Does it matter what you call it? A randomized trial of language used to describe palliative care services

INTRODUCTION

Integration of palliative care into oncology practice remains suboptimal. Misperceptions about the meaning of palliative care may negatively impact utilization.

PURPOSE

We assessed whether the term and/or description of palliative care services affected patient views.

METHODS

2x2 between-subject randomized factorial telephone survey of 169 patients with advanced cancer. Patients were randomized into one of four groups that differed by name (supportive care vs. palliative care) and description (patient-centered vs. traditional). Main outcomes (0-10 Likert scale) were patient understanding, impressions, perceived need, and intended use of services.

RESULTS

When compared to palliative care, the term supportive care was associated with better understanding (7.7 vs. 6.8; p = 0.021), more favorable impressions (8.4 vs. 7.3; p = 0.002), and higher future perceived need (8.6 vs. 7.7; p = 0.017). There was no difference in outcomes between traditional and patient-centered descriptions. In adjusted linear regression models, the term supportive care remained associated with more favorable impressions (p = 0.003) and higher future perceived need (p = 0.022) when compared to palliative care.

CONCLUSIONS

Patients with advanced cancer view the name supportive care more favorably than palliative care. Future efforts to integrate principles of palliative medicine into oncology may require changing impressions of palliative care or substituting the term supportive care.

Acute care practices relevant to quality end-of-life care: a survey of Pennsylvania hospitals

BACKGROUND

Improving end-of-life care in the hospital is a national priority.

PURPOSE

To explore the prevalence and reasons for implementation of hospital-wide and intensive care unit (ICU) practices relevant to quality care in key end-of-life care domains and to discern major structural determinants of practice implementation.

DESIGN

Cross-sectional mixed-mode survey of chief nursing officers of Pennsylvania acute care hospitals.

RESULTS

The response rate was 74% (129 of 174). The prevalence of hospital and ICU practices ranged from 95% for a hospital-wide formal code policy to 6% for regularly scheduled family meetings with an attending physician in the ICU. Most practices had less than 50% implementation; most were implemented primarily for quality improvement or to keep up with the standard of care. In a multivariable model including hospital structural characteristics, only hospital size independently predicted the presence of one or more hospital initiatives (ethics consult service, OR 6.13, adjusted p = 0.02; private conference room in the ICU for family meetings, OR 4.54, adjusted p<0.001).

CONCLUSIONS

There is low penetration of hospital practices relevant to quality end-of-life care in Pennsylvania acute care hospitals. Our results may serve to inform the development of future benchmark goals. It is critical to establish a strong evidence base for the practices most associated with improved end-of-life care outcomes and to develop quality measures for end-of-life care to complement existing hospital quality measures that primarily focus on life extension.

Sociodemographic differences in early access to liver transplantation services

The question of whether health care inequities occur before patients with end-stage liver disease (ESLD) are waitlisted for transplantation has not previously been assessed. To determine the impact of gender, race and insurance on access to transplantation, we linked Pennsylvania sources of data regarding adult patients discharged from nongovernmental hospitals from 1994 to 2001. We followed the patients through 2003 and linked information to records from five centers responsible for 95% of liver transplants in Pennsylvania during this period. Using multinomial logistic regressions, we estimated probabilities that patients would undergo transplant evaluation, transplant waitlisting and transplantation itself. Of the 144,507 patients in the study, 4361 (3.0%) underwent transplant evaluation. Of those evaluated, 3071 (70.4%) were waitlisted. Of those waitlisted, 1537 (50.0%) received a transplant. Overall, 57,020 (39.5%) died during the study period. Patients were less likely to undergo evaluation, waitlisting and transplantation if they were women, black and lacked commercial insurance (p < 0.001 each). Differences were more pronounced for early stages (evaluation and listing) than for the transplantation stage (in which national oversight and review occur). For early management and treatment decisions of patients with ESLD to be better understood, more comprehensive data concerning referral and listing practices are needed.

Hospital staff attributions of the causes of physician variation in end-of-life treatment intensity

Discrepancies between patient wishes and end-of-life treatment decisions have been documented, and the determinants of end-of-life treatment decisions are not well understood. Our objective was to understand hospital staff perceptions of the role of acute care hospital medical doctors in end-of-life treatment intensity. In 11 purposively sampled Pennsylvania hospitals, we completed 108 audiotaped semistructured interviews with key informants involved in decision making or discharge planning. Using grounded theory, we qualitatively analysed transcripts using constant comparison to identify factors affecting end-of-life treatment decisions. A predominant theme identified was that end-of-life treatment intensity depends on the doctor. Communication with patients and families and collaboration with other care team members also were reported to vary, contributing to treatment variation. Informants attributed physician variation to individual beliefs and attitudes regarding the end-of-life (religion and culture, determination of when a patient is dying, quality-of-life determination and fear of failing) and to socialization by and interaction with the healthcare system (training, role perception, experience and response to incentives). When end-of-life treatment depends on the doctor, patient and family preferences may be neglected. Targeted interventions may reduce variability and align end-of-life treatment with patient wishes.

