U.S. medical students' perceptions of the adequacy of their schools' curricular attention to care at the end of life: 1998-2006.

BACKGROUND: Little is known about the long-term effectiveness of recent efforts to improve end-of-life care education at U.S. medical schools. OBJECTIVE AND DESIGN: Longitudinal, observational study using national data from the Graduation Questionnaire of the Association of American Medical Colleges from 1998-2006, comparing national trends with those at New York Medical College (NYMC), where a required 1-day clinical rotation to a palliative care hospital began in 1998. RESULTS: The fraction of graduating U.S. students reporting that their instruction time on death and dying was at least adequate rose from 70.8% in 1998 to 79.5% in 2006 (p < 0.001); instruction time in pain management rated as at least adequate rose from 34.3% in 1998 to 55.3% in 2005 (p < 0.001); training in palliative care rated as at least adequate rose from 59.9% in 2000 to 74.8% in 2006 (p < 0.001). Improvement began earlier at NYMC compared with national trends, but by 2004 NYMC was no longer significantly different. In multivariate analyses, women, Asians, and older students gave lower ratings of the quality of their end-of-life care education. CONCLUSION: While much remains to be done, there have been significant improvements since 1998 in graduating U.S. medical students' ratings of the adequacy of their instruction time in end-of-life care.

Historical perspective on more than 60 years of hemodialysis access.

Chronic hemodialysis will likely remain the predominant renal replacement therapy for years to come and vascular access will probably continue as the Achilles heel of hemodialysis. The concept of needle puncture as part of the vascular access method is now well established. This article describes the evolution of vascular access and the AV Fistula needle technique for hemodialysis.

Belief in an afterlife, spiritual well-being and end-of-life despair in patients with advanced cancer.

Despite the plethora of research linking spirituality, religiosity and psychological well-being among people living with medical illnesses, the role of afterlife beliefs on psychological functioning has been virtually ignored. The present investigation assessed afterlife beliefs, spiritual well-being and psychological functioning at the end of life among 276 terminally ill cancer patients. Results indicated that belief in an afterlife was associated with lower levels of end-of-life despair (desire for death, hopelessness and suicidal ideation) but was not associated with levels of depression or anxiety. Further analyses indicated that when spirituality levels were controlled for, the effect of afterlife beliefs disappeared. The authors concluded that spirituality has a much more powerful effect on psychological functioning than beliefs held about an afterlife. Treatment implications are discussed.

A clinician's understanding of ethics in palliative care: an American perspective.

I believe the standard for making ethical decisions should be the same for all patients: appropriate medical interventions, carefully weighing their benefits and burdens, and trying to honor the wishes of the patients. When cure is not possible, the balance between benefits and burdens should shift to greater consideration of the burden side of the equation. The ascendancy of autonomy over other medical ethical principles is the center for most of the ethical dilemmas encountered in palliative care. This paper discusses the issues of autonomy, informed consent, patient capacity, advance directives, futility, "do-not-resuscitate" orders, withholding or withdrawing interventions, euthanasia, and sedation therapy. After 41 years of my personally caring for over 4000 terminally ill patients, primarily at Calvary Hospital, the most practical approach has been to establish trust with patients and families, determining their goals, and diligently applying the principles of beneficence (benefits) and nonmaleficence (burdens) in everyday practice.