Privacy and patient-clergy access: perspectives of patients admitted to hospital.

BACKGROUND: For patients admitted to hospital both pastoral care and privacy or confidentiality are important. Rules related to each have come into conflict recently in the US. Federal laws and other rules protect confidentiality in ways that countermand hospitals' methods for facilitating access to pastoral care. This leads to conflicts and poses an unusual type of dilemma-one of conflicting values and rights. As interests are elements necessary for establishing rights, it is important to explore patients' interests in privacy compared with their desire for attention from a cleric. AIM: To assess the willingness of patients to have their names and rooms included on a list by religion, having that information given to clergy without their consent, their sense of privacy violation if that were done and their views about patients' privacy rights. METHODS AND PARTICIPANTS: 179 patients, aged 18-92 years, admitted to hospital in an acute care setting, were interviewed and asked about their preferences for confidentiality and pastoral support. RESULTS: Most (57%) patients did not want to be listed by religion; 58% did not think hospitals should give lists to clergy without their consent and 84% welcomed a visit by their own clergy even if triggered from a hospital list. CONCLUSIONS: Values related to confidentiality or privacy and pastoral care were found to be inconsistent and more complicated than expected. Balancing the right to privacy and the value of religious support continue to present a challenge for hospitals. Patients' preferences support the importance of providing balance in a way that protects rights while offering comprehensive services.

Ethical issues at the end of life.

Providing good care for dying patients requires that physicians be knowledgeable of ethical issues pertinent to end-of-life care. Effective advance care planning can assure patient autonomy at the end of life even when the patient has lost decision-making capacity. Medical futility is difficult to identify in the clinical setting but may be described as an intervention that will not allow the intended goal of therapy to be achieved. Medical interventions, including artificial nutrition and hydration, can be withheld or withdrawn if this measure is consistent with the dying patient's wishes. Physicians caring for terminally ill patients receive requests for physician-assisted suicide. The physician should establish the basis for the request and work with the healthcare team to provide support and comfort for the patient. Physician-assisted suicide could negate the traditional patient-physician relationship and place vulnerable populations at risk. Physicians need to incorporate spiritual issues into the management of patients at the end of life. The integrity of the physician as a moral agent in the clinical setting needs to be recognized and honored. The physician has a moral imperative to assure good care for dying patients.

Sign of lipid peroxidation as measured in the urine of patients with probable Alzheimer's disease.

Free radical-induced oxidative damage may be involved in the neurodegenerative process associated with Alzheimer's disease (AD). 8-Isoprostaglandin F(2alpha) (iPF(2alpha)-III) is an isoprostane derived from free radical-induced non-enzymatic oxidation of arachidonic acid. It is formed in vivo and is an indicator of lipid peroxidation. Measurements were made of iPF(2alpha)-III in the urine of patients with mild to moderate dementia associated with probable AD and compared to those in the urine of non-demented subjects, who were similar in age and gender. 2,3-Dinor thromboxane B(2) (dinor TXB(2)), a urinary metabolite of TXB(2) was also measured, and served as an indicator of the enzymatic transformation of a product of arachidonic acid. Enzyme linked immunoassays were used to measure iPF(2alpha)-III and dinor TXB(2) in the urine. The concentration of iPF(2alpha)-III was significantly elevated in urine of patients assessed to have mild to moderate dementia as compared to non-demented patients. The concentration of urinary dinor TXB(2) was also significantly elevated in the patients with dementia and probable AD as compared to the non-demented subjects. There was considerable overlap of values obtained for demented and non-demented patients for iPF(2alpha)-III and dinor TXB(2), respectively. The observed elevation of iPF(2alpha)-III suggests that patients with mild to moderate dementia associated with probable AD are experiencing significant oxidative stress. This finding is consistent with current data suggesting that oxidative stress may be occurring in patients with dementia and probable AD. The increase of dinor TXB(2) may indicate that enzymatic processes related to the metabolism of arachidonic acid-derived products are also increased in demented patients with probable AD.

Opinions and reactions of physicians in New Jersey regarding the Oregon Death with Dignity Act.

