Bernard Lo

The physician's responsibility toward hopelessly ill patients. A second look.

Physicians have a specific responsibility toward patients who are hopelessly ill, dying, or in the end stages of an incurable disease. In a summary of current practices affecting the care of dying patients, we give particular emphasis to changes that have become commonplace since the early 1980s. Implementation of accepted policies has been deficient in certain areas, including the initiation of timely discussions with patients about dying, the solicitation and execution in advance of their directives for terminal care, the education of medical students and residents, and the formulation of institutional guidelines. The appropriate and, if necessary, aggressive use of pain-relieving substances is recommended, even when such use may result in shortened life. We emphasize the value of a sensitive approach to care--one that is adjusted continually to suit the changing needs of the patient as death approaches. Possible settings for death are reviewed, including the home, the hospital, the intensive care unit, and the nursing home. Finally, we consider the physicians response to the dying patient who is rational and desires suicide or euthanasia.

To tell the truth: ethical and practical issues in disclosing medical mistakes to patients.

While moonlighting in an emergency room, a resident physician evaluated a 35-year-old woman who was 6 months pregnant and complaining of a headache. The physician diagnosed a “mixed tension/sinus headache.” The patient returned to the ER 3 days later with an intracerebral bleed, presumably related to eclampsia, and died.

Discussing palliative care with patients

In addition to addressing the physical suffering of dying patients, physicians can extend their caring by acknowledging and exploring psychosocial, existential, or spiritual suffering. As patients ...

How do medical residents discuss resuscitation with patients

OBJECTIVE: To describe how medical residents discuss do-not-resuscitate (DNR) orders with patients.DESIGN: Prospective observational study.SETTING: Inpatient medical wards of one university tertiary care center, one urban city public hospital, and one Veterans Affairs medical center.PARTICIPANTS: Thirty-one medical residents self-selected 31 of their English-speaking, competent patients, with whom they had DNR discussions.MEASUREMENTS: Three independent observers rated audiotaped discussions about DNR orders between the medical residents and their patients. Ratings assessed whether the physicians met standard criteria for requesting informed consent (e.g., disclosed the nature, benefits, risks, and outcomes), addressed the patients’ values, and attended to the patients’ emotional concerns.MAIN RESULTS: The physicians often did not provide essential information about cardiopulmonary resuscitation (CPR). While all the physicians mentioned mechanical ventilation, only 55% mentioned chest compressions and 32% mentioned intensive care. Only 13% of the physicians mentioned the patient’s likelihood of survival after CPR, and no physician used a numerical estimate. The discussions lasted a median of 10 minutes and were dominated in speaking time by the physicians. The physicians initiated discussions about the patients’ personal values and goals of care in 10% of the cases, and missed opportunities to do so.CONCLUSIONS: Medical ethicists, professional societies, and the public recommend more frequent discussions about DNR orders. Even when housestaff discuss resuscitation with patients, they may not be accomplishing the goal of increasing patient autonomy. Research and education must focus on improving the quality, as well as the quantity, of these discussions.

Patient-Centered Communication: Do Patients Really Prefer It?

OBJECTIVE: To investigate patient preferences for a patient-centered or a biomedical communication style.DESIGN: Randomized study.SETTING: Urgent care and ambulatory medicine clinics in an academic medical center.PARTICIPANTS: We recruited 250 English-speaking adult patients, excluding patients whose medical illnesses prevented evaluation of the study intervention.INTERVENTION: Participants watched one of three videotaped scenarios of simulated patient-physician discussions of complementary and alternative medicine (CAM). Each participant watched two versions of the scenario (biomedical vs. patient-centered communication style) and completed written and oral questionnaires to assess outcome measurements.MEASUREMENTS AND MAIN RESULTS: Main outcome measures were 1) preferences for a patient-centered versus a biomedical communication style; and 2) predictors of communication style preference. Participants who preferred the patient-centered style (69%; 95% confidence interval [CI], 63 to 75) tended to be younger (82% [51/62] for age < 30; 68% [100/148] for ages 30–59; 55% [21/38] for age > 59; P<.03), more educated (76% [54/71] for postcollege education; 73% [94/128] for some college; 49% [23/47] for high school only; P=.003), use CAM (75% [140/188] vs. 55% [33/60] for non-users; P=.006), and have a patient-centered physician (88% [74/84] vs. 30% [16/54] for those with a biomedical physician; P<.0001). On multivariate analysis, factors independently associated with preferring the patient-centered style included younger age, use of herbal CAM, having a patient-centered physician, and rating a “doctor’s interest in you as a person” as “very important.”CONCLUSIONS: Given that a significant proportion of patients prefer a biomedical communication style, practicing physicians and medical educators should strive for flexible approaches to physician-patient communication.