National survey of oncology fellows on palliative care education

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Background: Palliative care (PC) is recognized as an integral part of the practice of oncology, yet many oncologists report inadequate training in critical PC domains, such as symptom management, psychosocial care and communication skills. We sought to assess the quantity and quality of PC education within oncology fellowships. Methods: Second year fellows enrolled in US oncology fellowships were invited to complete a 104 item survey that was modified from a national telephone survey of medical students and residents. Topics included: 1) quality and quantity of teaching and education, 2) observation and feedback, 3) knowledge, 4) attitudes and preparation. Items were designed to allow comparison between PC and non-PC topics. To reduce Type I errors from multiple testing, an alpha level of 0.01 was considered statistically significant. Results : Of 402 eligible fellows, 63.5% responded (n=254). Respondents were: 52% male, 62% White, 27% Asian and 64% US medical school graduates. One-quarter (26%) had completed a PC rotation and 68% reported exposure to palliative care during their fellowship. On a 5-point Likert Scale, fellows rated teaching on PC less highly than the overall quality of fellowship teaching (3.0 v 3.7; p<0.001). Fellows rated attending oncologists less favorably in performing PC skills compared to other oncology skills: managing pain in the terminally ill versus managing spinal cord compression (3.9 v. 4.5; p < 0.001); discussing the decision to stop chemotherapy versus discussing chemotherapy side effects (3.8 v. 4.2; p < 0.001). Fellows were less likely to be observed (81% v 93%; p =0.005) or receive feedback (80 v 93%; p= 0.02) on end-of-life (EOL) discussions than bone marrow biopsies. Many fellows reported not receiving explicit education on PC topics: managing depression at the EOL (68%), opioid rotation (67%), telling a patient she is dying (42%) and hospice referral (37%). Fellows who completed a PC rotation were more likely to report explicit teaching on opioid rotation (p =0.005) and hospice referral (p = 0.002). Conclusions: Our study reveals opportunities for improving the PC training of oncology fellows.

No significant financial relationships to disclose.

Palliative care training and burnout in oncology fellows

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Background: Burnout among physicians is associated with fatigue, exhaustion, and depression, and can result in increased medical errors and sub-standard patient care. We sought to determine rates and predictors of burnout in oncology fellows. Methods: As part of a larger study on fellows' attitudes, education, and experiences in palliative care, we administered the 22 item Maslach Burnout Inventory (MBI) to second year U.S. oncology fellows. The 104 item instrument, modified from a survey of medical students, was revised after field testing and a pilot survey. The MBI measures three domains: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA); higher EE and DP scores and lower PA scores indicate burnout. Bivariate and multivariate analyses were used to find associations between burnout and fellow demographics, attitudes, and educational experiences. To accommodate for multiple testing, p<0.01 was considered statistically significant. Results: The response rate was 63.2% (254 of 402 eligible fellows). Gender, race, and location of medical school (U.S. vs. other) did not differ between respondents and non-respondents. Among respondents, 28.1% reported high EE, 30.0% reported high DP, and 26.8% reported low PA. Over half reported burnout in at least one domain (32.9% in one, 16.5% in two, and 5.5% in all three domains). The following associations were found on multivariate analyses. Fellows who identified as white had higher rates of EE (p=0.0006) while EE was lower in those who: 1) rated their program's overall teaching ‘very good‘ or ‘excellent‘ (p=0.005), 2) felt prepared to address spiritual issues around end-of-life care (p=0.002), and 3) felt prepared to manage their own feelings about illness and dying (p=0.008). Fellows who identified as white (p=0.008) or reported dreading encounters with emotionally distressed family members (p=0.0002) had higher DP. The only factor associated with higher PA scores was agreement that doctors have a responsibility to help patients prepare for death (p<0.0001). Conclusions: Over half of oncology fellows experience at least one domain of burnout. Higher quality teaching within their fellowship program and higher levels of self-assessed preparation to care for patients at the end of life are associated with lower levels of burnout.

No significant financial relationships to disclose.

Symptom distress, quality of life and challenges of illness according to race and income in women with metastatic breast cancer

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Background: Response to a diagnosis of metastatic breast cancer (MBC) may vary according to race and income. The aims of this study were: 1) to identify quality of life, symptom distress and challenges of illness during MBC treatment and 2) to determine if these variables differ according to race and income. Methods: The study was a 2×2 prospective design conducted at an urban breast cancer center. Women with MBC were categorized into four groups based on race and income: white low (WL), white high (WH), African American high (AAH) and African American low (AAL). Instruments were 1) Symptom Distress Scale (SDS), (higher scores /worse distress) 2) Functional Assessment of Cancer Therapy (FACT), (higher scores/better QOL) and a 3) semi structured interview assessing patient perspectives of MBC. Interview analysis utilized grounded theory. Results: Preliminary results are for 51 women. Mean age was 58.2 years, with mean 24 months since MBC diagnosis. Quantitative data indicated worse quality of life in AA than white women. (P=0.06), with AALI women exhibiting worse symptom distress (P=0.03) as compared to white women. Qualitative data (n=48) corroborated quantitative data. The most prevalent themes among all sociodemographic groups were of hope (33/48 - 69%), faith (28/48 - 58%) and progressive loss (29/48, 60%). Each racial/economic delineation expressed unique themes: AALI talked about physical (7/7,100%)and social distress (6/7, 86%) as well as uncertainty regarding “whether treatment was worth it” (6/7 - 86%). WLI women verbalized an overall optimism, describing themselves as “lucky” (6/14 - 43%), with minimization of symptoms (10/14 - 71%). WHI women articulated a sense of betrayal at their progressive illness (9/20 - 45%) and fear of physical and economic dependence. Conclusion: Race and economic delineation brings unique symptom experience, quality of life and patient perspective to the metastatic breast cancer experience. These findings will advise tailored intervention.

[Table: see text]

No significant financial relationships to disclose.