Physician-assisted suicide (PAS) was legalized in Oregon in 1997. In the study reported here, the authors surveyed a sample of New Jersey physicians with regard to Oregon's Death with Dignity Act and to whether similar legislation should be enacted in New Jersey. A 49-item questionnaire was sent to 563 physicians in New Jersey who were licensed in the specialties of family practice, internal medicine, surgery, psychiatry, and obstetrics/gynecology. The questionnaire contained sections pertaining to demographics, physicians' attitudes regarding PAS, and physicians' opinions on Oregon's Death with Dignity Act. A brief summary of the legislation was included in the mailing, which participants were asked to read before completing the questionnaire. Of the 191 physicians who responded to the survey, 55% agreed with legislation that would legalize PAS, and 59% said that a law similar to that enacted in Oregon should exist in New Jersey. However, only 47% of respondents indicated that they believed PAS to be consistent with the role of a physician to relieve pain and suffering. Slightly more than half of respondents indicated that they would refuse to participate in PAS and were concerned about issues such as professional and personal liability and the potential for abuse. Physicians in New Jersey will require additional information, education, and discussion of the ethical and legal implications of PAS before a law similar to that in Oregon could be proposed or considered.

Management of osteoporosis in the new millennium.

Key to effect management of osteoporosis is early diagnosis. Careful assessment of risk and determination of bone mineral density can enable the clinician to recognize this disease before it manifests with fractures. Treatment strategies have been shown to reduce fracture rates and potentially improve bone mineral content. Effective nonpharmacologic treatment includes nutritional considerations, exercise, prevention of falls, behavioral alterations, and osteopathic manipulative treatment. Approved pharmacologic strategies include estrogen replacement therapy, alendronate, and calcitonin. Because of the multiple health benefits of estrogen replacement therapy, unless contraindicated, it should be used whenever possible. The effectiveness of combination therapy is yet to be determined. Serial determinations of bone mineral density and the use of urinary biomarkers are effective to monitor therapy. A "four-step approach" to management is proposed. The primary physician can play a key role in the early recognition and treatment of this potentially devastating disorder.

Training osteopathic geriatric academicians: impact of a model geriatric residency program.

The need for osteopathic geriatric academic leaders who are educators and researchers is well recognized. The University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine's Geriatric Residency program, a federally funded Faculty Training Project in Geriatric Medicine and Dentistry, has served as a model program in the osteopathic medical professional since its inception in 1989. Targeting internal medicine and family medicine physicians interested in academic careers in geriatrics, the program promotes interdisciplinary training, which develops clinical, research, and teaching/administrative skills. A survey of program graduates assessed their perceptions about the field of geriatrics and the impact of training on career choice and level of satisfaction. Results indicated that 100% of the former trainees entered the field of geriatrics; 57% hold full-time faculty appointments at an osteopathic medical school, and 43% practice as clinical geriatricians. Of those in an academic setting, all taught medical students and housestaff and were involved in research. All of the respondents wee satisfied with their career choice, although 71% indicated that a higher salary and greater respect for the discipline would further enhance their satisfaction. Greater than half perceived the need for additional geriatricians and ranked complexity of care, lower salaries, inadequate reimbursement, and indebtedness after medical school as significant barriers to entering the field. This program has been successful in training academic geriatricians, it has created role models for students, and it has responded to the shortage of osteopathic academic and clinical geriatricians. Financial incentives and reimbursement that is commensurate with complexity of care would serve to attract more trainees to this important primary care discipline.

Quality medical management of the geriatric population using practice guidelines, physician-managed home health services, and continuous quality-improvement management strategies.

One challenge confronting physicians in the 1990s is the delivery of cost-effective quality healthcare to the elderly. Given current utilization, federal expenditures on Medicare and other federal healthcare programs are projected to increase to more than 6% of the gross national product by the year 2030. Physicians' practice habits will have an impact on the cost of caring for the nation's elderly. It is therefore essential for physicians to recognize their role in delivering quality geriatric care. First, they must be active and diligent in the pursuit of practice guidelines that support changes in the current standards of care. Second, physicians should consider alternative approaches to present practice patterns such as physician-managed home health services. Finally, physicians need to take a proactive approach to quality by supporting continuous quality improvement. The purpose of this review is to present some of the existing established practice guidelines, data to support the use of physician-managed home care as an alternative practice approach, and suggestions to incorporate the principles of continuous quality improvement to serve as one practice model that can be used by physicians to improve the quality of medical care given to America's elderly.

Use of the Beck Depression Inventory for Primary Care to screen for major depression disorders.

