Search

Purpose: To describe the demographic and clinical factors associated with the importance of religiousness and spirituality among patients with human immunodeficiency virus (HIV) infection in the United States. Methods: Longitudinal study of a nationally representative cohort of 2266 patients receiving care for HIV infection surveyed in 1996 and again in 1998. Measures included 12 items assessing religious affiliation and attendance, the importance of religion and spirituality in life, and religious and spiritual practices. Multi-item religiousness and spirituality scales were constructed. Results: Eighty percent of respondents reported a religious affiliation. Sixty-five percent affirmed that religion and 85% that spirituality was "somewhat" or "very" important in their lives. A majority indicated that they "sometimes" or "often" rely on religious or spiritual means when making decisions (72%) or confronting problems (65%). Women, nonwhites, and older patients were more religious and spiritual. Residents of regions other than the western United States reported higher religiousness. High school graduates were more religious and spiritual than those with less education. Patients who did not report one of the risk factors assessed for HIV infection had higher religiousness scores than injection drug users (IDUs). Women, nonwhites other than Hispanics, patients older than 45 years of age compared to those between 18 and 34 years of age, and more educated patients reported higher spirituality. Clinical stage was not associated with religiousness or spirituality. Conclusions: A large majority of HIV-infected patients in the United States affirm the importance of religiousness and spirituality. These findings support a comprehensive, humanistic approach to the care of HIV-infected patients. [ABSTRACT FROM AUTHOR]

Objective: To identify the desired features of end-of-life medical decision making from the perspective of elderly individuals.Design: Qualitative study using in-depth interviews and analysis from a phenomenologic perspective.Setting: A senior center and a multilevel retirement community in Los Angeles.Participants: Twenty-one elderly informants (mean age 83 years) representing a spectrum of functional status and prior experiences with end-of-life decision making.Main Results: Informants were concerned primarily with the outcomes of serious illness rather than the medical interventions that might be used, and defined treatments as desirable to the extent they could return the patient to his or her valued life activities. Advanced age was a relevant consideration in decision making, guided by concerns about personal losses and the meaning of having lived a "full life." Decision-making authority was granted both to physicians (for their technical expertise) and family members (for their concern for the patient's interests), and shifted from physician to family as the patient's prognosis for functional recovery became grim. Expressions of care, both by patients and family members, were often important contributors to end-of-life treatment decisions.Conclusions: These findings suggest that advance directives and physician-patient discussions that focus on acceptable health states and valued life activities may be better suited to patients' end-of-life care goals than those that focus on specific medical interventions, such as cardiopulmonary resuscitation. We propose a model of collaborative surrogate decision making by families and physicians that encourages physicians to assume responsibility for recommending treatment plans, including the provision or withholding of specific life-sustaining treatments, when such recommendations are consistent with patients' and families' goals for care. [ABSTRACT FROM AUTHOR]

Primary care physicians perform simple laboratory tests in clinical practice, frequently with little formal training. To determine the frequency of tests that are performed and evaluate house officer laboratory skills, we surveyed house officer attitudes and tested their ability to perform four common laboratory tests. We received 193 responses from 254 house officers at one university teaching hospital. While most perceived the need to use ward laboratories (ie, self-service laboratories located on patient care wards), 67% used them infrequently. Barriers included poor laboratory condition, inadequate time, accuracy, and infectious exposure concerns. Twenty-four percent felt they did not know or were unsure if they knew how to perform simple tests. Forty-seven house officers completed the practical examination. Most accurately reported a spun hematocrit and correctly identified white blood cell findings on a blood smear. Only 50% counted 100 cells. Urinary dipstick interpretation was generally acceptable but the microscopic examination was less accurate. Twenty-three percent failed to identify gram-negative rods on a slide with both gram-positive cocci and gram-negative rods. If physicians are to perform selected laboratory tests, these data suggest, at least in one institution, more formal training, practice, and evaluation are necessary to ensure their performance with adequate proficiency. [ABSTRACT FROM AUTHOR]

