Lawrence J. Schneiderman

Effects of Offering Advance Directives on Medical Treatments and Costs

OBJECTIVE To examine the effects of advance directives on medical treatments and on patient satisfaction and well-being and to determine whether the enhancement of patient autonomy through advance directives provides a more ethically feasible approach to cost control than does the imposition of limits through rationing. DESIGN Randomized, controlled trial. SETTING University and Veterans Affairs medical center. PATIENTS Two hundred and four patients with life-threatening illnesses, 100 of whom died after enrollment in the study. INTERVENTION Patients randomly assigned to the experimental group were offered the California Durable Power of Attorney (a typical proxy-instruction directive), and patients assigned to the control group were not offered the advance directive. Hospital admissions were monitored to assure that a summary of the document was present in the active medical record at each hospitalization. MEASUREMENTS Cognitive function, patient satisfaction, psychological well-being, health locus of control, sense of coherence, health-related quality of life, receipt of medical treatments, and medical treatment charges. RESULTS No significant differences were found between advance-directive and control groups regarding psychosocial variables, health outcome variables, and medical treatments or charges. Patients offered an advance directive had an average hospital stay of 40.8 days (95% CI, 32.2 to 49.4 days), compared with an average of 33.1 days (95% CI, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of

Impact of ethics consultations in the intensive care setting: a randomized, controlled trial.

19,502 (95% CI,

Proposed quality measures for palliative care in the critically ill: a consensus from the Robert Wood Johnson Foundation Critical Care Workgroup.

13,030 to

Futility and rationing

25,974) for medical treatments in the last month of life compared with

Counseling patients to counsel physicians on future care in the event of patient incompetence

19,700 (95% CI,

Defining Medical Futility and Improving Medical Care

13,704 to

Comparison of the quality of well-being scale and the SF-36 results among two samples of ill adults : AIDS and other illnesses

25,696) for controls. CONCLUSIONS Despite claims that public demand for longer life accounts for rising medical costs, most surveys suggest that patients are calling for less, not more, of the expensive, high-technology treatment often used in terminal phases of illness. Executing the California Durable Power of Attorney for Health Care and having a summary copy placed in the patients medical record had no significant positive or negative effect on a patients well-being, health status, medical treatments, or medical treatment charges.

Medical Futility: The Duty Not to Treat

ObjectiveTo determine the following: a) whether ethics consultations in the intensive care setting reduce nonbeneficial treatments, defined as days in the intensive care unit (ICU) and treatments delivered to those patients who ultimately fail to survive to hospital discharge; and b) whether physicians, nurses, social workers, and patients/families agree that ethics consultations in the ICU are beneficial in addressing treatment conflicts. DesignProspective, randomized, controlled trial of ethics consultations. SettingMedical and pediatric ICUs in a university medical center. PatientsSeventy-four patients in whom value-based treatment conflicts arose during the course of treatment. InterventionsThe patients were randomly assigned to an intervention (ethics consultation offered) or nonintervention (ethics consultation not offered) arm of the trial. MeasurementsMedical data and ICU hospital days were compared between the intervention and control groups before and after the randomization. Likert scale and commentary responses were recorded to structured and open-ended interviews with the responsible physicians, nurses, social workers, and families of patients assigned to the intervention arm within 1 month after the patient’s death or hospital discharge. Interviewees were asked whether ethics consultations helped with the following: a) to identify ethical issues; b) to analyze ethical issues; c) to resolve ethical issues; d) to educate about ethical issues; and e) to present personal views. Main ResultsThere were no differences in overall mortality between the control patients and patients receiving ethics consultations. However, ethics consultations were associated with reductions in ICU hospital days and life-sustaining treatments in those patients who ultimately failed to survive to discharge. Also, ethics consultations were regarded favorably by most participants. ConclusionsEthics consultations seem to be useful in resolving conflicts that may be inappropriately prolonging futile or unwanted treatments and are perceived to be beneficial.

Genetic studies of a family with two unusual autosomal dominant conditions: Mascular dystrophy and Pelger-Huet anomaly: Clinical, pathologic and linkage considerations☆☆☆

For critically ill patients and their loved ones, high-quality health care includes the provision of excellent palliative care. To achieve this goal, the healthcare system needs to identify, measure, and report specific targets for quality palliative care for critically ill or injured patients. Our objective was to use a consensus process to develop a preliminary set of quality measures to assess palliative care in the critically ill. We built on earlier and ongoing efforts of the Robert Wood Johnson Foundation Critical Care End-of-Life Peer Workgroup to propose specific measures of the structure and process of palliative care. We used an informal iterative consensus process to identify and refine a set of candidate quality measures. These candidate measures were developed by reviewing previous literature reviews, supplementing the evidence base with recently published systematic reviews and consensus statements, identifying existing indicators and measures, and adapting indicators from related fields for our objective. Among our primary sources, we identified existing measures from the Voluntary Hospital Associations Transformation of the ICU program and a government-sponsored systematic review performed by RAND Health to identify palliative care quality measures for cancer care. Our consensus group proposes 18 quality measures to assess the quality of palliative care for the critically ill and injured. A total of 14 of the proposed measures assess processes of care at the patient level, and four measures explore structural aspects of critical care delivery. Future research is needed to assess the relationship of these measures to desired health outcomes. Subsequent measure sets should also attempt to include outcome measures, such as patient or surrogate satisfaction, as the field develops the means to rigorously measure such outcomes. The proposed measures are intended to stimulate further discussion, testing, and refinement for quality of care measurement and enhancement.

Impact of pediatric ethics consultations on patients, families, social workers, and physicians.

It seems more than coincidental that at a time of great concern over rising health care costs and fears of rampant technology, debates are suddenly taking place about medical futility and health care rationing. This article examines the economic, historical, and demographic factors that have motivated increased attention to both these concepts, explores differences and similarities in the meaning of these terms, and discusses their ethical implications. Specifically, we identify four common sources of current debates on futility and rationing: the rise in health care costs; the development of high-technology medicine; the aging of society; and the effort to limit the scope of patient autonomy. We propose that when rationing criteria refer to medical benefit, the meanings of futility and rationing share certain common features. Futility and rationing differ, however, in important ways. Futility refers to treatment and outcome relationships not in a general population but in a specific patient. Rationing criteria usually are supported by reference to theories of justice, whereas the definition of futility, if achieved, will probably be arrived at by empirical community agreement. Rationing always occurs against a backdrop of resource scarcity, but futility need not. Toward the end of the paper, we clarify how the various connotations and contexts we associate with each term enhance or frustrate ethical debate.