To ascertain how effective the Beck Depression Inventory for Primary Care (BDI-PC) was in screening for DSM-IV major depression disorders (MDD) in outpatients who were scheduled for routine office visits with physicians specializing in internal medicine, the BDI-PC was administered to 60 male and 60 female outpatients. The internal consistency of the BDI-PC was high (alpha 0.85), and the Mood Module from the Primary Care Evaluation of Mental Disorders was used to diagnose MDD. The BDI-PC scores were not significantly correlated with sex, age, ethnicity, or total number of medical diagnoses. A BDI-PC cutoff score of 4 and above yielded 98% maximum clinical efficiency with 97% (95% CI 82%-99%) sensitivity and 99% (95% CI 94%-99%) specificity rates, respectively, for identifying patients with and without MDD. The BDI-PC is discussed as an effective case-finding instrument for screening primary care patients for MDD.

HIV-related medical issues in older people.

AIDS: HIV disease most commonly affects the young and middle-aged adults, but 11 percent of new cases are diagnosed in persons of 50 years or older. Many physicians are slow to diagnose HIV in older people and rarely question them about HIV-related risk behaviors. This is due, in part, to the common misperception that older people are not at risk for HIV infection, and symptoms of HIV disease, such as weight loss and depression, can be mistaken for symptoms of aging. Because the older patient population often receives delayed diagnosis, it is important for health care providers to screen these patients for HIV infection more actively and often.^ieng

Evaluation of a two-hour oral health education program for medical students.

This study used a pretest-posttest design to assess the effectiveness of a two-hour oral health training program for medical students that was developed and taught by a geriatric dentist as a model undergraduate medical education curriculum. A 3D-item multiple choice and true-false written evaluation assessed medical students' knowledge and attitudes of geriatric oral health. Medical students' scores on the evaluation improved significantly after attending the two-hour program. The addition of a geriatric dentist as a member of the interdisciplinary teaching team can impact medical students' knowledge and attitudes about oral health in the elderly. [Article copies available from The Haworth Document Delivery Service:

Occurrence and impact of suspected delirium in hospitalized elderly patients.

The records of 95 consecutive people older than 65 years and admitted to a community hospital were retrospectively reviewed to determine the prevalence of undiagnosed delirium in hospitalized elderly patients. Chart review focused on identification of patients with documented diagnosed delirium according to Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R) criteria and patients with unrecognized delirium. Unrecognized delirium was considered present when information contained in a patient's chart met some or all criteria for delirium as described in DSM-III-R, but the physician's progress notes failed to indicate delirium as a diagnosed clinical entity. The prevalence of diagnosed delirium was 2%. Thirty-six percent of the patients were suspected of having unrecognized delirium. The mean length of hospital stay and the rate of mortality were significantly higher for patients with suspected delirium than for non-delirious patients. The findings of this study suggest that unrecognized delirium in the hospitalized elderly may occur frequently and is associated with an increased length of hospital stay and increased mortality.

Comprehensive geriatric assessment: applications for community-residing, elderly people with mental retardation/developmental disabilities.

The effects of using comprehensive geriatric assessment, a recently developed approach found to be effective in evaluating elderly patients, was explored with 41 community-based elderly individuals with mental retardation/developmental disabilities to determine whether it would reveal a greater number of medical, dental, and psychiatric diagnoses when compared to their previous medical care. Functional status and medication usage of these subjects was assessed and described. Statistically significant increases in the number of medical and dental diagnoses were found. An increased number of psychiatric diagnoses, though not significant, was also found. Results suggest that comprehensive geriatric assessment is useful in the evaluation of the health care needs of individuals with mental retardation/developmental disabilities.

Geriatric assessment teams in nursing homes: do they work?

Several studies have examined the effectiveness of geriatric assessment teams in outpatient and acute care settings. This project compared medical records of 69 consecutive nursing home patients randomly assigned on arrival to team (n = 33) and nonteam (standard care, n = 36) conditions. Quality-of-care indices and healthcare service utilization were compared over a 12-month postadmission period. Team patients had a significantly greater number of diagnoses and ancillary services combined with nonsignificant trends toward decreased mortality, fewer emergency department visits, and fewer drugs prescribed. The team approach improves quality of care. Additional clinical studies evaluating the effectiveness of geriatric assessment teams should be made in other nursing homes.

When outside the norm is normal: interpreting lab data in the aged.

Laboratory tests that are frequently ordered in a primary care practice include complete blood count, arterial blood gases, erythrocyte sedimentation rate, creatinine clearance, and glucose tolerance. Yet, the impact of age-associated physiologic changes on interpretation of laboratory data has only recently been elucidated. With advancing age, many laboratory parameters increase or decrease, some remain unchanged, and the effect of age on still others remains unclear. Interpreting lab data in the elderly is further confounded by the multiple disease states, polypharmacy, and atypical disease presentations commonly found in this population. Additional clinical research is needed to better establish reference laboratory values in elderly patients.