Advance directives: legal remedies and psychosocial interventions.

Although the legal basis to refuse life supports is firmly embedded in the laws of all 50 states, there is evidence that a gap exists between patients' preferences and physicians' actions. Patients and their families have increasingly begun to turn to the courts for redress, requesting damages when a physician has ignored their request to forgo life-sustaining treatment. This article explores the reasons why patients' end-of-life medical choices are often ignored by the medical profession and the results of recent attempts to remedy these situations through the courts. Implications for practice are discussed, including practical suggestions for increasing the likelihood that a patient's wishes will be respected by medical providers.

Dynamic changes in cerebral glucose metabolism in conscious infant monkeys during the first year of life as measured by positron emission tomography.

Recently, advances in spatial resolution have provided the opportunity to utilize positron emission tomography (PET) to examine local cerebral metabolic rates for glucose (lCMR(glc)) in large animals noninvasively, thereby allowing repeated lCMR(glc) measurements in the same animal. Previous studies have attempted to describe the ontogeny of cerebral glucose metabolism in anesthetized nonhuman primates using [18F]fluorodeoxyglucose (FDG) and PET. However, the use of sedation during the tracer uptake period may influence lCMR(glc). This study was conducted to describe lCMR(glc) in conscious infant vervet monkeys (Cercopithecus aethiops sabaeus) during the first year of life utilizing FDG-PET. Cross-sectional studies (n=23) displayed lowest and highest lCMR(glc) in all structures at the 2-3 and 8-9 month age groups, respectively. The metabolic pattern suggested an increase in lCMR(glc) values between 2 and 8 months of age with decreased metabolism observed at 10-12 months of age in all regions. Peak lCMR(glc) values at 8 months were an average of 84+/-24% higher than values seen at the youngest age examined quantitatively (2-3 months). The regions of greatest and smallest increases in lCMR(glc) at 8 months were the cerebellar hemispheres (90%) and the thalamus (39%), respectively. Longitudinal analysis in 4 animals supported this developmental pattern, demonstrating the ability to detect changes in cerebral glucose metabolism within animals and the potential for FDG-PET in nonhuman primate models of brain maturation. By determining the normative profile of lCMR(glc) during development in monkeys, future application of FDG-PET will provide the opportunity to longitudinally assess the effects of environmental or pharmacological intervention on the immature brain.

Home-based multicomponent rehabilitation program for older persons after hip fracture: a randomized trial.

OBJECTIVE: To determine whether a home-based systematic multicomponent rehabilitation strategy leads to improved outcomes relative to usual care. DESIGN: A randomized controlled trial with 12 months of follow-up. SETTING: General community; 27 home care agencies. PARTICIPANTS: Three hundred four nondemented persons at least 65 years of age who underwent surgical repair of a hip fracture at two hospitals in New Haven, CT, and returned home within 100 days. INTERVENTION: Systematic multicomponent rehabilitation strategy addressing both modifiable physical impairments (physical therapy) and activities of daily living (ADL) disabilities (functional therapy) versus usual care. MAIN OUTCOME MEASURES: A battery of self-report and performance-based measures of physical and social function. RESULTS: There was no significant difference in the proportion of participants in the two groups who recovered to prefracture levels in self-care ADL at 6 months (71% vs 75%) or 12 months (74% in both groups) or in home management ADL at 6 months (35% vs 44%) or 12 months (44% vs 48%). There also was no difference between the two groups in social activity levels, two timed mobility tasks, balance, or lower extremity strength at either 6 or 12 months. Compared with participants who received usual care, those in the multicomponent rehabilitation program showed slightly greater upper extremity strength at 6 months (p = .04) and a marginally better gait performance (p = .08). CONCLUSIONS: The systematic multicomponent rehabilitation program was no more effective in promoting recovery than usual home-based rehabilitation. Compared with previous cohorts, however, participants randomized to usual care in our study received more rehabilitative and home care services and experienced a higher rate of recovery. This finding is important given the current pressures to reduce home services. The challenge is to determine the composition and duration of rehabilitation and home services that will ensure optimal functional recovery most efficiently in older persons after hip fracture.

Application of positron emission tomography to determine cerebral glucose utilization in conscious infant monkeys.

