Advance directives, preemptive suicide and emergency medicine decision making.

As the United States population ages, there is a growing group of aging, elderly, individuals who may consider "preemptive suicide"(Prado, 1998). Healthy aging patients who preemptively attempt to end their life by suicide and who have clearly expressed a desire not to have life -sustaining treatment present a clinical and public policy challenge. We describe the clinical, ethical, and medical-legal decision making issues that were raised in such a case that presented to an academic emergency department. We also review and evaluate a decision making process that emergency physicians confront when faced with such a challenging and unusual situation .

Knowledge, attitudes, and preferences regarding advance directives among patients of a managed care organization.

OBJECTIVES: To examine attitudes, experiences, and preferences regarding advance directives (ADs) among adults of all ages. STUDY DESIGN: Subjects were surveyed regarding end-of-life (EOL) care wishes. The survey included items measuring knowledge, experiences, and attitudes regarding ADs, as well as preferences toward initiation of discussions. METHODS: Subjects included a random sample of patients (age range, 20 to >80 years) from a large midwestern managed care organization stratified by age decade. Descriptive statistics were used to summarize variables, and chi2 tests were performed to examine differences by age category. RESULTS: One hundred eighty-seven surveys were completed. The likelihood of having completed an AD increased with age (P <.001). Of those without an AD, 44% reported having talked with someone about their wishes. Many (62%) subjects thought that it was up to them to raise the topic of EOL care. However, 70% of subjects reported that they would be comfortable if their provider initiated discussion. Participants 60 years or older were more likely to report being very comfortable with their provider bringing up the subject compared with those younger than 60 years (60% vs 39%, P = .02). Few differences were found by age. CONCLUSIONS: Room for improvement exists for increasing the number of patients who complete an AD or engage in discussion of their wishes. Ways to involve healthcare providers in the process should be explored, as it seems that patients are receptive to physician-initiated discussions of ADs.

Treatment of elderly and other adult patients for depression in primary care.

OBJECTIVES: To determine whether depression is treated differently in older and younger patients in primary care clinics. DESIGN: Administrative data were used to identify patients with a depression diagnosis code. The sources of data were baseline and 3-month follow-up surveys, the health plan electronic database, and chart audits. SETTING: Nine primary care clinics owned by a health maintenance organization in the Midwest. PARTICIPANTS: The study sample (N=1023) consisted of adult patients, aged 19 to 93, and was divided into six age groups, from young adult, under age 35, to old old, 75 or older. MEASUREMENTS: Independent variables were a series of dummy variables: age groups, baseline depression severity, sex, and incident depression. Outcomes were defined as care processes (assessment, resources) and improvement in depression symptoms (Center for Epidemiologic Studies-Depression scale short form). Univariate and multivariate logistic regression analyses were used to analyze patient characteristics, depression symptoms, and care process variables. Significance level was reported based on the chi-square test of probability, P

Signal detection and threshold measures to loud tones and radiant heat in chronic low back pain patients and cohort controls.

Eleven chronic low back pain (CLBP) and 11 age- and sex-matched control subjects were tested during two separate sessions for the perception of radiant heat and uncomfortably loud tones. Following the determination of a subject's pain threshold (PT) for radiant heat, a standard signal detection methodology was used to present 26 trials each of 4 stimulus levels. The stimuli were rated on a 9-point scale ranging from 'nothing' to 'very strong pain.' A similar procedure was used for the tone stimuli with the 9-point scale ranging from 'nothing' to 'very strongly uncomfortable.' It was found that the CLBP group had both higher heat pain and tone discomfort thresholds than the control group. For radiant heat only, the CLBP group had poorer discrimination as determined by P(I). The results are discussed within the framework of the hypervigilance and adaptation theories of pain perception.