Donald J. Murphy

The development of outpatient clinical glidepaths

For clinicians who are struggling with the complexities of medical decision‐making, practice guidelines and evidence‐based medicine (EBM) have become increasingly popular and have potential to positively influence the practice of medicine. Nevertheless, they have their limitations. Guidelines are often rigid, based solely on age, and usually do not take into account a patients comorbidities, life expectancy, and nonmedical preferences. EBM studies may not always include particular patient populations commonly seen by the geriatric clinician (e.g., studies on lipid‐lowering agents or antihypertensive drug usually exclude the very old or patients who are frail, demented, or at the end of life). These limitations have made it difficult for geriatric clinicians to use these guidelines because of the need to individualize evaluation and treatment approaches and take into account the varied preferences of their older patients. The purpose of this paper is to present an alternative model of care for geriatric clinicians called The Clinical Glidepaths. The Clinical Glidepaths are outpatient tools intended to assist geriatric clinicians in their decision‐making process. They are based on the following principles. (1) Clinicians need guidance concerning many different types of patients, not rigid guidelines based solely on age. (2) EBM should be used but has some limitations of which to be aware. (3) Clinical experience, which emphasizes individual outcomes instead of populations, is an important component of medical decisions. (4) There needs to be room for patient preferences in medical decision‐making. (5) An approach to patients based on probable life expectancy and function, instead of age, will be more applicable and useful. (6) Making a useful tool will focus on common problems seen in every day geriatric practices.

Improving Advance Directives for Healthy Older People

The quality and quantity of advance directives for healthy older people need to increase. Quality will improve with literal interpretations of do‐not‐resuscitate orders and more comprehensive directives. Changing the term “DNR” to “No ACLS (Advanced Cardiac Life Support)” should discourage health‐care providers from subsuming other limitations under the directive to withhold resuscitation. Other aggressive medical and surgical interventions should be prospectively considered in addition to resuscitation. The quantity of advance directives will increase when physicians feel motivated to devote time and expertise to thorough discussions of advance directives. Although education and legislation will motivate physicians to some extent, their roles are limited. Fair reimbursement for this primary‐care service is the most effective motive. The initial investment by Medicare may save large sums in the long run by reducing expensive, undesired care for older people.

An Overview of Allocation and Rationing: Implications for Geriatrics

Geriatricians are faced with increasing pressure from insurers and the public to control costs. At the same time, sub‐specialist colleagues, patients, and the courts often demand ever more costly high‐technology interventions. This conflict will only intensify given the sustained increase in the percentage of GNP spent on medical care. A number of prominent biomedical ethicists and others have explored rationing of medical care services as one response to these concerns.

CPR in Nursing Homes; To the Editor:

To the Editoc-In their study, “The Outcome of CPR Initiated in Nursing Homes,“ Applebaum et all confirm the notion that cardiopulmonary resuscitation (CPR) is inappropriate for certain chronically ill patients. Based on this and other similar studies, the authors suggest changing the current policies that “dictate CPR be attempted on all residents unless a spealic order to the contrary is written.” The authors outline the burdens of current policies in bold strokes. I would like to add two more burdens to their list of seven (not that I think their argument to change policies is not convincing enough). First, futile attempts at CPR in nursing homes tell us something about ourselves as health-care professionals. They are symbolic, or should I say symptomatic, of our fear of litigation. These attempts do not, as we would like to believe, symbolize our respect for patient autonomy or sanctity of life. The integrity of the medical profession is burdened enough with the fear of litigation. The second burden relates to the point made by Dr. Solomon in his editorial, “The US and the U K An Ocean Apart?” Dr. Solomon does tear away the “extra layers” when he identifies the problemAmericans have a hard time accepting death. The problem, however, involves more than the fear of death. We also lose our respect for death with futile attempts at CPR? Twenty years ago I was on rounds with my father, an internist, when he was called to the bedside of an elderly woman who had just died. I followed the lead of my father and stood silently for a minute. He then placed his hand on her forehead. More silence. Then we left. I am not sure what he was thinking, but I sensed a respect for death and all it implies about our limitations as healers. Throughout training I was compelled to perform a different ritual at the deathbed, one that discouraged me from reflecting after it was clear that death was inevitable. These rituals, which are encouraged by current policies, were indeed burdensome. As Applebaum and colleagues suggest, it is time for a radical change in some of these policies.