The do-not-resuscitate order: a comparison of physician and patient preferences and decision-making
Article Abstract:
Do-not-resuscitate (DNR) orders instruct a patient's medical care provider to waive resuscitation efforts if cardiac or respiratory arrest occurs. The acceptance and use of DNR orders in American hospitals reflects the development of the principle of informed consent, with competent patients having the right to refuse life-sustaining measures. Ideally, such decisions are made cooperatively among patients, family, and physicians, at a time before life-threatening illnesses occur. More often, however, these decisions are not well discussed between patients and their physicians, and physicians often make DNR decisions with little input from the patient. To enhance physicians' understanding of patients' values about terminal care, the attitudes of 131 family practice physicians, including 28 who were working in a university hospital, were evaluated and compared with previous responses from 338 patients treated at a family practice center. Physicians in private practice and those who had worked for over 10 years were less likely to discuss DNR orders with their patients. Physicians felt that aside from the patient, the spouse, physician, and children, in that order, were most important in deciding the DNR status. A good quality of life was considered more important than longevity by 95 percent of physicians. Patients and physicians both felt that being able to think clearly and being treated with dignity were very important. Patients tended to feel that leaving good memories of their last days for the family was important, while physicians felt that being with loved ones and being able to make their own decisions were more important. Physicians and patients were similar in accepting DNR more often for those with Alzheimer's disease and those with severe pain, disability, or cancer, but patients were more accepting of the idea of DNR orders for those who abused alcohol or drugs. Although many responses of patients and physicians were similar, the study indicated that patients valued some life aspects in a manner different from physicians. Physicians should approach their patients so as to discuss these values, as decisions in treatment, such as medication for pain and allowing death at home, may be affected. (Consumer Summary produced by Reliance Medical Information, Inc.)
Publication Name: American Journal of Medicine
Subject: Health care industry
ISSN: 0002-9343
Year: 1991
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Comparison of efficacy of automatic implantable cardioverter defibrillator in patients older and younger than 65 years of age
Article Abstract:
The automatic implantable cardioverter defibrillator (AICD) is now commonly used to treat patients with irregular or abnormally fast heart beats (tachycardia). The device, which is surgically implanted, issues electrical impulses (countershocks) to prevent abnormal conduction of electricity in the heart. The one-year survival rate from sudden cardiac deaths in tachycardia patients has risen from 65 percent before the devices were used to 98 percent. AICD implantation is a complex surgical procedure which requires extensive preoperation examination and evaluation and postoperative follow-up care. Complications and side effects also commonly occur. This therapy may not be justifiable for elderly patients because of increased risk of death during surgery as well as increased risk for other complications due to age. The results of AICD implantation in the elderly were compared with results among younger patients. A total of 133 patients receiving AICD implants were studied. Patients were divided into two groups by age: 79 were less than 65 years of age, and 54 were older. Average age for the younger group was 52.8 years, while for the older group it was 69.8 years. The majority of patients in both groups had underlying coronary artery disease (85 percent of the elderly and 78 percent of the younger patients). Two patients from each group died in the hospital shortly after surgery. The length of the hospital stay was similar for both groups. The devices were subsequently removed for various reasons in four of the elderly, and seven of the younger patients. Three patients required replacements (two younger, one elderly) because of infections. After an average follow-up time of 25.1 months following surgery, 16 younger patients and 11 elderly patients had died. Sudden death occurred in only one younger and three elderly patients. Survival curves were similar for both groups. These results indicate that elderly patients can derive as much benefit from AICD implantation as younger patients, and age alone is not a reason to forgo this treatment. (Consumer Summary produced by Reliance Medical Information, Inc.)
Publication Name: American Journal of Medicine
Subject: Health care industry
ISSN: 0002-9343
Year: 1991
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