Cerebral glucose metabolism has been used as a marker of cerebral maturation and neuroplasticity. In studies addressing these issues in young non-human primates, investigators have used positron emission tomography (PET) and [18F]2-fluoro-2-deoxy-D-glucose (FDG) to calculate local cerebral metabolic rates of glucose (1CMRG1c). Unfortunately, these values were influenced by anesthesia. In order to avoid this confounding factor, we have established a method that permits reliable measurements in young conscious vervet monkeys using FDG-PET. Immature animals remained in a conscious, resting state during the initial 42 min of FDG uptake as they were allowed to cling to their anesthetized mothers. After FDG uptake, animals were anesthetized and placed in the PET scanner with data acquisition beginning at 60 min post-FDG injection. FDG image sets consisted of 30 planes separated by 1.69 mm, parameters sufficient to image the entire monkey brain. Our method of region-of-interest (ROI) analysis was assessed within and between raters and demonstrated high reliability (P < 0.001). To illustrate that our method was sensitive to developmental changes in cerebral glucose metabolism, quantitative studies of young conscious monkeys revealed that infant monkeys 6-8 months of age exhibited significantly higher 1CMRG1c values (P < 0.05) in all regions examined, except sensorimotor cortex and thalamus, compared to monkeys younger than 4 months of age. This method provided high resolution images and 1CMRG1c values that were reliable within age group. These results support the application of FDG-PET to investigate questions related to cerebral glucose metabolism in young conscious non-human primates.

Confidentiality of social work records in the computer age.

Computers have brought social, cultural, and economic benefits. They also are challenging social workers to preserve a basic tenet of the profession--confidentiality. Electronic record systems and rapid changes in communication over the Internet are outpacing the profession's ability to ensure privacy. This article discusses ideas of information protection and makes recommendations to minimize violations of privacy.

The mental health provider's view.

What do we want from primary care physicians to make their care of our patients better and our jobs less difficult? We want reasonable access to primary care services, effective communication, reduction in excessive practice interference, and flexible collaboration.

The integrated system's view.

Truly integrated systems in public sector settings have been few, and most of us are operating in uncharted waters. However, we can embark on this new effort with some eagerness and confidence that collaboration will contribute significantly to the care of our mutual patients.

Who dies at home? Determinants of site of death for community-based long-term care patients.

OBJECTIVE: To determine characteristics associated with site of death in a cohort of long-term homecare patients. DESIGN: Cohort study. SETTING: Community-based long-term care program. SUBJECTS: All patients 65 years of age or older who died within 1 year of admission during 1989 and 1990. MAIN OUTCOME MEASURE: Site of death. RESULTS: Of 620 subjects, site of death was hospital for 302 (49%), home for 132 (21%), nursing home for 124 (20%), and inpatient hospice for 45 (7%). Among patients living at home before death, factors associated with dying at home rather than in a hospital or inpatient hospice included female gender (relative risk (RR) 1.40, 95% confidence interval (CI) 1.00, 1.90); severely dependent functional status (RR 2.38, CI 1.39, 4.17) and cognitive status (RR 1.51, CI 1.10, 2.06); and dying of cancer (RR 1.68, CI 1.11, 2.55), chronic lung disease (AOR 1.75, CI 1.04, 2.95), or coronary artery disease (RR 1.93, CI 1.21, 3.09). Living with a child (RR 1.45, CI .99, 2.11) showed a trend toward association with dying at home. CONCLUSIONS: Even among a subgroup of older persons receiving community-based long-term care, the frequency of home death is low. The finding of an association between functional, social, and disease status and site of death suggests that the relationship between these factors and patients' preferences and care needs must be examined in order to understand how to optimize the site of terminal care.

A psychiatric defense of aid in dying.

In November 1997, the voters of Oregon resoundingly affirmed the Oregon Death With Dignity Act. This law allows competent, terminally ill persons who are suffering in the final 6 months of life to obtain a lethal prescription from a physician. This paper presents a psychiatric defense of the Death With Dignity Act including the role of mental health professionals in evaluating competence in compliance with the law. Ethical, logistical, and political issues related to aid-in-dying are reviewed and a strategy for assessing competence is offered.

A three-decade perspective on community and public psychiatry training in Oregon.

The public psychiatry training program at Oregon Health Sciences University, established in 1973, educates psychiatric residents to work in community mental health centers and state hospitals. The authors present a brief history of this program, which spans three decades, and describe recent developments in its operation, with special attention to financing, administrative structure, and educational elements. Several program graduates have chosen careers in public-sector work. The program is founded on the principle that just as dollars should follow patients in health care systems, so should residents in training follow patients. Administrative and fiscal arrangements must be flexible to support this mobility.

Survival of premenopausal women with breast carcinoma: effects of menstrual timing of surgery.

