Breaking bad news and discussing death.

The ability to discuss bad news with a patient and family is one clinical skill that is essential to providing effective end-of-life care. Patients and families value direct, nontechnical explanations that are given by a physician with compassion and kindness. Patients and families also value time to talk, express their feelings and ask questions. The authors review research on delivering bad news, then describe a six step process to guide physicians in discussing bad news with patients: (1) create an appropriate environment; (2) open the meeting; (3) discuss the news; (4) develop a follow-up plan; (5) document the conference; and (6) engage in self-reflection.

Physician interaction with battered women: the women's perspective.

BACKGROUND: Programs that train health professionals to identify and treat battered women have not previously incorporated systematically obtained advice from battered women to guide physician behavior. OBJECTIVES: To survey battered women to (1) rate the desirability of specific physician behaviors, (2) describe their actual experiences with physicians while seeking abuse-related medical services, and (3) examine relationships between participants' demographics, history of victimization, history of seeking medical help, and ratings of physician behavior. PARTICIPANTS: One hundred fifteen women who had been battered by a male partner, recruited from support groups and other battered women's programs in a 5-county area in southeastern Wisconsin. METHODS: Self-report survey of demographic information, relationship history, observations of physician behavior, and ratings of desirability for those behaviors. Analysis used cross-tabulations, chi2, and multiple t tests with Bonferonni adjustments for multiple comparisons. RESULTS: Women identified specific physician behaviors as desirable and undesirable. Desirability ratings did not differ with history of victimization, history of seeking medical help, or most other demographic variables. African American and white women rated a few physician behaviors differently. CONCLUSIONS: We identified discrete sets of desirable and undesirable physician behaviors. Further research is needed to clarify racial differences found in this study. Findings can help guide both clinical practice and the development of physician training curricula.

Dating violence.

Dating violence presents many challenges to pediatric health care providers. It spans an age range from early high school to early adult years. Prevalence of dating violence appears to be greater than for violence among married couples. In addition, both males and females appear to be at risk for perpetration and victimization. Therefore, physicians and other health care providers need to screen all adolescent and young adult patients for dating violence. Primary prevention at the community level is also an important task to stem the tide of dating violence.

A survey of competencies and concerns in end-of-life care for physician trainees.

A survey was developed to explore physician trainee competencies and concerns surrounding end-of-life care. Thirty-one medical students, interns, and residents from the Department of Internal Medicine completed the survey in August 1996. The survey instrument found differing levels of competence/concern among medical students, interns, and residents. Self-reported competence increased with level of training. All trainees indicated the least comfort around discussions of hydration and feeding withdrawal. Both residents and interns indicated concern about potential illegality, breach of ethics or potential malpractice when reviewing eight currently legal and ethical end-of-life scenarios involving pain management or treatment withdrawal. Pain management, ethical issues, and delirium were the top three topics for which residents indicated an interest in future educational sessions. Results from the survey will be used to guide the development of educational initiatives that address trainee concerns. The competence/concern survey adds an important dimension to understanding how best to incorporate end-of-life education into residency training programs.

Partner violence: a systematic approach to identification and intervention in outpatient health care.

Although partner violence is a common source of injury for women, physicians and female patients rarely discuss this problem. We outline a systematic approach to clinical practice that includes screening, case finding, intervention, and changes in the office environment. The clinician can begin to address partner violence by artfully applying these techniques. Future health outcomes research will provide additional guidance to clinical practice. We conclude with a quote from a third year medical student at the Medical College of Wisconsin who has a clear and challenging vision of the future: "I look forward to helping victims of domestic violence and eradicating domestic violence from the face of the earth just as smallpox has been eliminated."

Optimal sedation of mechanically ventilated pediatric critical care patients.