Do incentives matter? Providing benefits to families of organ donors

Whether the number of organs available for transplant would be positively or negatively affected by providing benefits to families of organ donors has been debated by policymakers, ethicists and the transplant community at large. We designed a telephone survey to measure public opinion regarding the use of benefits in general and of five types in particular: funeral benefits, charitable contributions, travel/lodging expenses, direct payments and medical expenses. Of the 971 adults who completed the survey (response rate = 69%), all were from Pennsylvania households, 45.6% were registered organ donors, and 51.7% were nonwhite. Although 59% of respondents favored the general idea of incentives, support for specific incentives ranged from 53% (direct payment) to 84% (medical expenses). Among those registered as donors, more nonwhites than whites supported funeral benefits (88% vs. 81%; p = 0.038), direct payment (63% vs. 41%; p < 0.001) and medical expenses (92% vs. 84%; p = 0.013). Among those not registered as donors, more nonwhites supported direct payment (64% vs. 46%; p = 0.001). Most respondents believed that benefits would not influence their own behavior concerning donation but would influence the behavior of others. While benefits appear to be favored, their true impact can only be assessed through pilot programs.

Palliative care and the hospitalist: an opportunity for cross-fertilization

Most US citizens die in acute care hospitals, often in physical pain, without attention to emotional and spiritual suffering. This represents an ethical failure of our current health-care system. The field of palliative medicine aims to address the physical, emotional, and spiritual needs of patients with advanced disease. At the same time, a new specialty of hospitalists is emerging, providing care for acutely ill hospitalized patients, many of whom will die. Thus, the hospitalist may become the primary deliverer of palliative care. This presents many potential opportunities for dying patients and their families, including increased time and attention from a physician; enhanced knowledge and skills around the physical symptoms, and emotional and spiritual distress; perhaps more detached and therefore more accurate prognostication; and increased efficiency, leading to a more rapid discharge to home. Hospitalists could enhance the quality of care for the dying by emphasizing interdisciplinary communication and involvement of hospital-based health professionals to address emotional and spiritual distress and bereavement issues, as well as through specific quality-improvement efforts. Finally, hospitalists can provide strong role modeling of optimal care for dying patients and their families. When hospitalists are not selected and trained effectively around palliative care issues, the risks are great. Discontinuity of physicians can lead to miscommunication and misunderstanding (by professionals, patient, and family); disagreement about treatment focus (especially as it relates to a shift from curative to palliative); inappropriate deferring of advance care planning to the hospital setting; and, most worrisome, a lack of expertise in symptom control, communication skills, and attention to patient and family distress and the provision of emotional and spiritual support. This article evaluates the convergence of the 2 fields of palliative medicine and hospitalist medicine and reviews the opportunities for mutual education and improved patient care.

Patient satisfaction in resident and attending ambulatory care clinics

OBJECTIVE

To measure and compare patient satisfaction with care in resident and attending physician internal medicine ambulatory care clinics.

DESIGN

A cross-sectional survey using a questionnaire derived from the Visit-Specific Satisfaction Questionnaire (VSQ) and Patient Satisfaction Index (PSI) distributed from March 1998 to May 1998.

SETTING

Four clinics based at a university teaching hospital and the associated Veterans' Affairs (VA) hospital.

PARTICIPANTS

Two hundred eighty-eight patients of 76 resident and 25 attending physicians.

RESULTS

Patients of resident physicians at the university site were more likely to be African American, male, have lower socioeconomic status and have lower physical and mental health scores on the Short Form-12 than patients of university attendings. Patients of resident and attending physicians at the VA site were similar. In multivariate analyses, patients of university attending physicians were more likely to be highly satisfied than patients of university residents on the VSQ-Physician (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.6 to 7.8) and the PSI-Physician (OR, 10.1; 95% CI, 3.7 to 27.4) summary scores. Differences were not seen on the summary scores at the VA site. Two individual items displayed significant differences between residents and attendings at both sites: "personal manner (courtesy, respect, sensitivity, friendliness) of the doctor" (P <or= .03 at both sites) and "my doctor always treats me with the highest respect" (P < .001 at both sites).

CONCLUSIONS

After controlling for patient characteristics, patients of resident physicians were less satisfied than those of attending physicians, especially in regard to the doctor's personal manner and respect toward the patient. Medical education should continue to emphasize the importance of these aspects of the physician-patient encounter.

Philosophical debates about the definition of death: who cares?

Since the Harvard Committee's bold and highly successful attempt to redefine death in 1968 (Harvard Ad Hoc committee, 1968), multiple controversies have arisen. Stimulated by several factors, including the inherent conceptual weakness of the Harvard Committee's proposal, accumulated clinical experience, and the incessant push to expand the pool of potential organ donors, the lively debate about the definition of death has, for the most part, been confined to a relatively small group of academics who have created a large body of literature of which this issue of the Journal of Medicine and Philosophy is an example. Law and public policy, however, have remained essentially unaffected. This paper will briefly review the multiple controversies about defining death in an attempt to explain why they have and will remain unresolved in the academic community and have even less chance of being understood and resolved by politicians, legislators, and the general public. Considering this, we will end by suggesting the probable course of public policy and clinical practice in the decades ahead.

Factors influencing families' consent for donation of solid organs for transplantation

CONTEXT

Transplantation has become the therapy of choice for patients with organ failure. However, the low rate of consent by families of donor-eligible patients is a major limiting factor in the success of organ transplantation.

OBJECTIVE

To explore factors associated with the decision to donate among families of potential solid organ donors.

DESIGN AND SETTING

Data collection via chart reviews, telephone interviews with health care practitioners (HCPs) or organ procurement organization (OPO) staff, and face-to-face interviews with family for all donor-eligible deaths at 9 trauma hospitals in southwestern Pennsylvania and northeastern Ohio from 1994 to 1999.

PARTICIPANTS

Family members, HCPs, and OPO staff involved in the donation decision for 420 donor-eligible patients.

