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Patients accidentally overdosing on acetaminophen appear to have worse liver disease characteristics and die more frequently than those attempting suicide with an acetaminophen overdose. Liver disease, death rates, and alcohol consumption were compared among 21 patients accidentally overdosing with acetaminophen and 50 patients attempting suicide with the drug. A greater percentage of the patients accidentally overdosing were in a coma associated with liver disease, had evidence of liver cell death, were alcoholics, and died than those attempting suicide. Those attempting suicide had taken more acetaminophen.

The article describes the case of a 39-year-old female with human immunodeficiency virus and acquired immunodeficiency syndrome in which her ability to exercise autonomy was influenced by her cultural beliefs. Topics covered include the need for health institutions to bridge barriers to safe and effective health care, ability to communicate a choice and understand relevant information, and difficulty of surrogate decision making when the patient refuses to disclose personal health information.

The article explores the ethical considerations for nurses facing disaster. Topics covered include vulnerability of dialysis-dependent patients if not able to receive dialysis and adhere to a renal diet, advanced planning for family and personal obligations, and advance consideration to determine what lines the nurse chooses not to cross to maintain professional integrity.

The article discusses the author's views on advance directive in medical care which is a legal documentation that prevents bad deaths in the U.S. It discusses the topics within this issue including the federal law regarding advance directives, case studies from the author's clinical experience, and recommendations that will implement advance directives in practical application in the real-world clinical setting. The article mentions that advanced directives has two types of documents including living will and durable powers of attorney. It also highlights the Health-Care Decisions Act in relation to the advance directives.

The author discusses the difference between hospice and palliative care. Topics discussed include the American Nurses Association Code of Ethics, the barriers to patients obtaining hospice and palliative care, and discussions concerning desires for care and when to shift from a curative to comfort model.

Background: The prevalence and characteristics of acetaminophen-associated liver injury in hospitalized patients are not well defined. Methods: We identified patients hospitalized for excessive acetaminophen ingestion at an urban county hospital over a 40-month period (1992 to 1995) and reviewed their medical records to determine the incidence and clinical features of the ingestions and their outcomes. Results: Of the 71 patients studied, 50 were classified as having taken acetaminophen during suicide attempts and 21 as having accidentally poisoned themselves while attempting to relieve pain. The suicidal patients had ingested almost twice as much acetaminophen as those in the accidental-overdose group (median, 20 vs. 12 g; P = 0.009). Among the patients for whom data were available, 63 percent of those in the accidental-overdose group and 25 percent of those in the suicidal group were chronic alcohol abusers (P = 0.009). The patients in the accidental-overdose group more often had severe liver necrosis (aminotransferase levels, >3500 IU per liter; 52 percent vs. 14 percent; P = 0.002) and were more likely to have hepatic coma (33 percent vs. 6 percent, P = 0.006). There were four deaths (19 percent) in the accidental-overdose group and one (2 percent) in the suicidal group (P = 0.04). Five patients — three in the accidental-overdose group and two in the suicidal group — had ingested 4 g of acetaminophen or less. Acetaminophen ingestion accounted for 12 percent of all patients hospitalized with overdoses (71 of 589) and 40 percent of patients with acute liver failure (10 of 25) during the study period. Conclusions: In an urban county hospital, patients hospitalized with acetaminophen toxicity related to accidental misuse had higher rates of morbidity and mortality than those who attempted suicide, even though the latter had taken more acetaminophen. A higher frequency of chronic alcohol abuse among the patients with accidental overdoses may be one explanation. (N Engl J Med 1997;337:1112-7.) [ABSTRACT FROM AUTHOR]