Why don't emergency department patients have advance directives?

OBJECTIVES: In 1997 the authors determined that only 27% of their adult ED patients had advance directives (ADs). The purpose of this follow-up study was to determine the reasons why their adult ED patients do not have ADs. METHODS: This prospective study enrolled patients from a convenience sample of representative shifts in the ED selected over a three-month period. Survey questions included demographic information, whether the patients had a life-threatening medical problem, whether they had an AD, with whom they had discussed their ADs, and the reasons why they did not have an AD. We excluded those who refused participation or who were incapacitated (i.e., any patient with a condition that precluded him or her from answering the questionnaire himself or herself, such as an altered level of consciousness, dementia, mental retardation, or inability to understand English). RESULTS: Four hundred seventy-six subjects were enrolled during the study period from an ED census of 816 adult patients. Three hundred forty patients were not included in the study for the following reasons: inability to complete the survey, refusal to participate, or not being approached by the interviewers. Of those enrolled, 77% of the patients did not have an AD (females, 73%; males, 80%). The most frequent reasons given for not having an AD were: 40% never thought about it, 24% preferred family to make the decision, and 23% were procrastinating. Factors jointly predictive of having an AD were older age, having a specialist, having a life-threatening medical problem, and not being Catholic. Patients who had ADs were discussing their ADs with their primary care physicians (PCPs) only 5% of the time. CONCLUSION: Many patients, even when they have life-threatening medical problems, do not have an AD, and several reasons for this have been identified. Few of these ED patients who had ADs had discussed them with their physicians. Further studies should assess whether more physician intervention would increase the percentage of patients who have ADs.

Clinical features of bleb disorder of the cornea.

BACKGROUND: Bleb disorder of the cornea is a rare corneal epithelial disorder that has previously been described in asymptomatic patients or those with recurrent nontraumatic corneal erosions. METHODS: We report two cases of bleb disorder, each presenting with blurred vision from irregular astigmatism secondary to the bleb changes. We also report on the detection of bleb disorder in siblings. RESULTS: Both patients underwent surgical debridement of the epithelium with resolution of symptoms on epithelial resurfacing. CONCLUSION: The diagnostic clues, inheritance pattern, differential diagnosis, and treatment options of bleb disorder of the cornea are discussed.

Are emergency department patients thinking about advance directives?

OBJECTIVES: To assess the percentage of adult patients presenting to an urban ED who have a written advance directive (AD) and to determine whether age, sex, a patient's perception of his or her health status, and having a regular physician are associated with the patient's having an AD. METHODS: This was a cross-sectional patient survey performed at a community teaching hospital ED. Surveys were completed by 511 adult ED patients during representative shifts over a 3-month period. The questions included age, sex, "self-reported" health status, whether the patient had a "regular" physician, a patient-generated list of medical problems, and whether the patient had a written AD. For this study, ADs included health care proxies, living wills, and do-not-attempt-resuscitation (DNAR) orders. RESULTS: Of the patients surveyed, 27% reported having an AD. Males and females were equally likely to have an AD. Factors associated with an increased likelihood of having an AD were older age, having a "regular" physician, and the patient's perception of his or her health status as ill. Most patients who had an AD (82%) discussed it with their families, but only 48% discussed it with their physicians. CONCLUSION: Only 27% of the adult patients presenting to the ED had an AD. Older age, the patient's perception of his or her health status as ill, and having a "regular" physician increased the likelihood of having an AD.

CO2 laser in vitreoretinal surgery.

Radiation from a CO2 laser has the dual effect of phototransection and photocoagulation. Incisions have been made in scleral-chorioretinal tissue, lens tissue, and the vitreous body (with and without membrane formation). Results indicate that the CO2 laser may be useful in intravitreal surgery. Its simultaneous cutting and coagulating properties may make the experimental transvitreal chorioretinal biopsy reported by Griffin et al [12] and the full-thickness ocular wall resection for small melanosarcomas of the choroid reported by Peyman and Sanders [13] clinical possibilities in the not too distant future. Finally, the effects of CO2 laser radiation on the normal human lens suggests the possibility of the dissolution of cataracts by laser irradiation.

CO2 laser in vitreoretinal surgery: 1. Quantitative investigation of the effects of CO2 laser radiation on ocular tissue.

Scleral, lens, and vitreoretinal tissue was incised using CO2 laser radiation in a controlled and predictable fashion without producing untoward effects on neighboring ocular tissue. The penetration depth of infrared radiation into normal human vitreous was measured and was found to be exceedingly small. A quantitative correlation was observed between the CO2 laser power and the depth of penetration in scleral-chorio-retinal wall incisions and in lens tissue from human eyebank eyes. The results of this investigation suggest that the CO2 laser may be useful in intravitreal surgery, full-thickness scleral-chorio-retinal wall resections, transvitreal chorioretinal biopsy, and even dissolution of cataracts.

Comparison of tissue reaction to nylon and prolene sutures in rabbit iris and cornea.

The tissue reaction in rabbit iris and cornea to prolene suture is equivalent to the tissue reaction to nylon suture. The prolene suture retains its tensile strength indefinitely and this may make it particularly useful in situations where a permanent suture is desired, such as in refractive keratoplasty, scleral buckle, or to suture an intraocular lens to the iris. The prolene suture also has a greater elasticity and this property may be advantageous in some clinical applications. We feel that a clinical study on humans is now warranted and we have started such a study.