Susan W. Tolle

Family decision-making to withdraw life-sustaining treatments from hospitalized patients.

BACKGROUND With a national trend toward less aggressive treatment of hospitalized terminally ill patients, families increasingly participate in decisions to withdraw life-sustaining treatment. Although prior research indicates decision making is stressful for families, there have been no psychometric reports of actual stress levels and few discussions of the reasoning used by families compared to clinicians in reaching the decision. OBJECTIVES The purpose of this study was to assess levels of family stress associated with decisions to withdraw life-sustaining treatments, to assess factors that affected stress, and to compare families and clinicians on their reasoning about the decision. METHODS Data were collected from hospital decedent charts, family members of decedents, and clinicians who cared for decedents. Data from families were collected in individual interviews, shortly after decedent death and 6 months later, using psychometric measures and semi-structured interview questions. Clinicians were interviewed once shortly following patient death. RESULTS Family stress associated with the withdraw decision was high immediately following the death of the decedent and, while it decreased over time, remained high a half a year later. Several factors affected stress; most notably, stress was highest in the absence of patient advance directives. In reaching the decision, both families and clinicians prioritized what the patient would want, although families, more strongly than clinicians, endorsed doing everything medically possible to prolong the patients life. CONCLUSIONS Findings add compelling evidence for the power of advance directives, whether written or verbal, to reduce the stress associated with family decision-making.

Legalizing Assisted Suicide — Views of Physicians in Oregon

BACKGROUND Since the Oregon Death with Dignity Act was passed in November 1994, physicians in Oregon have faced the prospect of legalized physician-assisted suicide. We studied the attitudes and current practices of Oregon physicians in relation to assisted suicide. METHODS From March to June 1995, we conducted a cross-sectional mailed survey of all physicians who might be eligible to prescribe a lethal dose of medication if the Oregon law is upheld. Physicians were asked to complete and return a confidential 56-item questionnaire. RESULTS Of the 3944 eligible physicians who received the questionnaire, 2761 (70 percent) responded. Sixty percent of the respondents thought physician-assisted suicide should be legal in some cases, and nearly half (46 percent) might be willing to prescribe a lethal dose of medication if it were legal to do so; 31 percent of the respondents would be unwilling to do so on moral grounds. Twenty-one percent of the respondents have previously received requests for assisted suicide, and 7 percent have complied. Half the respondents were not sure what to prescribe for this purpose, and 83 percent cited financial pressure as a possible reason for such requests. The respondents also expressed concern about complications of suicide attempts and doubts about their ability to predict survival at six months accurately. CONCLUSIONS Oregon physicians have a more favorable attitude toward legalized physician-assisted suicide, are more willing to participate, and are currently participating in greater numbers than other surveyed groups of physicians in the United States. A sizable minority of physicians in Oregon objects to legalization and participation on moral grounds. Regardless of their attitudes, physicians had a number of reservations about the practical applications of the act.

Women in academic medicine: combining career and family

We conducted a national survey to explore how women in academic medicine balance career and family responsibilities. A questionnaire was mailed to all women 50 years of age and under who held full-time appointments in departments of medicine (n = 862), as listed in the faculty roster of the Association of American Medical Colleges. The survey included questions about childbearing and child rearing, attitudes about personal and professional issues, and role models. Of the 694 questionnaires that were delivered, over 80 percent were completed (n = 558). The mean age of the respondents was 38.1 years, and 63 percent had children. The 350 mothers had a mean of 1.9 children; only 3 had 4 or more children. Approximately half the respondents with children had their first child after completing medical training (mean age, 30.6 years), and they were absent from work for a median of 6 weeks post partum; 72 percent took no time off before labor and delivery, and 83 percent were back at work within 12 weeks. The majority were satisfied with their decision to have children and with their careers, despite the fact that 78 percent believed that their career progress had been slowed or markedly slowed by their having had children. We conclude that it is possible for women to combine motherhood with a fulfilling career in academic medicine, but it is difficult, and most such women believe that motherhood slows the progress of their careers.

A comparison of methods to communicate treatment preferences in nursing facilities: traditional practices versus the physician orders for life-sustaining treatment program.

OBJECTIVES: To evaluate the relationship between two methods to communicate treatment preferences (Physician Orders for Life‐Sustaining Treatment (POLST) program vs traditional practices) and documentation of life‐sustaining treatment orders, symptom assessment and management, and use of life‐sustaining treatments.

The Consistency Between Treatments Provided to Nursing Facility Residents and Orders on the Physician Orders for Life-Sustaining Treatment Form

To evaluate the consistency between treatments provided and Physician Orders for Life‐Sustaining Treatment (POLST) orders.

Out-of-Hospital Death: Advance Care Planning, Decedent Symptoms, and Caregiver Burden

Objectives: To examine the end‐of‐life experiences of elderly decedents dying out of the hospital and their family caregivers in a state in which the vast majority of Medicare deaths occur in community settings.

Use of the Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in the hospice setting.

BACKGROUND The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm Program was designed to ensure the full range of patient treatment preferences are honored throughout the health care system. Data are lacking about the use of POLST in the hospice setting. OBJECTIVE To assess use of the POLST by hospice programs, attitudes of hospice personnel toward POLST, the effect of POLST on the use of life-sustaining treatments, and the types of treatments options selected by hospice patients. DESIGN A telephone survey was conducted of all hospice programs in three states (Oregon, Wisconsin, and West Virginia) to assess POLST use. Staff at hospices reporting POLST use (n = 71) were asked additional questions about their attitudes toward the POLST. Chart reviews were conducted at a subsample of POLST-using programs in Oregon (n = 8), West Virginia (n = 5), and Wisconsin (n = 2). RESULTS The POLST is used widely in hospices in Oregon (100%) and West Virginia (85%) but only regionally in Wisconsin (6%). A majority of hospice staff interviewed believe the POLST is useful at preventing unwanted resuscitation (97%) and at initiating conversations about treatment preferences (96%). Preferences for treatment limitations were respected in 98% of cases and no one received unwanted cardiopulmonary resuscitation (CPR), intubation, intensive care, or feeding tubes. A majority of hospice patients (78%) with do-not-resuscitate (DNR) orders wanted more than the lowest level of treatment in at least one other category such as antibiotics or hospitalization. CONCLUSIONS The POLST is viewed by hospice personnel as useful, helpful, and reliable. It is effective at ensuring preferences for limitations are honored. When given a choice, most hospice patients want the option for more aggressive treatments in selected situations.

Oregon's low in-hospital death rates: what determines where people die and satisfaction with decisions on place of death?

The dancing neurologist pleases me He sails the calm Aegean every Spring Like Sophocles, he contemplates the sea And treats our cares as a diminished thing. Such fancy footwork is a gracious gift To shift attentions locus to the feet And let the minds free concentration drift To this rhythmic swaying Ionic beat. In such a state, what relics from the past, What precious driftwood casually afloat Might rise to fevered consciousness at last Or slip into the gently rocking boat? What jealous gods or goddesses might seize The dancing neurologists reveries?Use and availability of beds in acute care hospitals have been confirmed to be the principal determining factors in location of death. Within that constraint, however, the availability of other res...

Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon

To examine the relationship between Physician Orders for Life‐Sustaining Treatment (POLST) for Scope of Treatment and setting of care at time of death.

Disconnecting a ventilator at the request of a patient who knows he will then die: The doctor's anguish

Excerpt Recently we assisted in withdrawing life support from a patient who had repeatedly asked to have his ventilator disconnected, even after being informed that he would then die. We found litt...