ISSN:1096-6218    

DOI:10.1089/jpm.2000.3.1

出版商:Mary Ann Liebert, Inc.    

年代:2000

数据来源: MAL

ISSN:1096-6218    

DOI:10.1089/jpm.2000.3.5

出版商:Mary Ann Liebert, Inc.    

年代:2000

数据来源: MAL

摘要:

Teaching medical students to respond to needs of the dying represents an important challenge for medical educators. This article describes the goals and objectives that should beidentified before medical schools can meet this challenge, as well as strategies that, when implemented, will provide students with the necessary knowledge, skills, and attitudes to meetthe needs of the dying patients. The goals and objectives were identified through a modified group consensus process developed during Choice In Dying's 5-year project "Integrating Educationon Care of the Dying into Medical Schools." The authors have diverse experiences and backgrounds and are actively involved in death and dying teaching at 11 medical schools.They conclude that after accepting the goals and objectives, key medical school faculty can work cooperatively to develop strategies to integrate them into the school's curriculum. Without first establishing a set of goals and objectives and developing evaluation methods, medicalschools could miss their mark in fostering the student's ability to care for the dying.

ISSN:1096-6218    

DOI:10.1089/jpm.2000.3.7

出版商:Mary Ann Liebert, Inc.    

年代:2000

数据来源: MAL

ISSN:1096-6218    

DOI:10.1089/jpm.2000.3.17

出版商:Mary Ann Liebert, Inc.    

年代:2000

数据来源: MAL

ISSN:1096-6218    

DOI:10.1089/jpm.2000.3.23

出版商:Mary Ann Liebert, Inc.    

年代:2000

数据来源: MAL

摘要:

Purpose:To determine the frequency of advance care planning (ACP) in hospitalized cancer patients and to assess their reactions to a proposed policy in which medical housestaff would offer to discuss ACP at the time of hospital admission.Methods:Structured interviews with 111 consecutively admitted cancer patients on the oncology inpatient service of a tertiary care medical center.Results:We found that 69% (77/111) of patients had discussed their advance care preferences with someone, usually a family member, and 33% (37/111) had completed at least one formal advance directive (e.g., a living will or durable power of attorney for health care); 32%(36/111) had done both; and 30% (33/111) had done neither. However, only 9% (10/111) of patients reported having discussed their advance care preferences with their clinic oncologistsand only 23% (23/101) of the remaining patients stated that they wished to do so. By contrast, 58% (64/110) of patients supported a policy in which medical housestaff would offer to discussthese advance care preferences as a part of the admission history.Conclusions:Our data suggest that while oncology inpatients frequently have ACPs that they discuss with family and/or document in formal advance directives, they rarely discussor wish to discuss these ACPs with clinic oncologists. We also show that most of the reticent patients would nevertheless consider discussing the same ACPs with admitting housestaffon the day of hospital admission.

ISSN:1096-6218    

DOI:10.1089/jpm.2000.3.27

出版商:Mary Ann Liebert, Inc.    

年代:2000

数据来源: MAL

摘要:

Background:Surrogates and clinicians often make treatment decisions for decisionally incapacitated patients with limited knowledge of their preferences. This study examined patients' life-sustaining treatment preferences to facilitate advance care planning discussions and surrogatedecision making.Methods:We interviewed 342 participants from 7 groups: younger and older well adults; persons with chronic illness, terminal cancer, and acquired immunodeficiency syndrome(AIDS); stroke survivors; and nursing home residents. Preferences for antibiotics, short- and long-term mechanical ventilation, hemodialysis, tube feeding, and cardiopulmonary resuscitation(CPR) were elicited for each participant's current health state and three hypothetical health states representing severe dementia, coma, and severe stroke.Results:Participants chose to forego more invasive or long-term treatments at a higher rate than less invasive, short-term treatments in all health states. Participants were much morewilling to forego treatments in coma than in their current health state, with stroke and dementia somewhere in between. Participants who were older, female, had worse functionalstatus, had more depressive symptoms, or lived in a nursing home were more inclined to forego treatment in their current health state. In contrast, treatment preferences in hypotheticalhealth states showed either no associations or much weaker associations with these factors.Participants who were willing to accept more invasive treatments were highly likely to accept less invasive treatments and participants who preferred to forego a less invasive treatmentwere highly likely to forego more invasive treatments. Participants who preferred to receive a treatment in a health state with severe impairments were highly likely to want thesame treatment in a less impaired health state. Similarly, participants who preferred to forego a treatment in a less impaired health state were highly likely to forego the same treatment ina more impaired state.Conclusions:In advance care planning discussions, clinicians might explore with patients their preferences about short- and long-term treatments with variability in their invasiveness (including CPR) in both their current health state and hypothetical situations representing different levels of functional impairment. When surrogates have no knowledge about the wishes of formerly competent patients, clinicians may help them with medical decisions by discussing what other people commonly want in similar circumstances.