OBJECTIVE: To derive a target range of optimal sedation for the COMFORT Scale and to prospectively test that target range against intensivist assessment of adequacy of sedation. DESIGN: Serial prospective agreement cohort studies. SETTING: Twelve-bed pediatric intensive care unit in an urban academic teaching hospital. PATIENTS: Eighty-five mechanically ventilated children (aged 0 to 102 months). INTERVENTIONS: Three serial prospective studies comparing simultaneous, independent ratings conducted by trained observers using an objective scale and intensive care physicians using global assessment. The initial study was designed to derive the target range. The second study was conducted to verify that target range in a second population. The third study was added to evaluate relative variability in methods used in the second study. MEASUREMENTS AND MAIN RESULTS: Adequacy of sedation using visual analog scale and descriptive ratings or the COMFORT Scale (a previously validated behaviorally anchored scale to rate eight behavioral or physiologic dimensions of distress). The first study comprised 100 observations. Groups of patients described by the intensivist as inadequately sedated, optimally sedated, and excessively sedated had different mean COMFORT scores (30.5 +/- 0.7 vs. 22.9 +/- 5.8 vs. 14.3 +/- 0.7, respectively, p < .05). The target range of optimal sedation was defined as COMFORT scores of 17 to 26. The second study verified the target range prospectively in a second group of 96 observations. The COMFORT score was strongly associated with the sedation adequacy rating by the intensivist (p < .001; r2 = .662). COMFORT scores accurately predicted the patient assignment to adequacy of sedation categories by the intensivist in 66.1% of observations. Discrepancy between physicians occurred in 38.5% of 16 paired physician ratings in the second study. In the third study, 120 observations comparing paired COMFORT scores to paired physician ratings of the same subjects demonstrated significantly less variability in COMFORT assessment of adequacy of sedation. COMFORT scores were similarly unbiased (1.1% vs. 0.22%) but more precise (8.0% vs. 16.7%) than intensivist ratings (p < .025). CONCLUSION: Adequacy of sedation is measured more consistently by observers using the COMFORT Scale than by intensivist global assessment.

Pediatric intensive care sedation: survey of fellowship training programs.

Children hospitalized in a pediatric intensive care unit are frequently distressed. The purpose of this study was to identify the patterns of use of sedative agents in pediatric critical care patients. A questionnaire survey was mailed to 45 directors of Pediatric Critical Care Fellowship Training Programs listed in Critical Care Medicine, January 1989. The response rate was 75.6% (34 questionnaires). The most commonly identified goals of sedation were reduced patient discomfort or distress and fewer unplanned extubations. The agents most frequently employed for this purpose were opioids (morphine or fentanyl), chloral hydrate, or benzodiazepines. Although conventional doses are used, opioids and benzodiazepines are often given hourly or by continuous infusion. Satisfaction with the efficacy and safety of commonly used opioids was greater (most common response "very satisfied") than for the benzodiazepines ("somewhat satisfied"). The physician's or nurse's clinical impression was reported to be the "most important" criterion for deciding when a patient required a dose of sedative; objective criteria were selected as less important. The majority of patients (65.7%) in the surveyed units were ideally "sedated to the point of no distress with as-needed medication." The majority of respondents (76.4%) identified efficacy as the major problem with sedation. Drug withdrawal was considered to be the major problem with sedative use by only a minority of respondents (6.9%). Although withdrawal is seen in 61.8% of units, it is generally treated when recognized, rather than prevented by routine tapering of sedation. Optimal sedation of pediatric intensive care unit patients is considered problematic, despite the use of frequent doses of many sedatives. Systematic investigation of pharmacodynamic response to these agents in the pediatric critical care population is indicated.

Cognitive-behavioral treatment of health-impairing food phobias in children.

Three cases reports describe assessment and treatment of three boys (ages 6 to 8 years) hospitalized because of weight loss and malnutrition, caused by severe dietary restriction and/or refusal to eat solid food. Psychological, behavioral, and medical assessments indicated that the boys were of average intelligence, without other significant psychological or medical disorders. Their eating disturbances were conceptualized as phobic disorders maintained by family factors reinforcing the children's avoidant behaviors. Cognitive-behavioral treatment consisted of an individualized combination of contingency management, shaping, desensitization, relaxation training, education, and cognitive restructuring. Generalization and maintenance were promoted by training parents to implement treatment at home before discharge. Treatment positively affected overall caloric intake, weight gain, number of solid foods accepted, and incidence of emesis.

Assessing distress in pediatric intensive care environments: the COMFORT scale.

Managing psychological distress is a central treatment goal in Pediatric Intensive Care Units (PICUs), with medical and psychological implications. However, there is no objective measure for assessing efficacy of pharmacologic and psychological interventions used to reduce distress. Development of the COMFORT scale is described, a nonintrusive measure for assessing distress in PICU patients. Eight dimensions were selected based upon a literature review and survey of PICU nurses. Interrater agreement and internal consistency were high. Criterion validity, assessed by comparison with concurrent global ratings of PICU nurses, was also high. Principal components analysis revealed 2 correlated factors, behavioral and physiologic, accounting for 84% of variance. An ecological-developmental model is presented for further study of children's distress and coping in the PICU.