(1/122) Legalized physician-assisted suicide in Oregon--the first year's experience.

BACKGROUND AND METHODS: On October 27, 1997, Oregon legalized physician-assisted suicide. We collected data on all terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. The data were obtained from physicians' reports, death certificates, and interviews with physicians. We compared persons who took lethal medications prescribed under the act with those who died from similar illnesses but did not receive prescriptions for lethal medications. RESULTS: Information on 23 persons who received prescriptions for lethal medications was reported to the Oregon Health Division; 15 died after taking the lethal medications, 6 died from underlying illnesses, and 2 were alive as of January 1, 1999. The median age of the 15 patients who died after taking lethal medications was 69 years; 8 were male, and all 15 were white. Thirteen of the 15 patients had cancer. The case patients and controls were similar with regard to sex, race, urban or rural residence, level of education, health insurance coverage, and hospice enrollment. No case patients or controls expressed concern about the financial impact of their illness. One case patient and 15 controls expressed concern about inadequate control of pain (P=0.10). The case patients were more likely than the controls to have never married (P=0.04) and were more likely to be concerned about loss of autonomy due to illness (P=0.01) and loss of control of bodily functions (P=0.02). At death, 21 percent of the case patients and 84 percent of the controls were completely disabled (P<0.001). CONCLUSIONS: During the first year of legalized physician-assisted suicide in Oregon, the decision to request and use a prescription for lethal medication was associated with concern about loss of autonomy or control of bodily functions, not with fear of intractable pain or concern about financial loss. In addition, we found that the choice of physician-assisted suicide was not associated with level of education or health insurance coverage.  (+info)

(2/122) Patient removals from general practitioner lists in Northern Ireland: 1987-1996.

BACKGROUND: Being struck off a general practitioner's list is a major event for patients and a subject for much media attention. However, it has not hitherto received much research attention. AIMS: To quantify the numbers of patients removed at doctors' request in Northern Ireland between 1987 and 1996. To describe the characteristics of those removed and to determine if the rate of removal has increased. METHODS: This is a descriptive epidemiological study involving a secondary data analysis of records held by the Central Services Agency. RESULTS: Six thousand five hundred and seventy-eight new patients were removed at general practitioner (GP) request between 1987 and 1996. This equated to 3920 removal decisions, a rate of 2.43 per 10,000 person-years. The very young and young adults had the highest rates of removal; most of the young being removed as part of a family. Ten point six per cent of removed patients had a repeat removal, and 16.3% of first removal decisions required an assignment to another practice. Family removals have decreased and individual removals have increased over the 10 years. Disadvantaged and densely populated areas with high population turnover were associated with higher rates of removal, though heterogeneity is evident between general practitioners serving similar areas. Compared to the period 1987 to 1991, removal rates for the years 1992 to 1993 were reduced by 20.0% (95% confidence interval (CI) for rate ratio (RR) 0.73-0.87), and those for the years 1994 to 1996 increased by 8% (95% CI = 1.01-1.16). The greatest increase was in the over-75 years age group (standardized RR = 1.60; 95% CI = 1.57-1.62). CONCLUSIONS: Removals are relatively rare events for both patients and practices, though they have been increasing in recent years. Further research is needed to understand the processes that culminate in a removal.  (+info)

(3/122) Issues of medical necessity: a medical director's guide to good faith adjudication.

The term medical necessity is difficult to define, a problem for insurers who need to clearly describe what is and is not covered in their contracts with subscribers. An unclear, vague definition of medical necessity leaves insurers vulnerable to litigation by subscribers denied care deemed medically unnecessary. To avoid lawsuits, insurers must make every effort to educate their subscribers about their medical coverage, going beyond merely providing a lengthy subscriber handbook. In decisions on medical necessity, medical directors at insurance companies play a key role. They can bolster the insurer's position in denial-of-care cases in numerous ways, including keeping meticulous records, eliminating unreasonable financial incentives, maintaining a claims denial database, and consulting with other insurers to achieve a consensus on medical necessity.  (+info)

(4/122) Factors associated with refusal to treat HIV-infected patients: the results of a national survey of dentists in Canada.

