Paul J. Hutchison

A Qualitative Study of Unmet Healthcare Needs in Chronic Obstructive Pulmonary Disease. A Potential Role for Specialist Palliative Care

RATIONALE Patients with chronic obstructive pulmonary disease (COPD) have high symptom burdens and poor health-related quality of life. The American Thoracic Society issued a consensus statement outlining the need for palliative care for patients with chronic respiratory diseases. A better understanding of the unmet healthcare needs among patients with COPD may help determine which aspects of palliative care are most beneficial. OBJECTIVES To identify the unmet healthcare needs of patients with COPD hospitalized for exacerbation using qualitative methods. METHODS We conducted 20 semistructured interviews of patients admitted for acute exacerbations of COPD focused on patient understanding of diagnosis and prognosis, effect of COPD on daily life and social relationships, symptoms, healthcare needs, and preparation for the end of life. Transcribed interviews were evaluated using thematic analysis. MEASUREMENTS AND MAIN RESULTS Six themes were identified. (1) Understanding of disease: Most participants correctly identified their diagnosis and recognized their symptoms worsening over time. Only half understood their disease severity and prognosis. (2) SYMPTOMS: Breathlessness was universal and severe. (3) Physical limitations: COPD prevented participation in activities. (4) Emotional distress: Depressive symptoms and/or anxiety were present in most participants. (5) Social isolation: Most participants identified social limitations and felt confined to their homes. (6) Concerns about the future: Half of participants expressed fear about their future. CONCLUSIONS There are many unmet healthcare needs among patients hospitalized for COPD exacerbation. Relief of symptoms, physical limitations, emotional distress, social isolation, and concerns about the future may be better managed by integrating specialist palliative care into our current care model.

Perioperative guidelines for elective surgery in the human immunodeficiency virus-positive patient.

Background: Human immunodeficiency virus (HIV)–positive patients with changes in body morphology can be challenging for the plastic surgeon. Uncertainty about the advisability of elective procedures for these patients and fears of infection transmission may cause trepidation. Plastic surgeons are likely to encounter these patients in increasing numbers. The authors provide an overview of HIV lipodystrophy and treatment options. Clinical parameters are established that must be met before elective procedures on HIV-positive patients. In addition, ethical and legal considerations are discussed. Methods: A literature review was conducted to identify articles reporting specific, identifiable factors influencing operative risk in HIV-positive patients. Legal and ethical experts were consulted. Results: Specific risk factors influencing operative morbidity include an absolute CD4 count of less than 200 cells/cc3 or viral load greater than 10,000 copies/ml. Patients with CD4 counts greater than 200 cells/cc3 and a low viral load have a risk of postoperative complications similar to that of the general population and should therefore be evaluated on established preoperative parameters (e.g., American Society of Anesthesiologists class, nutrition, and age). Conclusions: Patients with HIV-associated body morphology changes can be safely treated by the plastic surgeon, provided that a thorough preoperative workup is performed. There is minimal risk of disease transmission. There is an ethical and legal obligation to treat these patients if the patient is suitable and the procedure in question falls under the expertise of the consulting surgeon.

The hidden persuaders: subtle advertising in radiation oncology

When a pharmaceutical company gives a radiation oncologist a new stethoscope, with the name of one of the company’s prescription drugs engraved on the instrument, is it a gift, an advertisement, or a bribe? Should the physician accept the stethoscope or refuse it? A gift is something which is transferred to another without the expectation or receipt of an equivalent. An advertisement is the action of informing or notifying, generally for the purpose of selling a product or service. A bribe is an attempt to influence corruptly (1, 2). Is the stethoscope a freely given gift, an advertisement for a product, or a bribe to prescribe the product? The pharmaceutical industry spends

Dimensions and Role-Specific Mediators of Surrogate Trust in the ICU.