ISSN:1096-6218    

DOI:10.1089/jpm.2000.3.37

出版商:Mary Ann Liebert, Inc.    

年代:2000

数据来源: MAL

摘要:

Background:Constipation is a frequent and underdiagnosed complication in patients with advanced cancer. Constipation in this population is multifactorial, but the use of opioids is one of the main causes. The purpose of this retrospective study was to establish the associationbetween opioid type and laxative dose, as well as the contribution of other clinical factors in advanced cancer patients admitted to a palliative care unit.Methods:The records of consecutive patients admitted to the Acute Palliative Care Unit at the Grey Nuns Hospital between December 1995 and January 1997 were reviewed. Criteria ofeligibility were the presence of cancer pain treated by opioids (oral and subcutaneous morphine and hydromorphone, oral methadone), oral laxative treatment capable of achieving atleast one bowel movement every 3 days, and the absence of bowel obstruction or colostomy. During period(s) of stable analgesic doses, the charts were reviewed for demographic andclinical characteristics, average number of bowel movements, daily laxative doses, doses and type of opioid, laxative/opioid dose ratio (LOR) (calculated by dividing the total laxative doseby the total opioid dose), functional and cognitive status, food intake, and level of calcium, albumin, and potassium.Results:Forty-nine evaluable patients were identified. The LOR in patients receiving oral opioids was 0.150.19 vs. 0.180.17 in patients on parenteral opioids (p>0.2). The LOR in patients receiving methadone was 0.0250.027 as compared to 0.240.23 in patients receiving morphine and 0.170.13 in patients on hydromorphone (p<0.0001). We found a strong association between LOR and abdominal involvement (p<0.0006), opioid type (p<0.0001), age (p<0.0001), and female gender (p<0.034). There were no significant correlation between LOR and functional status, cognitive status, food intake, and level of calcium or potassium.Conclusion:We conclude that laxative dose needs to be titrated on an individualized basis. The LOR is lower in patients receiving methadone and in those of male gender, younger age,and absence of abdominal involvement.

ISSN:1096-6218    

DOI:10.1089/jpm.2000.3.49

出版商:Mary Ann Liebert, Inc.    

年代:2000

数据来源: MAL

摘要:

While the majority of end-stage renal disease (ESRD) patients on dialysis lead satisfying lives, an increasing number are choosing to withdraw from dialysis before death. A partnership betweennephrology and palliative care/hospice healthcare teams would seem likely in the care of ESRD patients, yet this is often not the case. In anticipation of increasing participation bypalliative care/hospice teams in the care of such patients, this article reviews the decision-making process of withdrawal and the medical care of the patient who withdraws. Whilewithdrawal can be an acceptable choice from a medical, legal, psychiatric, and ethical point of view, it can nonetheless be complex. Profound decisions are often characterized by theneed for time to process, and by ambivalence among patient, family and healthcare providers. In addition to caring for the patient and family, the palliative care/hospice team will want toconsider the needs of the referring nephrology team as well. A "uremic death" is characterized as painless; however, other symptoms related to the accumulation of toxins and fluidcan be anticipated and managed. Pharmacological intervention of uremic symptoms, as well as the pain attendant to other, nonrenal comorbid disease is accomplished with awareness ofthe impact of renal failure on the excretion of various drugs and their metabolites.

ISSN:1096-6218    

DOI:10.1089/jpm.2000.3.57

出版商:Mary Ann Liebert, Inc.    

年代:2000

数据来源: MAL

摘要:

Good care for dying patients has always been an obligation in medicine. To fulfill this obligation, physicians must embrace the integralness of dying in life, must recognize when tosubmit to death and dying with equanimity, and must develop attentive and individualized plans of care for each patient. Approaches to care should have, at their core, a reinvigoratedcommitment to communication between health professionals and patients and their intimates.

ISSN:1096-6218    

DOI:10.1089/jpm.2000.3.69

出版商:Mary Ann Liebert, Inc.    

年代:2000

数据来源: MAL