MAIN OUTCOME MEASURE

Factors associated with family decision to donate or not donate organs for transplantation.

RESULTS

A total of 238 of the 420 cases led to organ donation; 182 did not. Univariate analysis revealed numerous factors associated with the donation decision. Multivariable analysis of associated variables revealed that family and patient sociodemographics (ethnicity, patient's age and cause of death) and prior knowledge of the patients' wishes were significantly associated with willingness to donate (adjusted odds ratio [OR], 7.68; 95% confidence interval [CI], 6.55-9.01). Families who discussed more topics and had more conversations about organ donation were more likely to donate (adjusted OR, 5.22; 95% CI, 4.32-6.30), as were families with more contact with OPO staff (adjusted OR, 3.08; 95% CI, 2.63-3.60) and those who experienced an optimal request pattern (adjusted OR, 2.96; 95% CI, 2.58-3.40). Socioemotional and communication variables acted as intervening variables.

CONCLUSIONS

Public education is needed to modify attitudes about organ donation prior to a donation opportunity. Specific steps can be taken by HCPs and OPO staff to maximize the opportunity to persuade families to donate their relatives' organs.

The process of organ donation and its effect on consent

OBJECTIVE

To identify those factors that enhance or inhibit organ donation in order to provide data to help policy makers, hospital administrators and transplantation professionals make informed choices about how to modify the donor system and to structure 'best practice' interventions.

SUMMARY OF BACKGROUND DATA

Legislative efforts to increase donation rates have not been successful. An emphasis on process is needed to help explain this.

METHODS

The study was conducted using a stratified random sample of 23 hospitals in the Pittsburgh and Minneapolis/St Paul standard statistical metropolitan areas. Each week, the medical charts of all in-patient and emergency room patient deaths at each hospital were reviewed using a standardized review protocol to determine eligibility for organ, tissue, and cornea donation. A total of 10,681 patient charts were reviewed over a 4-yr period. Eight hundred and twenty-eight cases out of 1,723 eligible cases were selected for inclusion in the study. Data were collected on 827 of these cases. All health care providers (HCPs) who spoke with the family after the patient's death or discussed donation with the family were interviewed.

RESULTS

Of the 10,681 patient charts reviewed, 16.5% were eligible to donate either organs, tissues, or corneas, and 87.0% of donor-eligible patients' families were approached and asked to donate. Consent rates were 23.5% for corneas, 34.5% for tissues, and 46.5% for organ donation. Multiple logistic regression demonstrated that the best and strongest predictor of donation decisions was the family's initial response to the donation request, as reported by the HCP. Three initial response groups are examined and compared. Those families who expressed an initially favorable reaction were most likely to agree to donation. Furthermore, discussion patterns differed by initial reaction group, with families who expressed initial indecision about donation sharing more characteristics with families who were not favorable than those who were favorable. More detailed information was provided to the favorable families, as compared to the other two groups, concerning the effect of donation on funeral arrangements and costs. Families who were favorable were also more likely to meet with an organ procurement organization representative than were other families. The strongest predictor of a family's unfavorable response to a donation request was the belief that the patient would have been against donation. A number of other variables, including HCP attitudes, also had an impact on the family's decision to donate.

CONCLUSIONS

A number of discussion and HCP characteristics are associated with a family's willingness to consent to organ donation. Further study is needed to determine if interventions based on the characteristics identified in this study will increase consent to donation.

Consensus statement on the live organ donor

OBJECTIVE

To recommend practice guidelines for transplant physicians, primary care providers, health care planners, and all those who are concerned about the well-being of the live organ donor.

PARTICIPANTS

An executive group representing the National Kidney Foundation, and the American Societies of Transplantation, Transplant Surgeons, and Nephrology formed a steering committee of 12 members to evaluate current practices of living donor transplantation of the kidney, pancreas, liver, intestine, and lung. The steering committee subsequently assembled more than 100 representatives of the transplant community (physicians, nurses, ethicists, psychologists, lawyers, scientists, social workers, transplant recipients, and living donors) at a national conference held June 1-2, 2000, in Kansas City, Mo.

CONSENSUS PROCESS

Attendees participated in 7 assigned work groups. Three were organ specific (lung, liver, and kidney) and 4 were focused on social and ethical concerns (informed consent, donor source, psychosocial issues, and live organ donor registry). Work groups' deliberations were structured by a series of questions developed by the steering committee. Each work group presented its deliberations to an open plenary session of all attendees. This information was stored and shaped into a statement circulated electronically to all attendees for their comments, and finally approved by the steering committee for publication. The term consensus is not meant to convey universal agreement of the participants. The statement identifies issues of controversy; however, the wording of the entire statement is a consensus by approval of all attendees.

CONCLUSION

The person who gives consent to be a live organ donor should be competent, willing to donate, free from coercion, medically and psychosocially suitable, fully informed of the risks and benefits as a donor, and fully informed of the risks, benefits, and alternative treatment available to the recipient. The benefits to both donor and recipient must outweigh the risks associated with the donation and transplantation of the living donor organ.

Experts practice what they preach: A descriptive study of best and normative practices in end-of-life discussions

BACKGROUND

Advance directives (ADs) are widely regarded as the best available mechanism to ensure that patients' wishes about medical treatment at the end of life are respected. However, observational studies suggest that these discussions often fail to meet their stated goals.

OBJECTIVES

To explore best practices by describing what physicians who are considered expert in the area of end of-life bioethics or medical communication do when discussing ADs with their patients and to explore the ways in which best practices of the expert group might differ in content or style from normative practice derived from primary care physicians' discussions of ADs with their patients collected as part of an earlier study.

