Increasing the completion of the durable power of attorney for health care. A randomized, controlled trial.

OBJECTIVE: Wider use of written advance directives may prevent many ethical dilemmas about life-sustaining interventions for patients who have lost decision-making capacity. We investigated whether a simple educational intervention increased patient completion of the durable power of attorney for health care. DESIGN: A randomized, controlled trial. SETTING: A health maintenance organization. SUBJECTS: All patients aged 65 years and older and discharged from a hospital between January 1991 and May 1991 (n = 1101) were randomized to either an intervention group or a control group. INTERVENTION: An educational pamphlet on the durable power of attorney for health care and a durable power of attorney for health care form were mailed to all patients in the intervention group. The control group received conventional care only. MAIN OUTCOME MEASURE: Completion of the durable power of attorney for health care form. RESULTS: There were no significant baseline differences between the intervention group and the control group. Following our intervention, 18.5% of the subjects in the experimental group completed a durable power of attorney for health care form, compared with 0.4% of the control group (P < .0001). CONCLUSIONS: A simple educational intervention significantly increased the completion of the durable power of attorney for health care. Our findings should stimulate further efforts to empower patients to make informed decisions about their health care.

Fluconazole-resistant Candida in AIDS patients. Report of two cases.

Oropharyngeal candidiasis develops in up to 95% of patients with acquired immunodeficiency syndrome. Oral fluconazole is frequently prescribed for persons who are human immunodeficiency virus-seropositive as initial or suppressive therapy for oropharyngeal and esophageal candidiasis or as suppressive therapy for cryptococcal meningitis. We report two cases of oropharyngeal candidiasis, caused by Candida albicans, which developed in two patients with acquired immunodeficiency syndrome who had taken fluconazole for extended periods. In addition to the clinical resistance we observed, isolates of the organism appeared to be resistant in vitro to fluconazole and ketoconazole.

Do patients want to participate in medical decision making?

Although shared decision making by patients and clinicians has been advocated, little is known about the degree of participation in decision making that patients actually prefer or about clinicians' appreciation of these preferences. We administered questionnaires about three aspects of decision making to 210 hypertensive outpatients and to their 50 clinicians, who represented three types of medical practices. We found that 41% of patients preferred more information about hypertension; clinicians underestimated patient preferences for discussion about therapy in 29% of cases and overestimated 11% (k = .22); and 53% of patients preferred to participate in making decisions, while clinicians believed that their patients desired to participate in 78% of cases. Many patients who preferred not to make initial therapeutic decisions did want to participate in ongoing evaluation of therapy. Thus, clinicians underestimate patients' desire for information and discussion but overestimate patients' desire to make decisions. Awareness of this discrepancy may facilitate communication and decision making.

KIE: A survey of hypertensive outpatients and their physicians in three different clinic settings revealed differences between patients and physicians in their perceptions of disclosure and decision making. Patients wanted more discussion of therapy and of decisions about treatment but preferred to leave decision making to their clinicians. Physicians underestimated both the amount of information patients received and the amount they desired, but overestimated both the amount of actual patient participation in decision making and their patients' desire to make decisions. The authors suggest that, in view of these discrepancies, physicians and patients should engage in direct discussion of their preferences.

Influence of dietary sodium on renin activity and arterial pressure during anesthesia.

The effect of pentobarbital anesthesia on plasma renin activity (PRA) and mean arterial pressure (MAP) was studied in chronically catheterized dogs maintained on normal or low-sodium intake. Within 1 min of administration, pentobarbital caused a rapid fall in MAP which was followed by a restoration of MAP toward control within 5 min. Thirty minutes after induction of anesthesia, PRA was unchanged in sodium-replete dogs and elevated two-fold in sodium-depleted dogs. MAP was significantly lowered (20 mmHg) in normal salt dogs and only slightly decreased in low-salt dogs 30 min after pentobarbital. MAP returned to preanesthetic control value in dogs given converting enzyme inhibitor before anesthesia. Surgical stress or cutaneous electrical stimulation causey hexamethonium. These results indicate that change in PRA and MAP of pentobarbital-anesthetized dogs is significantly influenced by the sodium intake of the animal and by the degree of surgical stress.