New ISSCR Guidelines Underscore Major Principles for Responsible Translational Stem Cell Research

The International Society for Stem Cell Research (ISSCR) task force that developed new Guidelines for the Clinical Translation of Stem Cells discusses core principles that should guide the responsible transition of basic stem cell research into appropriate clinical applications.

Do house officers learn from their mistakes

Mistakes are inevitable in medicine. To learn how medical mistakes relate to subsequent changes in practice, we surveyed 254 internal medicine house officers. One hundred and fourteen house officers (45%) completed an anonymous questionnaire describing their most significant mistake and their response to it. Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases. Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families. House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice. Residents were less likely to make constructive changes if they attributed the mistake to job overload. They were more likely to report defensive changes if they felt the institution was judgmental. Decreasing the work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes.

Persons Found in Their Homes Helpless or Dead

BACKGROUND Health care providers and providers of emergency services are sometimes called to help with people who are found alone in their homes either helpless or dead. It is not known who is at risk for being found helpless or dead, what the mortality rates are among those found alive, or how frequently this situation occurs. METHODS We conducted a population-based study of patients who were found in their homes either helpless or dead. Over 12 weeks, paramedics employed by the city of San Francisco identified 387 such events involving 367 persons. We obtained information on these patients from the emergency-medical-services department or the hospitals to which they were taken and determined their outcomes. RESULTS The median age of the persons found helpless or dead was 73 years; 51 percent were women. The frequency of such incidents increased sharply with age, from a rate of 3 per 1000 per year among those 60 to 64 years of age to 27 per 1000 per year among those 85 years of age or older. The highest rate was among men 85 years and older who were living alone (123 per 1000 per year). In 23 percent of the cases, the person was found dead; an additional 5 percent died in the hospital. Thus, total mortality was 28 percent. Of the patients found alive, 62 percent were admitted to the hospital. The average hospital stay was eight days, and 52 percent of those admitted required intensive care. Of the survivors, 62 percent were unable to return to living independently. The total mortality was 67 percent for patients who were estimated to have been helpless for more than 72 hours, as compared with 12 percent for those who had been helpless for less than 1 hour. CONCLUSIONS For elderly people who live alone, becoming incapacitated and unable to get help is a common event, which usually marks the end of their ability to live independently.

Preferences of Homosexual Men with AIDS for Life-Sustaining Treatment

The acquired immunodeficiency syndrome (AIDS) raises questions about appropriate care for patients with this incurable and progressive disease. Although individual episodes of infection and maligna...

Ethical Issues in Stem Cell Research

Stem cell research offers great promise for understanding basic mechanisms of human development and differentiation, as well as the hope for new treatments for diseases such as diabetes, spinal cord injury, Parkinsons disease, and myocardial infarction. However, human stem cell (hSC) research also raises sharp ethical and political controversies. The derivation of pluripotent stem cell lines from oocytes and embryos is fraught with disputes about the onset of human personhood. The reprogramming of somatic cells to produce induced pluripotent stem cells avoids the ethical problems specific to embryonic stem cell research. In any hSC research, however, difficult dilemmas arise regarding sensitive downstream research, consent to donate materials for hSC research, early clinical trials of hSC therapies, and oversight of hSC research. These ethical and policy issues need to be discussed along with scientific challenges to ensure that stem cell research is carried out in an ethically appropriate manner. This article provides a critical analysis of these issues and how they are addressed in current policies.