Purpose: For patients hospitalized with serious illnesses, we identified factors associated with a stated preference to forgo cardiopulmonary resuscitation (CPR), examined physician-patient communication about these issues, and determined the relationship of patients' preferences to intensity of care and survival.Patients and Methods: The study was a cross-sectional evaluation of patient preferences. The setting was five geographically diverse academic acute-care medical centers participating in the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) project. Study participants were hospitalized patients > or = 18 years of age with 1 of 9 serious illnesses who were interviewed between days 3 and 6 after qualifying for the study. Using standardized interviews, patients provided information on demographics, preferences for CPR and other treatments, quality of life, functional status, perceptions of prognosis, and whether the patient had discussed CPR preferences with his or her physician. Data abstracted from the medical record included physiologic measures, therapeutic intensity, whether CPR was provided, and whether there was a do-not-resuscitate order.Results: Of 1,995 eligible patients, 84% were interviewed (mean age 62 years, 58% men, inhospital mortality 7%, 6-month mortality 33%). Of the respondents, 28% did not want CPR. Factors associated independently with not wanting CPR included: hospital site; diagnosis; being older; being more functionally impaired; and patient perception of a worse prognosis. Only 29% of patients had discussed their preferences with their physician; 48% of those who did not want CPR reported such discussions. After adjusting for illness severity and factors associated with CPR preferences, patients not wanting CPR had lower intensity of care; similar inhospital mortality; and higher mortality at 2 and 6 months following study entry.Conclusions: The diagnosis, patients' perception of the prognosis, and hospital site were significantly associated with patients' resuscitation preferences after adjusting for patient demographics, severity of illness, and functional status. The rate of discussing CPR was low even for patients who did not want CPR. Patient preferences not to receive CPR were associated with a small decrease in intensity of care but no difference in hospital survival. [ABSTRACT FROM AUTHOR]

Context: The professional integrity of scientists is important to society as a whole and particularly to disciplines such as medicine that depend heavily on scientific advances for their progress.Objective: To characterize the professional norms of active scientists and compare them with those of individuals with institutional responsibility for the conduct of research.Design: A mailed survey consisting of 12 scenarios in 4 domains of research ethics. Respondents were asked whether an act was unethical and, if so, the degree to which they considered it unethical and to select responses and punishments for the act.Participants: A total of 924 National Science Foundation research grantees in 1993 or 1994 in molecular or cellular biology and 140 representatives from the researchers' institutions to the US Department of Health and Human Services Office of Research Integrity.Main Outcome Measures: Percentage of respondents considering an act unethical and the mean malfeasance rating on a scale of 1 to 10.Results: A total of 606 research grantees and 91 institutional representatives responded to the survey (response rate of 69% of those who could be contacted). Respondents reported a hierarchy of unethical research behaviors. The mean malfeasance rating was unrelated to the characteristics of the investigator performing the hypothetical act or to its consequences. Fabrication, falsification, and plagiarism received malfeasance ratings higher than 8.6, and virtually all thought they were unethical. Deliberately misleading statements about a paper or failure to give proper attribution received ratings between 7 and 8. Sloppiness, oversights, conflicts of interest, and failure to share were less serious still, receiving malfeasance ratings between 5 and 6. Institutional representatives proposed more and different interventions and punishments than the scientists.Conclusions: Surveyed scientists and institutional representatives had strong and similar norms of professional behavior, but differed in their approaches to an unethical act. INSET: Scenario. [ABSTRACT FROM AUTHOR]

Objective: To compare the initial diagnosis of cases presented at morning report with the final morning report diagnosis reached at discharge from the Medicine service and the diagnosis as evaluated 6 months after discharge.Design: Prospective cohort study of morning report cases.Setting: A university internal medicine residency program.Measurements: Proportion of morning report cases in which the initial morning report diagnosis differed from the final morning report diagnosis at discharge or, in cases where a firm diagnosis was not reached at discharge, the proportion for which a diagnosis was established by 6 months after discharge.Main Results: In 24% of cases, a firm morning report diagnosis was not available at discharge. For 61% of these, a diagnosis could be established by 6-month follow-up: for 36% the diagnosis differed from the final morning report diagnosis; and for 25% it was the same. Among cases where a firm final diagnosis was reached during morning report, the initial morning report diagnosis differed for 17%.Conclusions: Most patients discharged without a firm diagnosis have one established by 6 months later--often with surprising results. Postdischarge follow-up information could enhance the educational value of inpatient cases. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of human immunodeficiency virus (HIV) antibody testing and education about HIV infection on communication about sexual risk behaviors for HIV transmission.Design: Randomized, controlled trial with three arms.Setting: University student health center.Patients: Of 2196 heterosexual university students attending the student health clinic for medical care, 435 were interested in education about HIV and HIV testing and were randomly assigned to three groups. Follow-up at 6 months was done in 370 subjects (85%): 90 control subjects, 144 subjects who received education alone, and 136 subjects who received education plus HIV testing.Measurements and Results: Subjects who received HIV testing plus education questioned sexual partners about their HIV status more than subjects receiving education alone or those in the control group (56%, 42%, and 41% of subjects, respectively; P = 0.01). No consistent differences among groups in the number of sexual partners or in the use of condoms were found at follow-up.Conclusions: Heterosexual university students who received education about HIV infection plus HIV testing had increased communication with sexual partners about the risk for HIV infection after 6 months. Further reduction in risk behaviors for HIV transmission may require additional interventions in this population. [ABSTRACT FROM AUTHOR]

