Fates Worse than Death: The Role of Valued Life Activities in Health-State Evaluations

One hundred eight college students (Study 1) and 109 elderly adults (Study 2) rated 28 health impairments for the quality of life perceived to be possible in that state, the extent to which the state was perceived as a fate better or worse than death, and the extent to which the state was perceived to interfere with the ability to engage in the activities each individual valued most in life. States perceived most negatively were those perceived to interfere most with valued life activities. For any given health state, evaluations were more negative the more the state was perceived by individuals as likely to interfere with engagement in their valued life activities. Implications of these results for end-of-life medical decision making in general and the use of advance medical directives in particular are discussed

Myocardial contrast echocardiography in humans. II. Assessment of coronary blood flow reserve

AbstractThe hypothesis that myocardial contrast echocardiography could be used to simultaneously assess coronary blood flow reserve and the size of the perfusion bed supplied by a coronary artery was examined in nine patients and six dogs. All patients were undergoing cardiac catheterization and had single vessel coronary artery disease (≥85% stenosis of either the proximal left anterior descending or the left circumflex coronary artery); the six dogs had a critical stenosis of the left circumflex coronary artery. Three milliliters of sonicated Renografin-76 (mean microbubble size 6 μm) was injected into the left main coronary artery before and after intracoronary administration of papavarine, 6 to 9 mg. The beds supplied by the normal and stenotic vessels could not be differentiated during contrast echocardiography before injection of papavarine. However, after papavarine, the normal vascular bed showed significantly more contrast enhancement than did the bed supplied by the stenotic artery. This disparity in contrast enhancement made it possible to delineate the size of the bed perfused by the stenotic vessels.When quantitative analysis of the time-intensity curves obtained from the echocardiograms was performed in the dogs, the absolute values for the area under the curve, peak contrast intensity and curve width did not correlate with absolute blood flows measured with radiolabeled microspheres. However, the ratios of the areas under the curves derived from the two vascular beds before and after papavarine correlated well with the ratios of blood flows between the two beds during the same stages (r2= 0.73 by linear regression and r2= 0.85 by an exponential function). In comparison, the ratios of peak amplitudes and curve widths before and after papavarine had poor correlations with ratios of flows from the two beds (r2= 0.18 and 0.02, respectively).In conclusion, myochardial contrast echocardiograpgy can be used to simultaneously assess coronary blood flow reserve and the size of the perfusion bed supplied by a stenotic vessel

Elderly Outpatients\u27 Understanding of a Physician-Initiated Advance Directive Discussion

OBJECTIVE: To examine elderly outpatients\u27 understanding of advance directives (ADs), cardiopulmonary resuscitation (CPR), and artificial nutrition and hydration (ANH) with and without the benefit of a physician-initiated discussion. DESIGN: Randomized controlled trial. SETTING: University-affiliated, community-based, urban family practice residency training program. PATIENTS: One hundred patients aged 65 and older, consecutively sampled and randomly assigned to one of two discussion groups. INTERVENTIONS: Physicians\u27 discussions based on a prepared script consisting of AD issues or health promotion issues. MAIN OUTCOME MEASURES: Test of comprehension of AD, CPR, and ANH information, using open-ended and yes-or-no questions. RESULTS: Patients in the AD and health promotion discussion groups showed good basic understanding. Younger and better-educated patients had a better working knowledge of AD-related information. Understanding of ADs was higher when the physician spent more time talking about AD-related issues after the discussion was completed. CONCLUSIONS: Many elderly outpatients have a good basic understanding of ADs, CPR, and ANH, even without explicit explanations from physicians. However, younger, better-educated patients and those who had longer unstructured discussions had greater AD-related knowledge. These factors need to be considered when framing discussions with patients about ADs and life-sustaining treatments

Elderly Outpatients\u27 Understanding of a Physician-Initiated Advance Directive Discussion

OBJECTIVE: To examine elderly outpatients\u27 understanding of advance directives (ADs), cardiopulmonary resuscitation (CPR), and artificial nutrition and hydration (ANH) with and without the benefit of a physician-initiated discussion. DESIGN: Randomized controlled trial. SETTING: University-affiliated, community-based, urban family practice residency training program. PATIENTS: One hundred patients aged 65 and older, consecutively sampled and randomly assigned to one of two discussion groups. INTERVENTIONS: Physicians\u27 discussions based on a prepared script consisting of AD issues or health promotion issues. MAIN OUTCOME MEASURES: Test of comprehension of AD, CPR, and ANH information, using open-ended and yes-or-no questions. RESULTS: Patients in the AD and health promotion discussion groups showed good basic understanding. Younger and better-educated patients had a better working knowledge of AD-related information. Understanding of ADs was higher when the physician spent more time talking about AD-related issues after the discussion was completed. CONCLUSIONS: Many elderly outpatients have a good basic understanding of ADs, CPR, and ANH, even without explicit explanations from physicians. However, younger, better-educated patients and those who had longer unstructured discussions had greater AD-related knowledge. These factors need to be considered when framing discussions with patients about ADs and life-sustaining treatments

