Susanna E. Bedell

Discussing cardiopulmonary resuscitation: a study of elderly outpatients.

Decisions about when to perform cardiopulmonary resuscitation (CPR) are frequently made without knowing the wishes of the patient. To evaluate the feasibility of outpatient discussions about CPR, the authors surveyed 22 male and 53 female, mentally competent, ambulatory patients 65 years of age and older. Only 7% of those interviewed had an accurate understanding of what CPR meant before hearing a standardized description. Eighty-seven per cent thought discussions about CPR should take place routinely, but only 3% had previously discussed this issue with their physicians. Seventy per cent felt such discussions should take place during periods of health, and 84% felt their views should be part of the medical record. When asked about three terminal illnesses, a minority of patients wanted CPR: 25% felt CPR was indicated in the presence of irreversible coma, 28% for terminal cancer, and 41% for irreversible heart failure. More patients felt they would request CPR if they had irreversible heart failure than if in a coma (p<0.002) or for terminal cancer (p=0.002). The majority of elderly outpatients have clearly defined opinions about the application of CPR and wish to discuss them with their physicians.

Sildenafil in the Cardiologist’s Office: Patients’ Attitudes and Physicians’ Practices toward Discussions about Sexual Functioning

Sildenafil is a medication increasingly prescribed to improve sexual function in patients who have erectile dysfunction. Because a major contraindication to the use of sildenafil is a history of coronary disease and the concomitant use of nitrates, it becomes increasingly important for cardiologists to prescribe this medication. We evaluated the nature of discussions in all 70 patients for whom sildenafil was prescribed in a cardiology practice between April and July 1998. We used a standardized questionnaire to determine the patients’ perspective on the sexual history and the extent to which they wanted their physicians to take a detailed history about sexuality. A separate chart review evaluated the nature of physicians’ discussions about sexual functioning before sildenafil was prescribed. Fifty-five of the 70 patients (79%) responded to the survey. The majority of patients (98%) felt that physicians should talk with patients about sexual functioning. However, only 73% of patients believed their doctor was comfortable talking with them about this subject. Sixty percent of patients reported that their doctor had ever talked with them about erectile function and only 15% had ever had a discussion with their doctors about specific difficulties during intercourse. Based on the results of the chart review, only 24% of the patients ever specifically discussed the used of sildenafil with their physician prior to the time that it was prescribed. The results of the study suggest that patients with coronary disease erectile dysfunction are comfortable talking with their physicians about sexual functioning, but these conversations occur infrequently.

Hand to hand

Examination of the hands has the potential to transform the encounter between physician and patient. Taking the hands conveys a sense of warmth and connectedness and is a means to communicate the physician’s mindfulness. The hands can focus the examination on the individual patient as a complete human being, and not merely a disease or a collection of symptoms. The hands provide readily accessible information that may not be available through other evaluations, and they offer clues to a patient’s physical and mental health. Commonplace observations, such as those revealed in the hands, can unravel medical mysteries and provide profound clinical insights.

Leukocytosis and left shift associated with quinidine fever

Fever is a well-known side effect of quinidine therapy, but an elevated white blood cell count is considered unusual. Two patients are described who had leukocytosis or a marked left shift in the white blood cell count (or both) in association with quinidine fever. Neither patient had evidence of infection. In each of these patients, the temperature and white blood cell count returned to normal within two days after quinidine was discontinued. Although infection should always be considered in a patient with fever, leukocytosis, and a left shift, these may also appear in association with quinidine therapy.

Management of Hyperglycemia and Diabetes in an Outpatient Cardiology Practice

There is inadequate information about how well cardiologists manage overt or latent diabetes. We reviewed charts of patients who died in an academic outpatient cardiology practice in the period from January 1995 to December 1997 in order to determine the prevalence of hyperglycemia and diabetes, as well as whether their management had been according to the established guidelines. We found that of 128 decedents (mean age 78 years), 22 had had recognized diabetes and 27 undiagnosed hyperglycemia. Evaluation and management of glycemia in either group had not adhered to guidelines, despite the presence of concomitant cardiovascular disease. This was true for assessment of long-term glycemic control or end organ damage, prescription of proper diet, and/or management of other cardiovascular complications. These findings indicate the need for more involvement by cardiologists in the care of patients with overt or latent diabetes beyond the steps taken against their established cardiovascular disease.