Background: Physicians are frequently unaware of patient preferences for end-of-life care. Identifying and exploring barriers to patient-physician communication about end-of-life issues may help guide physicians and their patients toward more effective discussions.Objective: To examine correlates and associated outcomes of patient communication and patient preferences for communication with physicians about cardiopulmonary resuscitation and prolonged mechanical ventilation.Design: Prospective cohort study.Setting: Five tertiary care hospitals.Patients: 1832 (85%) of 2162 eligible patients completed interviews.Measurements: Surveys of patient characteristics and preferences for end-of-life care; perceptions of prognosis, decision making, and quality of life; and patient preferences for communication with physicians about end-of-life decisions.Results: Fewer than one fourth (23%) of seriously ill patients had discussed preferences for cardiopulmonary resuscitation with their physicians. Of patients who had not discussed their preferences for resuscitation, 58% were not interested in doing so. Of patients who had not discussed and did not want to discuss their preferences, 25% did not want resuscitation. In multivariable analyses, patient factors independently associated with not wanting to discuss preferences for cardiopulmonary resuscitation included being of an ethnicity other than black (adjusted odds ratio [OR], 1.48 [95% CI, 1.10 to 1.99), not having an advance directive (OR, 1.35 [CI, 1.04 to 1.76]), estimating an excellent prognosis (OR, 1.72 [CI, 1.32 to 2.59]), reporting fair to excellent quality of life (OR, 1.36 [CI, 1.05 to 1.76]), and not desiring active involvement in medical decisions (OR, 1.33 [CI, 1.07 to 1.65]). Factors independently associated with wanting to discuss preferences for resuscitation but not doing so included being black (OR, 1.53 [CI, 1.11 to 2.11]) and being younger (OR, 1.14 per 10-year interval younger [CI, 1.04 to 1.25]).Conclusions: Among seriously ill hospitalized adults, communication about preferences for cardiopulmonary resuscitation is uncommon. A majority of patients who have not discussed preferences for end-of-life care do not want to do so. For patients who do not want to discuss their preferences, as well as patients with an unmet need for such discussions, failure to discuss preferences for cardiopulmonary resuscitation and mechanical ventilation may result in unwanted interventions. [ABSTRACT FROM AUTHOR]

Objective: To describe the association between hospital resource utilization and physicians' knowledge of patient preferences for cardiopulmonary resuscitation (CPR) among seriously ill hospitalized adult patients.Design: Prospective cohort study.Setting: Five U.S. academic medical center, 1989-1991.Patients: A sample of 2,636 patients with self- or surrogate interviews and matching physician interviews describing patient preferences for CPR, from a cohort of 4,301 patients with life-threatening illnesses enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).Measures: Patient, surrogate, and physician reports of preferences for resuscitation, and resource use derived from the Therapeutic Intensity Scoring System and hospital length of stay, converted into 1990 dollars.Results: Nearly one-third of the patients preferred to forego resuscitation. Of the 2,636 paired physician-patient answers, nearly one-third did not agree about preferences for resuscitation. The physicians' views of the patients' preferences and those preferences themselves were both associated with resource use. Standardized adjusted hospital resource consumption, expressed as average cost in dollars during the enrollment hospitalization, was lowest when the physician agreed with the patient preference for a do-not-resuscitate order ($20,527), and highest when the patient did not have a preference and the physician believed the patient wanted resuscitation in the case of a cardiopulmonary arrest ($34,829). Hospital resource use was intermediate when patient-physician pairs evidenced either lack of agreement or communication, or awareness of options about resuscitation.Conclusions: Both physician and patient preferences for CPR influence total hospital resource consumption. Physician misunderstanding of patient preferences to forego CPR was associated with increased use of hospital resources, and could have led to a course of care at odds with patients' expressed preferences in the event of cardiac arrest. Increasing physicians' knowledge of patient preferences, and increasing communication to help patients understand that options for medical care that include foregoing resuscitation efforts, might reduce hospital expenditures for the seriously ill. [ABSTRACT FROM AUTHOR]