DESIGN

Nonexperimental, descriptive study of audiotaped discussions.

SETTING

Outpatient primary care practices in the United States.

PARTICIPANTS

Eighteen internists who have published articles in the areas of bioethics or communication and 48 of their patients. Fifty-six academic internists and 56 of their established patients in 5 practice sites in 2 locations-Durham, NC, and Pittsburgh, Pa. Eligible patients were at least 65 years old or suffered from serious medical illness and had not previously discussed ADs with their physician. Expert clinicians had discretion regarding patient selection, while the internists chose patients according to a predetermined protocol.

MEASUREMENTS

Coders applied the Roter Interaction Analysis System (RIAS) to audiotapes of the medical visits to describe communication dynamics. In addition, the audiotapes were scored on 21 items reflecting physician performance in specific skills related to AD discussions.

RESULTS

Experts spent close to twice as much time (14.7 vs 8.1 minutes, P<.001) and were less verbally dominant (P<.05) than other physicians during AD discussions. When length of visit was controlled statistically, the expert physicians gave less information about treatment procedures and biomedical issues (P<.05) and asked fewer related questions (P<. 05) but tended toward more psychosocial and lifestyle discussion and questions. Experts engaged in more partnership building (P<.05) with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion (P<.001), and more positive talk (P<.05) than patients of community physicians. Expert physicians scored higher on the 21 items reflecting AD-specific skills (P<.001).

CONCLUSIONS

Best practices as reflected in the performance of expert physicians reflect differences in measures of communication style and in specific AD-related proficiencies. Physician training in ADs must be broad enough to include both of these domains. Arch Intern Med. 2000;160:3477-3485.

Lying to each other: when internal medicine residents use deception with their colleagues

BACKGROUND

While lying is morally problematic, physicians have been known to use deception with their patients and with third parties. Little is known, however, about the use of deception between physicians.

OBJECTIVES

To determine the likelihood that resident physicians say they would deceive other physicians in various circumstances and to examine how variations in circumstances affect the likelihood of using deception.

METHODS

Two versions of a confidential survey using vignettes were randomly distributed to all internal medicine residents at 4 teaching hospitals in 1998. Survey versions differed by introducing slight variations to each vignette in ways we hypothesized would influence respondents' willingness to deceive. The likelihood that residents say they would use deception in response to each vignette was compared between versions.

RESULTS

Three hundred thirty surveys were distributed (response rate, 67%). Of those who responded, 36% indicated they were likely to use deception to avoid exchanging call, 15% would misrepresent a diagnosis in a medical record to protect patient privacy, 14% would fabricate a laboratory value to an attending physician, 6% would substitute their own urine in a drug test to protect a colleague, and 5% would lie about checking a patient's stool for blood to cover up a medical mistake. For some of the scenarios, the likelihood of deceiving was influenced by variations in the vignettes.

CONCLUSIONS

A substantial percentage of internal medicine residents report they would deceive a colleague in various circumstances, and the likelihood of using deception depends on the context. While lying about clinical issues is not common, it is troubling when it occurs at any time. Medical educators should be aware of circumstances in which residents are likely to deceive, and discuss ways to eliminate incentives to lie.

Health care ethics consultation: nature, goals, and competencies. A position paper from the Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation

Patients, families, and health care providers have a right to expect that ethics consultants can deal competently with the complex issues that they are asked to address. The Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation explored core competencies and related issues in ethics consultation. This position paper summarizes the content of the resulting Task Force Report, which included nine general conclusions: 1) U.S. societal context makes "ethics facilitation" an appropriate approach to ethics consultation; 2) ethics facilitation requires certain core competencies; 3) core competencies can be acquired in various ways; 4) individual consultants, teams, or committees should have the core competencies for ethics consultation; 5) consult services should have policies that address access, patient notification, documentation, and case review; 6) abuse of power and conflicts of interest must be avoided; 7) ethics consultation must have institutional support; 8) evaluation of process, outcomes, and competencies is needed; and 9) certification of individuals and accreditation of programs are rejected.

Observations of withdrawal of life-sustaining treatment from patients who became non-heart-beating organ donors

OBJECTIVE

Non-heart-beating organ donation for transplantation is increasing despite the concern whether all the donors are dead. This concern is based on the adequacy of documentation of death and the appropriate duration that circulation and respiration should be absent before death certification. No studies have examined the documentation and deaths of patients who became non-heart-beating organ donors.

DESIGN

Retrospective study of observational data.

PATIENTS

All non-brain-dead patients who became non-heart-beating organ donors at the University of Pittsburgh Medical Center from January 1, 1993, to June 30, 1998, were identified. Records for 15 of 16 patients were available for review.

MEASUREMENTS AND MAIN RESULTS

Adequacy of documentation, extubation time, onset of severe hypotension, duration of absent circulation before death was certified, and the time of incision for organ procurement were ascertained. Twelve of 15 records had all required clinical documentation. The mean age of patients was 46.5 +/- 5.7 yrs. All 15 patients were extubated before death and had femoral arterial catheters; one had a biventricular assist device discontinued. The time of hypotension and pulselessness was not documented for one and three patients, respectively. All 12 patients with documentation had > or =2 mins of absent circulation. Time from certification to incision for procurement was 1.1 +/- 2.3 mins.

CONCLUSIONS

In a small study of non-heart-beating organ donation, circulation never resumed after >1 min of absent circulation, suggesting that 2 mins of absent circulation is sufficient to certify death. Three of 15 patients had inadequate documentation. Gaps and inconsistencies in documentation may raise concern about the potential for abuse.

