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Geriatric suicide and physician assisted suicide are important problems facing geriatric psychiatrists. Suicide in elderly populations is a major and growing concern, with those 85 and older having the highest rate of suicide among adults. As geriatric psychiatrists, we endeavor to understand why this is happening and provide essential services for prevention and treatment. Physician-assisted suicide occurs when a physician facilitates a patient's death by providing the necessary means and/or information to enable the patient to perform the life-ending act. There is growing public support for physician-assisted suicide, which is legal and increasingly common in other countries including the Netherlands, Belgium and Canada. However, most professional organizations in the USA maintain that allowing physicians to engage in assisted suicide would cause more harm than good, being incompatible with the physician's role as healer, and difficult or impossible to control. This session will highlight current issues related to geriatric suicide and physician assisted suicide. Dr. Karen Reimers will introduce the topic and speakers. Dr. Michael Redinger will provide an ethical and moral framework for these questions. Dr. Sherif Soliman will review the suicide of an older individual, Martin Manley, and discuss psychological changes of aging and coping with illness. Dr. Mark Komrad will discuss physician-assisted suicide, including special considerations for geriatric psychiatry and the slippery slope of extending it to those with non-terminal conditions. Dr. Maria Lapid will give an overview of the basics of hospice and palliative care, to put "end of life' into context, and to clearly distinguish it from any medically-assisted suicide. Dr. Melanie Gentry will serve as discussant. All speakers will highlight key directions for future advocacy efforts in prevention of geriatric suicide and physician assisted suicide, and what AAGP and other professional organizations can do to and promote quality geriatric mental health services in the future. Robust discussion and audience participation will be encouraged.

We used a computer data bank to evaluate 740 consecutive patients admitted to a cardiac care unit with myocardial infarction. Stroke occurred in 18 (2.4%) patients in the hospital; the anterior circulation was involved in 76% of strokes. Hospital mortality was 61% in patients with stroke and 13% in patients without stroke. Atrial arrhythmia was a significant (p less than or equal to 0.03) risk factor for stroke, but peak creatine kinase and ventricular arrhythmia were not. Cardiac pump failure, apical or anterior-lateral myocardial infarction, and history of previous stroke were associated with an increased risk of stroke. Clinical and pathologic data suggested an embolic etiology for most strokes that complicate acute myocardial infarction.

All illness represents a state of diminished autonomy and therefore the doctor-patient relationship necessarily and justifiably involves a degree of medical paternalism argues the author, an American medical student. In a broad-ranging paper he discusses the concepts of autonomy and paternalism in the context of the doctor-patient relationship. Given the necessary diminution of autonomy which illness inflicts, a limited form of medical paternalism, aimed at restoring or maximising the patient's autonomy is entirely acceptable, and indeed fundamental to the relationship he argues. However, the exercise of this paternalism should be flexible and related to the current 'level of autonomy' of the patient himself. An editorial in this issue comments briefly on this paper.After reviewing philosophical interpretations of autonomy and paternalism, the author considers these principles in the context of the physician-patient relationship. He concludes that, since illness entails a state of diminished autonomy, a limited form of medical paternalism--aimed at maximizing the patient's autonomy--is justified.

To the Editor.— I found Dr Berlin's article entitled "Attachment Behavior in Hospitalized Patients" 1 thought provoking. For the past three years, I have been the resident on call in a teaching hospital on the night of June 30th. These nights have taught me a lot about attachment behavior, in both patients and the medical staff. On July 1, there is more discontinuity of care than at any other time during the academic year. The patients understand that this night is different from others, as all of their usual physicians are "off service." In their minds, and mine, I am truly their physician until morning. On this night, patients extract intensity from our relationship to make up for what it lacks in duration. One night, I sat up for hours with a young patient who had started to grieve for the first time over her diagnosis of osteosarcoma, which had

To the Editor. — "Destigmatizing Mental Illness" is the year's theme for the American Psychiatric Association, proclaimed by its president, Paul J. Fink, MD. The effort to divest psychiatric and emotional disorders of sensationalism and to make psychiatric treatments comparable with other medical therapies is an important one for our patients and the medical profession at large. There is no better place to begin than in our own house. For the last year, I have been seeing a professional for marriage counseling. This has been a most valuable and significant endeavor. It has promoted my sense of well-being and cognitive sharpness as much, if not more, than exercise, weight loss, stress management, and other treatments prescribed by physicians for their essentially well and functional patients who wish an added measure of vigor and sophistication about their physical and emotional functioning. I was incredulous when I applied to the American Medical