Objective: To investigate the appropriateness of hospitalization as the time to elicit patients' medical care preferences, the authors evaluated the capability of seriously ill patients to participate in decision making early in hospitalization and their decision making capacity two weeks before hospital entry.Design: Cross-sectional study with retrospective evaluation of preadmission decision making capacity.Setting: Five acute care teaching hospitals.Patients: Four thousand three hundred one acutely ill hospitalized adults meeting predetermined severity of illness criteria in nine specific disease categories.Measurements: Surrogate decision makers' estimates of the prior mental capacities of patients unable to be interviewed early in hospitalization about care preferences due to intubation, coma, or cognitive impairment. Comparison of the demographics, degrees of sickness at admission, and outcomes of interviewable vs noninterviewable patients.Main Results: Forty percent of the patients were not interviewable concerning preferences. Of these, 83% could have participated in treatment decisions two weeks prior to hospitalization. The patients who were not interviewable were more acutely ill, had less chronic disease, and were more likely to die during hospitalization than the interviewable patients.Conclusions: Many acutely ill patients likely to die in the hospital lost their ability to make medical care decisions around the time of hospital admission. Preferences for care and advance directives should be discussed in the outpatient setting or very early in hospital admission. [ABSTRACT FROM AUTHOR]

Advance directives, such as the durable power of attorney for health care (DPAHC), help patients and physicians make end-of-life health care decisions. Medical education should prepare student physicians to be knowledgeable about and comfortable with discussing advance directives. The authors developed an educational module for the third-year medical school curriculum and conducted a randomized trial to evaluate in students its effect on various outcome measures regarding the DPAHC. Over a six-week period, students who received written material about the DPAHC and a two-hour seminar significantly increased knowledge about and reported increased skill, comfort, and experience with the DPAHC. [ABSTRACT FROM AUTHOR]

Background and Aims: There are guidelines for the medical management of cirrhosis and associated quality indicators (QIs), but QIs focusing on standards for palliative aspects of care are needed.Methods: We convened a 9-member, multidisciplinary expert panel and used RAND/UCLA modified Delphi methods to develop palliative care quality indicators for patients with cirrhosis. Experts were provided with a report based on a systematic review of the literature that contained evidence concerning the proposed candidate QIs. Panelists rated QIs prior to a planned meeting using a standard 9-point RAND appropriateness scale. These ratings guided discussion during a day-long phone conference meeting, and final ratings were then provided by panel members. Final QI scores were computed and QIs with a final median score of greater than or equal to 7, and no disagreement was included in the final set.Results: Among 28 candidate QIs, the panel rated 19 as valid measures of quality care. These 19 quality indicators cover care related to information and care planning (13) and supportive care (6).Conclusions: These QIs are evidence-based process measures of care that may be useful to improve the quality of palliative care. Research is needed to better understand the quality of palliative care provided to patients with cirrhosis. [ABSTRACT FROM AUTHOR]

The article cites a study which examines the correlation between patient ratings of health care and measures of technical quality of care. Patient ratings of the overall quality of care are gathered from two managed care organizations in the U.S. In conclusion, researchers revealed that patient ratings of health care do not appear to be good markers of technical quality of care.

The article presents an abstract of the article "Quality of Care Is Associated with Survival in Vulnerable Older Patients," published in the August 16, 2005 issue of the journal "Annals of Internal Medicine," vol. 143. In response to the question related to the problem, the author replied that evaluations of the quality of medical care often focus on processes of care, such as how often patients receive certain tests or treatments. Some people believe that a better way to measure quality of care would be to look at patient outcomes, such as how often they become sick enough to need hospitalization or how long they live. The author says that researchers found that the fewer quality-of-care measures that a patient's care met, the more likely a person was to die during the 3 years of follow-up.