Patients' knowledge of options at the end of life: ignorance in the face of death.

CONTEXT: Effectiveness of legislation promoting advance directives and legalizing physician-assisted suicide depends on patients' understanding their legal options about end-of-life care. However, outpatients' understanding of their legal options at the end of life has not been studied. OBJECTIVES: To estimate the percentage of outpatients who are informed about 4 areas relevant to end-of-life care: refusal and withdrawal of lifesaving treatments, physician-assisted suicide, active euthanasia, and double effect; and to determine whether authoring advance directives, experiencing illness, acting as a proxy for health care decisions, and caring for an ill loved one are associated with better knowledge in end-of-life care. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: One thousand consecutive English-speaking, adult patients attending 1 university-based internal medicine clinic and 3 community-based, university-affiliated, mixed internal medicine and family practice clinics in Oregon during May and June 1999. MAIN OUTCOME MEASURES: Percentage of correct responses in the 4 topic areas and total knowledge score, adjusted for demographic (eg, age, race, educational level, income level, marital status) and experiential (eg, health, proxy decision making, advance directives, and death of a loved one) factors. RESULTS: Of the 1000 patients invited to participate, 728 (73%) consented and completed the questionnaire and were included in the analysis. A total of 69% of respondents answered correctly regarding refusal of treatment, 46% for withdrawal of treatment, 23% for assisted suicide, 32% for active euthanasia, and 41% for double effect. Sixty-two percent of respondents did not distinguish between assisted suicide and euthanasia. After adjustment for other covariates, better knowledge was significantly associated with white race (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3-4.2), having at least a college degree (OR, 3.0; 95% CI, 1.4-6.7), and having been a proxy for health care decisions (OR, 1.8; 95% CI, 1.2-2.6). Personal experience with illness (OR, 1.0; 95% CI, 0.6-1.5), death or illness of a loved one (OR, 1.6; 95% CI, 1.0-2.7), and authoring an advance directive (OR,1.3; 95% CI, 0.9-2.0) were not associated with better knowledge. CONCLUSIONS: A significant proportion of outpatients at university-affiliated clinics in Oregon appear to misunderstand options in end-of-life care. Our results suggest that greater public knowledge about end-of-life care is needed, and advance care planning must be preceded by education about options in end-of-life care. JAMA. 2000;284:2483-2488.

Medical students' attitudes toward physician-assisted suicide.

CONTEXT: In November 1994, Oregon became the first US state to legalize physician-assisted suicide (PAS) as an option for end-of-life care. OBJECTIVE: This study compares the attitudes and experiences of medical students in Oregon regarding PAS to those of fourth-year medical students in the United States outside Oregon. DESIGN: A survey of all students at the Oregon Health Sciences University and fourth-year medical students at 3 non-Oregonian US medical schools. PARTICIPANTS: Oregon medical students returned 227 questionnaires (58%), and 113 were returned from control schools (33%). RESULTS: A similar percentage of both study groups favored the legalization of PAS (64% vs 66%; P = .74). If the practice were legal, 55% of the total surveyed reported they "might be willing to write a lethal prescription," (50% Oregon students vs 60% control; P = .13 and 44% fourth-year Oregon students vs 60% control; P = .04). Among fourth-year students, 20% reported a request by a patient to the student or a preceptor for a lethal prescription in the past year (26% vs 16%; P = .09). CONCLUSIONS: This study demonstrates support for and willingness by many medical students to participate in PAS. Some medical students reported observation of PAS during their training experience. Fourth-year Oregon students reported significantly less willingness than other students to provide a patient with a lethal prescription, perhaps indicating hesitancy to include PAS in clinical practice.

Cyclic GMP-independent mechanisms of nitric oxide-induced vasodilation.

1. The aim of the present study was to test in vitro if NO acts through a cyclic GMP-independent mechanism to activate Ca2+-dependent potassium channels (K+(Ca)), leading to membrane hyperpolarization and vasodilation in rat tail artery. 2. Acetylcholine and sodium nitroprusside stimulated a significant increase in cyclic GMP (190+/-23 and 180+/-15 pmol/g, respectively) compared with agonist-free conditions (132+/-15 and 130+/-15 pmol/g, respectively); these agonist-mediated increases in cyclic GMP were completely abolished by treatment with the guanylate cyclase inhibitor methylene blue (122+/-10 and 60+/-8 pmol/g, respectively). 3. In contrast, relaxation to acetylcholine (10(-7) mol/l; 61+/-3%) and sodium nitroprusside (10(-8) mol/l; 97+/-1%) were significantly, but not completely, attenuated by methylene blue (30+/-5 and 79+/-3%, respectively); maximum relaxation to sodium nitroprusside (10(-7) mol/l) was unaffected by methylene blue. 4. Depolarization-induced contraction of vessels with KCl inhibited relaxation to both acetylcholine (10(-7) mol/l; 18+/-4%) and sodium nitroprusside (10(-8) mol/l; 57+/-7%). Furthermore, the specific K+(Ca) antagonist charybdotoxin significantly inhibited relaxation to sodium nitroprusside (10(-8) mol/l; 52+/-7%). 5. An additive inhibitory effect on relaxation to sodium nitroprusside (10(-8) mol/l) was observed with a combination of methylene blue and KCl (26+/-6%) or charybdotoxin (34+/-3%). 6. These data suggest that NO stimulates membrane hyperpolarization via K+(Ca) activation, in addition to guanylate cyclase, to cause relaxation in rat tail artery.

Vascular relaxation and cGMP in hypertension.

Isolated aortas from hypertensive rats have a decreased relaxation response to acetylcholine chloride (ACh), the calcium ionophore A23187, and sodium nitroprusside (SNP). Since the vascular relaxation responses to these vasodilators may be a result of increases in guanosine 3',5'-cyclic monophosphate (cGMP), we measured the cGMP response to these agents in isolated aortas from normotensive rats and rats with either mineralocorticoid-induced hypertension (DOCA), renovascular hypertension (1K1C), or coarctation-induced hypertension (Coarc). The aortas from the hypertensive rats had decreased basal levels of cGMP and attenuated increases in cGMP in response to ACh and A23187. Rises in cGMP in response to SNP were also attenuated in aortas from the hypertensive rats, even at concentrations that induced maximum relaxation of blood vessels from normotensive and hypertensive rats. The relaxation responses to atrial natriuretic factor (ANF) and the cGMP generated in isolated aortas by ANF were attenuated in hypertension. Removal of the endothelium markedly attenuated cGMP generation in response to ANF in vessels from normotensive and Coarc rats, but the relaxation responses to ANF were unaltered in vessels after the removal of the endothelium. The reversal of experimentally induced hypertension was associated with increases in cGMP levels following exposure of the isolated vessels to ACh. Also, vessels treated with methylene blue relaxed in response to SNP despite inhibition of cGMP accumulation. The decreased relaxation response to endothelium-dependent vasodilators is accompanied by decreases in cGMP accumulation; the decreased vascular cGMP content in response to endothelium-dependent vasodilators is not due to increases in phosphodiesterase activity of vascular smooth muscle; and SNP may relax blood vessels through "cGMP-dependent" and "cGMP-independent" mechanisms.