13.9 billion dollars per year on promotion and marketing. It has been estimated that more than

A population-based study of the prevalence and influence of gifts to radiation oncologists from pharmaceutical companies and medical equipment manufacturers

8000 is spent per physician per year in this effort (3, 4). Money spent by pharmaceutical companies and equipment manufacturers on what are generally referred to as gifts may result in higher prescription prices and equipment costs. Gifts may also affect the physician–patient relationship insofar as the physician is supposed to be a fiduciary or trustee whose first consideration should be the patient in all clinical decisions (5). In attempting to influence a physician, the pharmaceutical company may compromise the physician’s objectivity (6–8). We hypothesized that gifts directed to radiation oncologists and medical physicists are frequent and have the potential to influence their judgment. We sought to document the extent of gift-giving by studying six hospitals in North Carolina and Virginia. With the permission of physicians, we studied their clinic examination rooms, patient waiting areas, check-in desks, and nurses’ stations. We recorded gifts or advertising items in plain sight of patients, such as wall posters, calendars, magnets on file cabinets, brochures, pens, note pads, anatomic models, clocks, computer mouse pads, drinking cups, and stethoscopes, which bore the name of the sponsoring pharmaceutical company or medical equipment manufacturer. Items not exposed to public view, because they were inside drawers or cabinets, were not recorded. Sixty-seven promotional and advertising items were discovered. There was a mean of 0.8 advertising items per room (range 0–4) in 25 clinic examination rooms. The seven nursing stations and clinic check-in desks had a mean of 5.6 advertising items each (range 1–8). The ten waiting rooms had a mean of 0.8 advertising items each (range 0–5). The most common items found in clinic examination rooms were “educational” pamphlets, posters, and plastic anatomic models bearing the sponsor’s name. At nursing stations and check-in desks the most common items were pens, mouse pads, and magnets. Waiting rooms most commonly had brochures promoting specific drugs and diagnostic imaging agents. The implications of the gifts from pharmaceutical companies and medical equipment manufacturers found in our clinics are complex. Radiation oncologists are frequently given pens, pads of paper, calendars, books, dinners, trips to resorts for continuing education meetings, invitations to cocktail parties at medical meetings, and other inducements designed to influence prescribing patterns and the purchase of linear accelerators, simulators, and treatment-planning software. By means of a gift, the company is attempting to get a physician to facilitate a purchase. It is one thing to influence someone to buy something. There is something ethically different in persuading an individual to initiate a course of action leading to the spending of a third party’s money (9). Since physicians are not directly purchasing the drugs that they prescribe nor hospital-based equipment they use for their patients, advertising to physicians is a way of persuading them to get someone else to spend money in a certain fashion. Gifts are of central importance as a means of initiating and sustaining relationships. In contemporary society one offers a gift to a person as a means of proffering friendship or a relationship. Gift exchange is also used to mark events

POINT: Do Physicians Have a Responsibility to Provide Recommendations Regarding Goals of Care to Surrogates of Dying Patients in the ICU? Yes

Objective:In the ICU, discussions between clinicians and surrogate decision makers are often accompanied by conflict about a patient’s prognosis or care plan. Trust plays a role in limiting conflict, but little is known about the determinants of trust in the ICU. We sought to identify the dimensions of trust and clinician behaviors conducive to trust formation in the ICU. Design:Prospective qualitative study. Setting:Medical ICU of a major urban university hospital. Subjects:Surrogate decision makers of intubated, mechanically ventilated patients in the medical ICU. Measurements and Main Results:Semistructured interviews focused on surrogates’ general experiences in the ICU and on their trust in the clinicians caring for the patient. Interviews were audio-recorded, transcribed verbatim, and coded by two reviewers. Constant comparison was used to identify themes pertaining to trust. Thirty surrogate interviews revealed five dimensions of trust in ICU clinicians: technical competence, communication, honesty, benevolence, and interpersonal skills. Most surrogates emphasized the role of nurses in trust formation, frequently citing their technical competence. Trust in physicians was most commonly related to honesty and the quality of their communication with surrogates. Conclusions:Interventions to improve trust in the ICU should be role-specific, since surrogate expectations are different for physicians and nurses with regard to behaviors relevant to trust. Further research is needed to confirm our findings and explore the impact of trust modification on clinician-family conflict.