Physicians\u27 Predictions of Elderly Outpatients\u27 Preferences for Life-Sustaining Treatment

13 resident and 4 faculty physicians predicted the life-sustaining treatment preferences of 57 patients (aged 65+ yrs) and then interviewed patients regarding their actual treatment preferences. Physicians\u27 professional experience, length of their relationship with the patient, and experience with direct feedback were measured to determine the association of these factors with the accuracy of the physicians\u27 predictions. Physicians became more accurate predictors as they interviewed more patients and received direct feedback regarding the accuracy of their predictions. Residents were more accurate than faculty in predicting patients\u27 preferences

Elderly Outpatients Respond Favorably To A Physician-Initiated Advance Directive Discussion

Background: Little is known about the emotional impact of physician-initiated advance directive discussions. Methods: One hundred ambulatory patients aged 65 years and older were randomly assigned to receive either a physician-initiated discussion of advance directive choices or a discussion of health promotion issues. Prediscussion, Immediate postdiscussion, and 1-week postdiscussion measures of positive and negative affect were measured for both groups. Results: Neither discussion topic resulted in adverse emotional or attitudinal responses. Only the advance directive participants showed positive affective and attitudinal responses to the discussion, including an increase in positive affect, an increased sense of physician-patient understanding, and increased thought and discussion about life-support issues in the week following the discussion. For those participants receiving the advance directive discussion, longer physician-patient relationships and higher educational levels significantly predicted a more positive affective response. Lower scores on indices of mental and physical health and a stronger belief that physicians should discuss advance directive issues signiftcantly predicted a more negative affective response to the advance directive discussion. Conclusions: Physicians should anticipate positive emotional responses when they initiate advance directive discussions with their elderly outpatients. Advance directive discussions will be received most positively by patients who enjoy good psychological and physical health and when initiated in the context of an established physician-patient relationship

Elderly Outpatients Respond Favorably To A Physician-Initiated Advance Directive Discussion

Background: Little is known about the emotional impact of physician-initiated advance directive discussions. Methods: One hundred ambulatory patients aged 65 years and older were randomly assigned to receive either a physician-initiated discussion of advance directive choices or a discussion of health promotion issues. Prediscussion, Immediate postdiscussion, and 1-week postdiscussion measures of positive and negative affect were measured for both groups. Results: Neither discussion topic resulted in adverse emotional or attitudinal responses. Only the advance directive participants showed positive affective and attitudinal responses to the discussion, including an increase in positive affect, an increased sense of physician-patient understanding, and increased thought and discussion about life-support issues in the week following the discussion. For those participants receiving the advance directive discussion, longer physician-patient relationships and higher educational levels significantly predicted a more positive affective response. Lower scores on indices of mental and physical health and a stronger belief that physicians should discuss advance directive issues signiftcantly predicted a more negative affective response to the advance directive discussion. Conclusions: Physicians should anticipate positive emotional responses when they initiate advance directive discussions with their elderly outpatients. Advance directive discussions will be received most positively by patients who enjoy good psychological and physical health and when initiated in the context of an established physician-patient relationship

Discussing Spirituality With Patients: A Rational and Ethical Approach

BACKGROUND This study was undertaken to determine when patients feel that physician inquiry about spirituality or religious beliefs is appropriate, reasons why they want their physicians to know about their spiritual beliefs, and what they want physicians to do with this information. METHODS Trained research assistants administered a questionnaire to a convenience sample of consenting patients and accompanying adults in the waiting rooms of 4 family practice residency training sites and 1 private group practice in northeastern Ohio. Demographic information, the SF-12 Health Survey, and participant ratings of appropriate situations, reasons, and expectations for physician discussions of spirituality or religious beliefs were obtained. RESULTS Of 1,413 adults who were asked to respond, 921 completed questionnaires, and 492 refused (response rate = 65%). Eighty-three percent of respondents wanted physicians to ask about spiritual beliefs in at least some circumstances. The most acceptable scenarios for spiritual discussion were life-threatening illnesses (77%), serious medical conditions (74%) and loss of loved ones (70%). Among those who wanted to discuss spirituality, the most important reason for discussion was desire for physician-patient understanding (87%). Patients believed that information concerning their spiritual beliefs would affect physicians’ ability to encourage realistic hope (67%), give medical advice (66%), and change medical treatment (62%). CONCLUSIONS This study helps clarify the nature of patient preferences for spiritual discussion with physicians