Talking to the older adult about advance directives

Discussing advance care plans with elderly patients can improve the experience of end-of-life care for patients, families, and health care teams. Specific goals for any particular discussion should be based on patients' particular clinical circumstances. Physicians should focus on patients' overall values and goals and should provide emotional support during the discussion. Decisions made during the advance care planning process should be documented.

Conflicts regarding decisions to limit treatment: a differential diagnosis

Conflicts between physicians and families about end-of-life decisions create challenging and emotionally difficult situations. In this article, we propose a "differential diagnosis" of such conflicts, distinguishing and describing the characteristics of families, physicians, and organizations and society that contribute to the "etiology" of the situation, as well as strategies for "diagnosing" the dominant factors. As a medical model, the differential diagnosis can be a useful tool to help physicians understand and manage conflicts about end-of-life care.

Two multi-center studies evaluating locally delivered doxycycline hyclate, placebo control, oral hygiene, and scaling and root planing in the treatment of periodontitis

BACKGROUND

The clinical efficacy and safety of doxycycline hyclate (8.5% w/w) delivered subgingivally in a biodegradable polymer (DH) was compared to placebo control (VC), oral hygiene (OH), and scaling and root planing (SRP) in 2 multi-center studies.

METHODS

Each study entered 411 patients who demonstrated moderate to severe periodontitis. Patients had 2 or more quadrants each with a minimum of 4 qualifying pockets > or =5 mm that bled on probing. At least 2 of the pockets were > or =7 mm. Treatment with DH, VC, OH, or SRP was provided at baseline and again at month 4. Clinical parameters were recorded monthly.

RESULTS

DH and SRP resulted in nearly identical clinical changes over time in both studies. Mean 9 month clinical attachment level gain (ALG) was 0.8 mm for the DH group and 0.7 mm for the SRP group in Study 1, and 0.8 mm (DH) and 0.9 mm (SRP) in Study 2. Mean probing depth (PD) reduction was 1.1 mm for the DH group and 0.9 mm for the SRP group in Study 1 and 1.3 mm for both groups in Study 2. Frequency distributions showed an ALG > or =2 mm in 29% of DH sites versus 27% of SRP sites in Study 1 and 31% of DH sites versus 34% of SRP sites in Study 2. PD reductions > or =2 mm were seen in 32% of DH sites versus 31% of SRP sites in Study 1 and 41% of DH sites versus 43% of SRP sites in Study 2. Comparisons between DH, VC, and OH treatment groups showed DH treatment to be statistically superior to VC and OH. Safety data demonstrated a benign safety profile with use of the DH product.

CONCLUSIONS

Results of this trial demonstrate that treatment of periodontitis with subgingivally delivered doxycycline in a biodegradable polymer is equally effective as scaling and root planing and superior in effect to placebo control and oral hygiene in reducing the clinical signs of adult periodontitis over a 9-month period. This represents positive changes resulting from the use of subgingivally applied doxycycline as scaling and root planing was not limited regarding time of the procedure or use of local anesthesia.

Commentary: a consensus about "consensus"?

Authors develop the notion of "consensus," which is at the heart of the "ethical consensus method" proposed by Martin, and the three approaches from which it is drawn.

Opening the black box: how do physicians communicate about advance directives?

BACKGROUND

The quality of communication that leads to the completion of written advance directives may influence the usefulness of these documents, but the nature of that communication remains relatively unexplored.

OBJECTIVE

To describe how physicians discuss advance directives with patients.

DESIGN

Prospective study.

SETTING

Five outpatient primary care medicine practices in Durham, North Carolina, and Pittsburgh, Pennsylvania.

PARTICIPANTS

56 attending internists and 56 of their established patients. Eligible patients were at least 65 years of age or had a serious medical illness.

MEASUREMENTS

Two raters coded transcripts of audiotaped discussions about advance directives to document how physicians introduced the topic of advance directives, discussed scenarios and treatments, provided information, elicited patient values, and identified surrogate decision makers.

RESULTS

Conversations about advance directives averaged 5.6 minutes; physicians spoke for two thirds of this time. In 91% of cases, physicians discussed dire scenarios in which most patients would not want to be treated, and 48% asked patients about their preferences in reversible scenarios. Fifty-five percent of physicians discussed scenarios involving uncertainty, typically using vague language. Patients' values were rarely explored in detail. In 88% of cases, physicians discussed surrogate decision making and documents to aid in advance care planning.

CONCLUSIONS

Although they accomplished the goal of introducing patients to advance directives, discussions infrequently dealt with patients' values and attitudes toward uncertainty. Physicians may not have addressed the topic in a way that would be of substantial use in future decision making, and these discussions did not meet the standards proposed in the literature.

Patient knowledge and physician predictions of treatment preferences after discussion of advance directives

OBJECTIVE

To determine patient knowledge about life-sustaining treatments and physician understanding of patient preferences for proxies and treatments after outpatient discussions about advance directives.

DESIGN

Cross-sectional interview-based and questionnaire-based survey.

SETTING

Two university general internal medicine practices, two Department of Veterans Affairs general internal medicine practices, and one university-based geriatrics practice, in two different cities.

PATIENTS

Fifty-six patients of primary care internists.

INTERVENTION

Physicians discussed "advance directives" (ADs) with one randomly selected patient during an outpatient visit.

