Advance directives: patient preferences in family practice.
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The author reports on six months' experience of obtaining advance directives from patients for care in a family practice. Patients were questioned about their preferences for comfort or prolonging life and then were asked to delegate a substitute decision maker. Of 20 patients, all who responded chose comfort over prolonging life. Delegated substitute decision makers included spouses, children, and professionals or friends. In this population, patients overwhelmingly favoured comfort over prolonging life in the event that they might be irreversibly disabled, and they tended to choose spouses or other first-degree relatives as substitute decision makers. (+info)
Record health care directives before terminal illness!
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Physicians share the grief and tension of families who must make decisions for incompetent, dying members. The author recorded the wishes of 1000 competent patients to guide families and the health care team during terminal illness. A questionnaire, which became part of the medical record, was used to determine views of organ donation, religious beliefs, and other directives. Patients were eager to record and discuss their wishes during an office or hospital visit; 94% of all patients wanted to participate in health care decisions. When directives for terminal care are available, families will not be forced to make blind crisis decisions for a dying member. (+info)
Artificial feeding for severely disoriented, elderly patients.
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The issue of artificial feeding for patients with dementia who refuse feeding by hand is a wrenching emotional problem that can cloud clinical judgement. It is helpful to apply an analytic approach to decision making. There are five steps: gathering a comprehensive clinical database; defining the goal of treatment; knowing the treatment options available, their burdens and potential benefits; understanding the law; and defining the moral framework in which care is being given. Such an approach can be used to formulate a plan of treatment in the best interests of incompetent elderly patients who cannot speak for themselves. (+info)
End-of-life decisions: physicians as advocates for advance directives.
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Physicians have a unique role in supporting patients and families throughout their lives; their expertise is called on not only in life, but also at its end. This study was designed to determine the effect of an individual's age, gender, and attachment to the decision maker with regard to life support choices. A total of 151 subjects completed the researcher-developed instrument. Results suggest that the age of patients is significantly related to the life support options chosen. Specifically, the greater the age of the patient, the more likely a less vigorous life support alternative was chosen. Gender and attachment had no effect on the level of care chosen. Study participants also identified reasons for selecting a particular life support choice for each case. The most common reasons given for a close relative centered around quality-of-life issues. In situations involving a nonrelative, life support decisions were likely to be made using the principle of best interest. The primary care physician has a unique opportunity to initiate discussions about life support issues with patients and families. These decisions must be framed in the context of individual patient expectations and desires throughout the life span. (+info)
Symptoms management at the end of life.
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Numerous, well-defined symptoms are associated with end of life when death is caused by a chronic or debilitating illness (or both) such as cancer, HIV/AIDS, Alzheimer's dementia, and congestive heart failure. These symptoms, if unrelieved, are distressing to both the patients and their families and preclude any possibility of relieving psychological, social, and spiritual suffering, improving quality of life, or completing life closure. Therefore, the objective of this article is to identify some common symptoms at end of life and various management strategies for each. (+info)
Ethical issues at the end of life.
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Providing good care for dying patients requires that physicians be knowledgeable of ethical issues pertinent to end-of-life care. Effective advance care planning can assure patient autonomy at the end of life even when the patient has lost decision-making capacity. Medical futility is difficult to identify in the clinical setting but may be described as an intervention that will not allow the intended goal of therapy to be achieved. Medical interventions, including artificial nutrition and hydration, can be withheld or withdrawn if this measure is consistent with the dying patient's wishes. Physicians caring for terminally ill patients receive requests for physician-assisted suicide. The physician should establish the basis for the request and work with the healthcare team to provide support and comfort for the patient. Physician-assisted suicide could negate the traditional patient-physician relationship and place vulnerable populations at risk. Physicians need to incorporate spiritual issues into the management of patients at the end of life. The integrity of the physician as a moral agent in the clinical setting needs to be recognized and honored. The physician has a moral imperative to assure good care for dying patients. (+info)
Intubating trauma patients before reaching hospital -- revisited.
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Endotracheal intubation is widely used for airway management in a prehospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome in adult patients. The benefits, in term of outcomes of invasive airway management before reaching hospital, remain controversial. However, inadequate airway management in this patient population is the primary cause of preventable mortality. An increase in intubation failures and in the rate of complications in trauma patients should induce us to improve airway management skills at the scene of trauma. If the addition of emergency physicians to a prehospital setting is to have any influence on outcome, further studies are merited. However, it has been established that sedation with rapid sequence intubation is superior in terms of success, complications and rates of intubation difficulty. Orotracheal intubation with planned neuromuscular blockade and in-line cervical alignment remains the safest and most effective method for airway control in patients who are severely injured. (+info)