Preliminary evidence of impaired thinking in sick patients.

BACKGROUND: Earlier anecdotal observations suggested to us that certain aspects of judgment in sick adults approximate the thinking of children. OBJECTIVE: To describe changes in judgment associated with serious illness in otherwise competent adults. DESIGN: Cohort study. SETTING: Urban acute-care hospital and senior citizen center. PARTICIPANTS: Sicker (Karnofsky score 50; n = 39) hospitalized patients were compared with controls (n = 28). Normal performance on the Mini-Mental State Examination (score >/= 24) was required for study entrance. MEASUREMENTS: Seven Piagetian tasks of judgment designed to study childhood cognitive development. Degree of sickness was determined by using the Karnofsky scale of physical function. RESULTS: Patients with Karnofsky scores of 50 or less responded correctly to fewer Piagetian tasks than controls (mean [+/-SD], 1.8 +/- 2.6 vs. 5.9 +/- 1.6; P < 0.001). Furthermore, a smaller proportion of sicker patients responded correctly to each of the seven tasks. Patients with Karnofsky scores greater than 50 did not perform differently than controls. CONCLUSION: In sicker hospitalized patients, performance on seven Piagetian tasks of judgment was similar to that among children younger than 10 years of age. This evidence of cognitive impairment warrants further investigation.

Diagnosing suffering: a perspective.

The alleviation of suffering is crucial in all of medicine, especially in the care of the dying. Suffering cannot be treated unless it is recognized and diagnosed. Suffering involves some symptom or process that threatens the patient because of fear, the meaning of the symptom, and concerns about the future. The meanings and the fear are personal and individual, so that even if two patients have the same symptoms, their suffering would be different. The complex techniques and methods that physicians usually use to make a diagnosis, however, are aimed at the body rather than the person. The diagnosis of suffering is therefore often missed, even in severe illness and even when it stares physicians in the face. A high index of suspicion must be maintained in the presence of serious disease, and patients must be directly questioned. Concerns over the discomfort of listening to patients' severe distress are usually more than offset by the gratification that follows the intervention. Often, questioning and attentive listening, which take little time, are in themselves ameliorative. The information on which the assessment of suffering is based is subjective; this may pose difficulties for physicians, who tend to value objective findings more highly and see a conflict between the two kinds of information. Recent advances in understanding how physicians increase the utility of information and make inferences allow one to reliably use the subjective information on which the diagnosis and treatment of suffering depend. Knowing patients as individual persons well enough to understand the origin of their suffering and ultimately its best treatment requires methods of empathic attentiveness and nondiscursive thinking that can be learned and taught. The relief of suffering depends on physicians acquiring these skills.

Teaching the fundamentals of primary care: a point of view.

In the United States today, major forces in society and within medicine are uniting in support of an enlarged pool of primary care physicians and a heightened status for primary care in medical practice. In the unsettled contemporary medical world, it is little noticed that, during its rise to prominence, primary care has changed from what was basically an administrative concept into one of a sophisticated generalism; the pressure for its new form arises from difficulties in current health care delivery and subspecialty medicine. Generalism takes as its theme the patient rather than the disease and is most appropriate for the contemporary world of chronic disease. It requires new forms and places of training, including postgraduate didactic teaching, so that doctoring is as specifically taught as medical science.

Medical futility. Committee on Bioethical Issues of the Medical Society of the State of New York.

The term futile is used in many different ways. It is therefore difficult to decide whether a procedure or treatment such as CPR or hemodialysis or blood transfusion would be futile in a given case. The AMA's guidelines on the appropriate use of DNR orders state that DNR decisions should be made openly. Institutions should have policies and physicians should elicit the patient's preferences about CPR. For physicians, the question is no longer whether we should discuss DNR orders with our patients; instead, the issue is how to do so with compassion and caring. Physicians should share with patients their judgment about what medicine can and cannot do. Then physicians must "make decisions about when to withhold or limit resuscitation openly" in honest and trusting conversation between doctor and patient. Often CPR is an exercise in futility. The medical profession should be vested with the authority to make futility decisions if they are the product of open discussion and shared deliberation between physician and patient, family, or surrogate. Rationing, triage, and medical futility in relation to AIDS patients require careful deliberation and consideration. What was considered medically futile five years ago for an AIDS patient may be appropriate care nowadays. The need for appropriate use or non-use of life-sustaining therapy for the elderly, the terminally ill, patients with AIDS and other incurable illnesses is evident to patients, health care providers, policy makers, and the public. CPR should only be administered if it is expected to confer lasting benefit to the patient. However, if 10% of elderly patients benefit from CPR in the case of out-of-hospital cardiac arrest, how can one consider this procedure futile? Although communication between physician and patient about difficult treatment limitation decisions has markedly improved in recent years, it remains a problem, largely because open dialogue with patients and families about futility is a demanding emotional and intellectual task. The medical profession is charged with setting standards for the proper implementation of judgments regarding futility.(ABSTRACT TRUNCATED AT 250 WORDS)