MEASUREMENTS AND MAIN RESULTS

After the discussions, physicians identified the patient's proxy and predicted the patient's preferences for treatment in 20 scenarios. Patients provided treatment preferences in the 20 scenarios, the name of their preferred surrogate decision maker, and their understanding of cardiopulmonary resuscitation and mechanical ventilation. Of the 39 patients who discussed resuscitation, 43% were able to identify two important characteristics; 26% identified none; 66% did not know that most patients need mechanical ventilation after undergoing resuscitation. None of the 43 patients who had a discussion about mechanical ventilation had a good understanding of it; 67% did not know that patients generally cannot talk while on ventilators; 46% expressed serious misconceptions about ventilators. There was poor agreement between physicians and their patients regarding treatment preferences in 18 of 20 scenarios (kappa -0.04 to 0.31). Physicians correctly identified the proxy 89% of the time (kappa 0.78).

CONCLUSIONS

Patients leave routine AD discussions with serious misconceptions about life-sustaining treatments. Physicians are unable to predict treatment preferences but do learn about patients' preferences for surrogate decision makers.

Pathologic migration of anterior teeth in patients with moderate to severe periodontitis

The purpose of this study was to determine the prevalence of pathologic migration of anterior teeth in patients with moderate to severe periodontitis. The correlation between pathologic migration of anterior teeth and attachment loss (AL) was investigated, and an attempt was made to identify the most common early form of pathologic migration. Prevalence of tooth migration was studied in a group of 343 patients with moderate to severe periodontitis before treatment. The presence of pathologic migration was determined from the chief complaint and patient awareness o tooth movement in the last 5 years. Forty-four patients (age range 18 to 69; mean = 48.75) with 75 pairs of migrated and non-migrated teeth were studied further to determine if there is a correlation between severity of periodontal AL and pathologic migration. Migrated teeth were compared to control contralateral teeth that did not have migration. In addition, tooth mobility of the anterior teeth on 36 of the 44 patients was measured using the mobility meter. It was anticipated that tooth mobility would follow the same pattern as AL in relation to pathologic migration. The type and severity of displacement was recorded for each tooth affected by migration. The types of pathologic migration recorded were diastema, extrusion, rotation, facial flaring, and drifting into edentulous spaces. Pathologic migration prevalence was 30.03% +/- 2.5 (103/343 subjects). The mean AL of migrated teeth (4.79 +/- 0.28 mm) was significantly greater (P < 0.0001) than control teeth (3.21 +/- 0.18 mm). The numeric values (called PTV) of migrated teeth (17.6 +/- 1.5) were significantly greater (P < 0.0001) than control teeth (9.4 +/- 1.1). It was difficult to identify a primary form of displacement, as most patients demonstrated a combination of movements. The percentage of the 44 patients who presented with a specific type of movement was: facial flaring (90.9 +/- 4.4%), diastema (88.6 +/- 4.8%), rotation (72.7 +/- 6.8%), extrusion (68.2 +/- 7.1%), and tipping (13.6 +/- 5.2%). The results of this study confirms clinical impressions that periodontal disease destruction of the attachment apparatus plays a major role in the etiology of pathologic migration.

Pyramidal molar roots and canine-like dental morphologic features in multiple family members: a case report

We report on three cases of unusual dental morphologic characteristics with pyramidal-shaped premolars and fused molar roots occurring in two generations. The dental abnormalities were hereditary in nature with morphologic features similar to those described by others. The features described in the literature were inherited in a pattern suggestive of a polygenic system with incomplete penetrance, although autosomal dominant inheritance with variable expression was possible. The present cases are found in a fashion suggestive of an autosomal dominant inheritance pattern, but insufficient evidence is available to state this for certain. In this case report, we describe a family with the previously stated anomalies and discuss potential causes for their condition as well as their clinical relevance.

Clinical evaluation of demineralized-unicortical-ilium-strips for guided tissue regeneration

This study compared demineralized-unicortical-ilium-strips (DUIS) and an expanded polytetrafluoroethylene (ePTFE) physical barrier in combination with decalcified freeze-dried bone allograft (DFDBA) for treatment of Class II mandibular furcations. Twenty patients with adult periodontitis and at least 2 furcation invasions participated in this study. Probing depth (PD), clinical attachment level (CAL), and bone fill were measured at 6 and 12 months. Standardized radiographs were analyzed using computer assisted densitometric image analysis (CADIA). Fifteen of 20 patients completed the 12-month evaluation. At 6 months both control and test groups showed significant reductions in PD from baseline (P < 0.01). PD reduction for the ePTFE + DFDBA sites was 2.13 mm +/- 1.25, and the DUIS + DFDBA, 1.77 mm +/- 1.21. CAL at 6 months was sustained to 12 months when the net gains in CAL for ePTFE + DFDBA being 1.30 mm +/- 1.45 (P < 0.01) and for DUIS + DFDBA sites 1.13 mm +/- 1.68 (P < 0.02). The horizontal furcation PD decreased 2.87 mm +/- 1.68 (P < 0.01) in the ePTFE + DFDBA and 1.70 mm +/- 1.69 (P < 0.01) for DUIS + DFDBA sites over 12 months. The evaluation of the hard tissue response at the 12-month re-entry demonstrated a bone fill of 2.37 mm (75%) +/- 2.04 (P < 0.01) with ePTFE + DFDBA and 1.83 mm (79%) +/- 1.57 (P < 0.01) with DUIS + DFDBA. DUIS material and ePTFE showed significant improvements in clinical parameters and neither material proved to be significantly better. However, a larger sample size may have permitted us to demonstrate statistically significant differences between the materials. The positive results from the utilization of DUIS for GTR and the advantage of its bioresorbability warrant further investigation. The study found limitations in the use of CADIA for evaluation of guided tissue regeneration in furcations.

