Clinical outcomes of integrated psychiatric and general medical care.

This pilot study explored the feasibility of providing integrated primary and psychiatric care in a primary care setting and compared preliminary outcomes to those from a traditional care model. The study population consisted of 23 patients who received integrated medical and psychiatric care in a primary care clinic and 23 comparison patients who received medical care in a primary care clinic and psychiatric care in a separate mental health clinic. This study suggests that integrated care can be provided to chronically mentally ill patients in a primary care setting and generate outcomes comparable to those of standard care.

Attitudes and experiences of Oregon hospice nurses and social workers regarding assisted suicide.

BACKGROUND: When the Oregon Death with Dignity Act (ODDA) legalizing physician-assisted suicide was enacted into law in 1997, Oregon hospice clinicians were uncertain how involved they would be with patients who wanted this option. However, 86% of the 171 persons in Oregon who have died by lethal prescription were enrolled in hospice programmes. METHOD: A mailed questionnaire was sent to all hospice nurses and social workers in Oregon in 2001 (n=573) to assess their attitudes about legalized assisted suicide and interactions with patients concerning this issue. Responses from 306 nurses and 85 social workers are included in this report. FINDINGS: Almost two-thirds of respondents reported that at least one patient had discussed assisted suicide as a potential option in the past year. Social workers were generally more supportive of both the ODDA and of patients choosing assisted suicide compared to nurses. Twenty-two per cent of all respondents were not comfortable discussing assisted suicide with patients. Ninety-five per cent of both groups, however, favoured hospice policies that would allow a patient to choose assisted suicide while enrolled in hospice and allow hospice clinicians to continue to provide care. INTERPRETATIONS: Nurses and social workers in hospices and other settings can expect to encounter patient questions about physician-assisted suicide, whether legalized or not, and must be prepared to have these discussions. Most hospice professionals in Oregon do not believe that assisted suicide and hospice enrollment are mutually exclusive alternatives.

Nurses' experiences with hospice patients who refuse food and fluids to hasten death.

BACKGROUND: Voluntary refusal of food and fluids has been proposed as an alternative to physician-assisted suicide for terminally ill patients who wish to hasten death. There are few reports of patients who have made this choice. METHODS: We mailed a questionnaire to all nurses employed by hospice programs in Oregon and analyzed the results. RESULTS: Of 429 eligible nurses, 307 (72 percent) returned the questionnaire, and 102 of the respondents (33 percent) reported that in the previous four years they had cared for a patient who deliberately hastened death by voluntary refusal of food and fluids. Nurses reported that patients chose to stop eating and drinking because they were ready to die, saw continued existence as pointless, and considered their quality of life poor. The survey showed that 85 percent of patients died within 15 days after stopping food and fluids. On a scale from 0 (a very bad death) to 9 (a very good death), the median score for the quality of these deaths, as rated by the nurses, was 8. On the basis of the hospice nurses' reports, the patients who stopped eating and drinking were older than 55 patients who died by physician-assisted suicide (74 vs. 64 years of age, P<0.001), less likely to want to control the circumstances of their death (P<0.001), and less likely to be evaluated by a mental health professional (9 percent vs. 45 percent, P<0.001). CONCLUSIONS: On the basis of reports by nurses, patients in hospice care who voluntarily choose to refuse food and fluids are elderly, no longer find meaning in living, and usually die a "good" death within two weeks after stopping food and fluids.

Oregon hospice nurses and social workers' assessment of physician progress in palliative care over the past 5 years.

BACKGROUND: The 1997 enactment of the Oregon Death with Dignity Act intensified interest in improving physician education and skills in caring for patients at the end of life. OBJECTIVE: To obtain hospice nurse and social workers' collateral ratings of efforts made by Oregon physicians to improve their palliative care skills over the previous 5 years. DESIGN: A descriptive survey of nurses and social workers from all 50 Oregon outpatient hospice agencies. MEASUREMENT AND RESULTS: Oregon hospice nurse (N=185) and social worker (N=52) respondents, who had worked in hospice for at least 5 years, rated changes they observed over the past 5 years in physicians' approach to caring for their hospice clients. Six characteristics, including willingness to refer patients to hospice, willingness to prescribe sufficient pain medications, knowledge about using pain medications in hospice patients, interest in caring for hospice patients, competence in caring for hospice patients, and fearfulness of prescribing sufficient opioid medications were evaluated. Positive changes were endorsed by the majority of respondents on all but the scale measuring fearfulness of prescribing opioid medications; on the latter, 47% of nurses rated doctors as less fearful, whereas 53% rated them as about the same or more fearful than they were 5 years earlier. CONCLUSIONS: Most respondents rated Oregon physicians as showing improvements in knowledge and willingness to refer and care for hospice patients.

Experiences of Oregon nurses and social workers with hospice patients who requested assistance with suicide.

BACKGROUND: Oregon's 1997 Death with Dignity Act legalizes physician-assisted suicide. To date, information about patients who have requested this option has come from surveys of physicians. Although 78 percent of the 91 Oregonians who have died by assisted suicide were enrolled in hospice programs, there is little information about the experiences of hospice practitioners with these patients. METHODS: In 2001, we mailed a questionnaire to all hospice nurses and social workers in Oregon. RESULTS: Of 545 eligible hospice nurses and social workers, 397 (73 percent) returned the survey, including 71 percent of nurses and 78 percent of social workers. Since November 1997, 179 of the respondents (45 percent) had cared for a patient who requested assistance with suicide. Hospice nurses reported on 82 patients who had received prescriptions for lethal medication. Ninety-eight percent of the nurses had discussed the request with a coworker, and 77 percent of the requests had been presented at a hospice interdisciplinary conference on patient care. A very important reason for the request was to control the circumstances of death. The least important reasons included depression, lack of social support, and fear of being a financial drain on family members. Although the patients were concerned about burdening others, only 11 percent of hospice nurses rated their family caregivers as more burdened than family caregivers for other hospice patients. CONCLUSIONS: Since assisted suicide was legalized in Oregon, many hospice nurses and social workers have provided care for a patient who requested assistance with suicide. They rated desire for control as a very important reason for these requests.