitis

Cerebral thrombotic disease is a rare and nearly always fatal complication of ulcerative colitis. It is associated with a necrotizing vasculitis. We report a fatal case with a confusing neurologic picture arising from this complication. Autopsy revealed necrosis and hemorrhages affecting both cortical grey and white matter. Microscopic examination showed thrombosis of small and medium size vessels associated with hemorrhages and a necrotizing angiitis. Ulcerations, hemorrhages, pseudopolyps, and cryptic abscesses were found in the rectosigmoid region of the colon compatible with active ulcerative colitis. A sudden neurologic deficit in a patient with ulcerative colitis should direct attention to the consideration of a cerebral thrombotic event and the possibility of an associated cerebral vasculitis. Diagnosis may be strongly suggested by MRI or arteriography, but it may require confirmation by biopsy of the brain parenchyma and leptomeninges. A hypercoagulable state has been associated with the thrombosis. Anticoagulation has yielded successful results in some patients with cerebral thrombosis but the risk of massive intracranial and gastrointestinal bleeding preclude to establish clear indications. Neurologic improvement has been obtained with the use of steroids and cyclophosphamide

Clostridial sepsis: is death avoidable?

Massive intravascular hemolysis is a rare yet often fatal complication of clostridial sepsis. The only chance for survival is an early diagnosis and prompt initiation of treatment. We report a rapidly fatal case who developed electrocardiographic changes of acute myocardial injury. Autopsy showed gas-filled bubbles and cysts in the myocardium partially filled with sporulating bacilli with the morphology of clostridia. Gas filled bubbles were also present in the lungs, liver, kidneys and spleen. The gastric mucosa showed hemorrhagic and necrotizing changes, the probable site of entry of the infection

Prevalence of hepatitis C virus infection at three hemodialysis units in the western region of Puerto Rico

OBJECTIVE: In the United States hepatitis C virus infection (HCV) affects approximately 20 percent of hemodialysis patients but its prevalence in Puerto Rico has not been established. We have sought to determine the prevalence of HCV infection in a homogeneous sample of patients on hemodialysis in the western region of Puerto Rico and to identify its risks factors. METHODS: All patients in the hemodialysis units of Aguadilla, Mayagüez and San Germán, during December 1997 to March 1998, completed a written questionnaire in which they were asked about transfusions, multiple sexual partners, i.v. drugs use, tattooing, occupation, imprisonment, organ transplantation and years on hemodialysis. Serum samples were analysed for HCV antibodies by an enzyme-linked immunoadsorbent assay (ELISA). Sera with positive results for HCV were subjected to a confirmatory test by the polymerase chain reaction (PCR). RESULTS: Thirteen of the 376 (3) subjects had a positive ELISA (one patient died prior the confirmatory test with PCR). Six out of the twelve patients had a positive PCR. Two had been transfused. Three were illicit i.v. drug users and one had received a renal transplant. The liver biopsies in all patients showed chronic hepatitis and in two there was cirrhosis. CONCLUSIONS: Our prevalence was two percent. As reported elsewhere blood transfusion, organ transplantation and illicit i.v. drug abuse were the major risk factors for HCV infection in our patients. Nosocomial factors were irrelevant in the results

Clostridial sepsis: is death avoidable?

Massive intravascular hemolysis is a rare yet often fatal complication of clostridial sepsis. The only chance for survival is an early diagnosis and prompt initiation of treatment. We report a rapidly fatal case who developed electrocardiographic changes of acute myocardial injury. Autopsy showed gas-filled bubbles and cysts in the myocardium partially filled with sporulating bacilli with the morphology of clostridia. Gas filled bubbles were also present in the lungs, liver, kidneys and spleen. The gastric mucosa showed hemorrhagic and necrotizing changes, the probable site of entry of the infection.

Prevalence of hepatitis C virus infection at three hemodialysis units in the western region of Puerto Rico.

OBJECTIVE: In the United States hepatitis C virus infection (HCV) affects approximately 20 percent of hemodialysis patients but its prevalence in Puerto Rico has not been established. We have sought to determine the prevalence of HCV infection in a homogeneous sample of patients on hemodialysis in the western region of Puerto Rico and to identify its risks factors. METHODS: All patients in the hemodialysis units of Aguadilla, Mayagüez and San Germán, during December 1997 to March 1998, completed a written questionnaire in which they were asked about transfusions, multiple sexual partners, i.v. drugs use, tattooing, occupation, imprisonment, organ transplantation and years on hemodialysis. Serum samples were analysed for HCV antibodies by an enzyme-linked immunoadsorbent assay (ELISA). Sera with positive results for HCV were subjected to a confirmatory test by the polymerase chain reaction (PCR). RESULTS: Thirteen of the 376 (3%) subjects had a positive ELISA (one patient died prior the confirmatory test with PCR). Six out of the twelve patients had a positive PCR. Two had been transfused. Three were illicit i.v. drug users and one had received a renal transplant. The liver biopsies in all patients showed chronic hepatitis and in two there was cirrhosis. CONCLUSIONS: Our prevalence was two percent. As reported elsewhere blood transfusion, organ transplantation and illicit i.v. drug abuse were the major risk factors for HCV infection in our patients. Nosocomial factors were irrelevant in the results.

Cardiopulmonary resuscitation personal choices of physicians and nurses.

Nine hundred and twenty-two attending physicians, residents and graduate nurses in five hospitals were requested to state their personal preference to receive either cardiopulmonary resuscitation (CPR) or intubation and mechanical ventilation (MV) when given three estimated outcomes: 1) complete recovery, 2) important loss in mental and physical functions, c) persistent unconsciousness. They also could choose not to accept either procedure. Seventy three percent would accept CPR and 70 percent MV, only if complete recovery was likely. Thirteen percent would accept CPR and MV if important losses of function were likely. Eight percent would accept CPR and 5 percent would accept MV if recovery of consciousness was unlikely. Six percent would not accept CPR and eleven percent would not accept MV under any circumstance. Men and women differed in the choice of outcomes which made resuscitation acceptable to them (p < .001). More women than men would accept CPR and MV if complete recovery was likely and were unwilling to accept CPR or MV under any circumstance at all. Half as many women as men would accept MV if they were likely to remain unconscious. Choices also varied with age and professional training. There are large individual differences as to how physicians and nurses would like their personal cardiopulmonary arrest to be managed. Their choice is appropriately influenced by the expected outcome and seems to be influenced by the local hospital setting.