Ethical issues in organ procurement: a review for intensivists

The current state of organ procurement and the ethical issues raised by the procurement process are reviewed in this article. After an examination of the legislative framework governing organ procurement, the intensivist's role in donation is discussed, including (1) donor identification, (2) asking the family to donate, and (3) obtaining consent. Recent proposals for changing the organ procurement system are analyzed, including increasing family donation or increasing the donor pool.

The unbearable rightness of bedside rationing. Physician duties in a climate of cost containment

A local internist is in the process of ordering an intravenous pyelogram for a patient she suspects of having kidney problems, when a medical student shadowing her in clinic interrupts. The student wants to know why the physician is not ordering a low-osmolality contrast agent for the patient, having read that they are less likely to cause serious side effects than high-osmolality contrast agents. The physician realizes that the medical student is correct, but rejects the suggestion, telling the student that "low-osmolality contrast agents are the standard of care for low-risk patients."

Medical ethics education: past, present, and future

This paper examines undergraduate medical ethics education in the United States during its 25-year history. Included is a brief description of early efforts in medical ethics education and a discussion of the traditional model of ethics teaching, which emphasizes the knowledge and cognitive skills necessary for ethical decision making. The authors also discuss alternatives to the traditional model that focus more directly on students' personal values, attitudes, and behavior. Current areas of consensus in the field are then explored. Finally, the authors identify three incipient trends in medical ethics education--toward increased emphasis on everyday ethics, student ethics, and macroethics. Throughout the paper, examples of specific courses and curricula are used to illustrate the modes and trends described.

Health care professional attitudes toward donation: effect on practice and procurement

Failure to procure organs, tissues, and corneas for transplantation can be attributed to a number of factors. The existing literature is largely speculative concerning why health care professionals (HCPs) fail to approach the families of medically suitable donors and why requests for donation are not successful. This study is based on the direct examination of 1,797 HCP attitudes and knowledge about donation in conjunction with how HCPs performed when faced with a donor-eligible patient. HCP attitudes, rather than knowledge, are more important to the successful procurement of organs. The HCPs with more positive attitudes about donation and their role in the procurement process were more likely to request donation. HCPs were more successful in obtaining consent to donation when they believed that the donation process would benefit the donor family and that their efforts to procure organs would be successful. These results indicate that educating HCPs about the donation process to make them more comfortable with it is crucial.

Elevator talk: observational study of inappropriate comments in a public space

OBJECTIVES

We conducted a study to determine the type and frequency of inappropriate comments made by hospital employees while riding hospital elevators.

METHODS

Four observers rode in elevators at five hospitals, listening for any comments made by hospital employees that might be deemed inappropriate. All potentially inappropriate comments were reviewed by the research team and were classified as inappropriate if they met at least one of the following criteria: violated patient confidentiality, raised concerns about the speaker's ability or desire to provide high-quality patient care, raised concerns about poor quality of care in the hospital (by persons other than the speaker), or contained derogatory remarks about patients or their families.

RESULTS

We observed 259 one-way elevator trips offering opportunity for conversation. We overheard a total of 39 inappropriate comments, which took place on 36 rides (13.9% of the trips). The most frequent comments (18) were violations of patients confidentiality. Next most frequent (10 comments) were unprofessional remarks in which clinicians talked about themselves in ways that raised questions about their ability or desire to provide high-quality patient care. Other comments included derogatory statements about the general quality of hospital care (8) and derogatory remarks about patients (5). Physicians were involved in 15 of the comments, nurses in 10, and other hospital employees in the remainder.

CONCLUSION

Inappropriate comments took place with disturbing frequency in the elevator rides we sampled. These comments did not exclusively involve violations of patient confidentiality, but encompassed a range of discussions that health care employees must be careful to avoid.

Public policy governing organ and tissue procurement in the United States. Results from the National Organ and Tissue Procurement Study

OBJECTIVE

To determine why Required Request policies, which mandate that hospitals request donation from donor-eligible families, have not resulted in increased organ procurement.

SETTING

Stratified sample of 23 acute-care general hospitals in two metropolitan areas.

DESIGN

Chart review identified all eligible donors in study hospitals during a 20-month period. Health care professionals who spoke with the families of eligible donors after death were interviewed to determine families' and health care providers' behaviors after patients' deaths with reference to the donation process.

PARTICIPANTS

All patient deaths (n = 10,681) were reviewed, and 841 donor-eligible cases were chosen for in-depth study; 1809 health care professionals who provided care to these patients were interviewed.

MEASUREMENTS

The ability of health care providers to identify donor-eligible patients, approach families about donation, and obtain families' consent to donation.

RESULTS

83% of health care professionals correctly identified donor-eligible patients. The families of donor-eligible patients were approached about donation in 73.0% of the cases. Families were more likely to be approached about organ (86.6%) donation than either tissue (69.5%) or cornea (67.3%) donation (P < 0.001). The families of organ-eligible patients were less likely to be approached if the patient was female, was on a general medical or surgical floor, or was being cared for by internists. Only 46.5% of families of eligible donors agreed to donate organs, 34.5% agreed to donate tissues, and 23.5% agreed to donate corneas.

CONCLUSIONS

Although health care professionals do request that families donate, families consent to donation less frequently than was previously assumed. Empirically based education campaigns are needed so that health care professionals can improve their communication skills and so that discussion about this important issue can be stimulated among family members.

Should competent patients or their families be notified before HECs review the patients' cases? Yes

In summary, it is, I believe, fairly uncontroversial that a patient always should be notified before a bioethics committee reviews the case. Respect for a patient"s confidentiality and autonomy also require that patients be asked prior to being interviewed or identifying the patient's name in a committee meeting. Permission is not required for an anonymous discussion of the case with a bioethics committee.