OBJECTIVES: This study investigated dentists refusal to treat patients who have HIV. METHODS: A survey was mailed to a random sample of all licensed dentists in Canada, with 3 follow-up attempts (n = 6444). Data were weighted to allow for probability of selection and nonresponse and analyzed with Pearson's chi 2 and multiple logistic regression. RESULTS: The response rate was 66%. Of the respondents, 32% had knowingly treated HIV-infected patients in the last year; 16% would refuse to treat HIV-infected patients. Respondents reported willingness to treat HIV-infected patients (81%), injection drug users (86%), hepatitis B virus-infected patients (87%), homosexual and bisexual persons (94%), individuals with sexually transmitted disease(s) (94%), and recipients of blood and blood products (97%). The best predictors of refusal to treat patients with HIV were lack of ethical responsibility (odds ratio = 9.0) and items related to fear of cross-infection or lack of knowledge of HIV. CONCLUSIONS: One in 6 dentists reported refusal to treat HIV-infected patients, which was associated primarily with respondents' lack of belief in an ethical responsibility to treat patients with HIV and fears related to cross-infection. These results have implications for undergraduate, postgraduate, and continuing education.  (+info)

(5/122) Unwelcome customers? The epidemiology of removal from general practitioner lists in Sheffield.

BACKGROUND: The 1990 contract and the 1991 fundholding scheme encouraged speculation that general practitioners (GPs) may remove patients from their lists for financial reasons. Despite assertions that patient removals are increasing, little evidence exists on the number or trends in removals. AIM: To describe the epidemiology of removals by time, place, and person, and to determine whether removals have increased in recent years. METHOD: Descriptive analysis of routine data relating to all removals of Sheffield residents from GP lists during 1991-1996. RESULTS: Removal from a doctor's list was a rare event (2.4 per 1000 patients per year) that did not become more common over the period examined. Removal rates varied by age, sex, and practice, with relatively high rates among children, young women, and the over-75s. There was a significant tendency for higher removal rates in more deprived parts of the city. CONCLUSION: Removal rates have not increased in Sheffield. The reasons for the variation in rates by age, sex, and practice are unknown. The higher rates noted in the under-fives and young women are consistent with the possibility that the 1990 target payment scheme may have increased removal rates in these age groups.  (+info)

(6/122) The effect of changing attitudes to Down's syndrome in the management of complete atrioventricular septal defects.

OBJECTIVES: To describe the evaluation, decision making, and care of children with a complete atrioventricular septal defect (CAVSD). STUDY DESIGN: Retrospective study of 136 consecutive cases from 1970 to 1996. RESULTS: A total of 115 (85%) children had Down's syndrome. Denial of surgery without obvious medical reasons was more common in the early years, as was parental refusal of offered surgery and institutional care of the children. Improved results in later years encouraged surgical treatment for all these patients, but more liberal attitudes towards patients with Down's syndrome preceded the improved results. The use of echocardiography as a screening method for all newborns with Down's syndrome made it possible to plan for correction within the 1st months of life. CONCLUSIONS: Changing attitudes in society and widespread use of echocardiography have significantly improved the management of children with a CAVSD and Down's syndrome.  (+info)

(7/122) Legal and ethical aspects of the vegetative state.

The diagnosis of persistent or permanent vegetative state (PVS) raises ethical and legal problems. Strict adherence to the doctrine of the sanctity of life would require carers to continue to maintain the individual, perhaps for many years. However, few would regard this as an appropriate outcome when the person clearly has no capacity to interact with the environment and has no likelihood of recovery. However, the ethical and legal commitment to the sanctity of life has led courts to employ a variety of approaches to this situation in order to find a way in which the person in PVS can be allowed to die. It is argued that each of the approaches is disingenuous and ultimately unhelpful. What the law is doing is endorsing non-voluntary euthanasia, but dressing it up as something else. This is unhelpful for all concerned and the time has come for a review of all end of life decisions so that doctors, patients, and relatives can make honest decisions without fear of legal reprisal.  (+info)

(8/122) The struck-off mystery.

Observations on ward rounds suggested that psychiatric patients might be at special risk of removal from their general practitioner's list. Little has been published on why patients are struck off and our first attempt at investigation was by direct appeals for patients. This drew a small and unsatisfactory sample. We then asked two family health services authorities to distribute questionnaires to struck-off patients. One agreed, but later withdrew cooperation. There is a danger that struck-off patients will become an underclass excluded from primary care. We propose anonymous collection of information by health authorities, so that policy can be reviewed if necessary.  (+info)