BACKGROUND: It is controversial whether the timing of tumor excision relative to the menstrual cycle influences the survival of patients with breast carcinoma. METHODS: Premenopausal patients (n=614) who had surgery for invasive, nonmetastatic breast carcinoma during the period 1978-1988 participated in an epidemiologic survey, reporting their menstrual cycle length and the date of their last menses. We ascertained deaths from any cause before 1993. RESULTS: Using Cox modeling, we found a nonlinear variation in the relative risk (RR) of death according to the timing of surgery during the menstrual cycle. The curve was best described by a cosine transformation of a 28-day cycle. For patients who had breast carcinoma surgery on the estimated day of ovulation, the risk of death was 0.59 (95% confidence limits [CLI=0.39-0.89, P=0.013) compared with patients who had surgery at the approximate time of menses. We observed this for patients treated in 1978-1981 (RR=0.43, 95% CL=0.23-0.83, P=0.011) and 1982-1983 (0.25, 95% CL=0.10-0.63, P=0.003), but not in 1984-1988 (1.48, 95% CL=0.64-3.4). The difference observed for 1984-1988 was explained by a significant improvement in the mortality rate (P=0.0004) for women whose surgery took place during menses or near to the date predicted for the next menses. No such improvement for women who underwent breast carcinoma surgery around the time of ovulation was observed during the period 1984-1988. These changes were not explained by the performance of lumpectomy or the increasing interval between biopsy and tumor excision. CONCLUSIONS: The shape of the survival curve contradicted the idea that it could be explained by levels of circulating estradiol or progesterone. Because observations that surgery was affected by menstrual timing seem not to have persisted beyond the mid-1980s, this study should not be used to support recommendations that surgeons perform breast carcinoma surgery on any particular day of the menstrual cycle.

Is there a role for physician assistants in community mental health?

The authors briefly describe the history and development of the medical discipline of physician assistants (PAs). A careful review of the literature reveals the limited use of PAs in psychiatry, usually only for primary health care needs. A model for using PAs as psychiatric assistants is presented, including the training required and a description of the clinical and administrative functions. The advantages of such a model are multiple. These include: 1) more effective and efficient use of the psychiatrist; 2) reduced costs of service; 3) increased primary medical screening capability in the CMHC; and 4) increased presence of ethnic minorities on the professional staff of the CMHC. Disadvantages of the model relate to training and "turf" issues. In view of the shortage and dissatisfaction of psychiatrists in CMHC settings, and other challenges to the provision of quality mental health care in the community, this model should be considered as a logical and positive response to that challenge. If the model is valid, then training facilities must make a systematic effort to recruit, train, and place psychiatric physician assistants in community agencies.

Factors associated with six-month mortality in recipients of community-based long-term care.

OBJECTIVES: To determine factors associated with short-term mortality in recipients of community-based long-term care (CBLTC). DESIGN: A cohort study. SETTING: A Medicaid home- and community-based waiver and state-funded homecare program. PARTICIPANTS: All persons age 65 and older newly admitted to the program from January 1, 1988, to March 31, 1991. MEASUREMENTS: Demographics, functional, cognitive, and health status, depression, and social support were obtained in an admission assessment. Six-month mortality data were obtained by linking assessment data to a state mortality registry. RESULTS: There were 718 deaths among 6784 CBLTC clients. Male sex (AOR 1.8, 95% CI 1.5-2.1), the presence of cancer (AOR 3.2, CI 2.6-3.9), heart disease (AOR 1.3, CI 1.1-1.5), chronic obstructive pulmonary disease (AOR 1.8, CI 1.4-2.2), or nutritional problems (AOR 1.7, CI 1.4-2.0), functional impairment (AOR for lowest compared to highest quartile 2.9, CI 2.0-4.1), severe cognitive impairment (AOR 1.6, CI 1.3-2.1), self-assessment of health as poor (AOR 1.5, CI 1.1-2.0), feeling depressed (AOR 1.2, CI 1.1-1.3), and hospitalization (AOR 2.7, CI 2.2-3.2) were independently associated with 6-month mortality in bivariate and multivariate analyses. CONCLUSIONS: Clinical data obtained during routine assessment of CBLTC clients can be used to assess short-term mortality. Six-month mortality is associated with poor functional and cognitive status, the presence of cancer, heart disease, COPD, and nutritional problems, depression, perception of poor health, and hospitalization.

Population-based guidelines for performance measurement: a preliminary report.

This paper describes the development of--and early efforts to validate--guidelines that indicate average amounts of service expected to be used by a population of patients with a given disorder who are served by a comprehensive mental health system. These guidelines address expected service use by individuals in 55 diagnostic groups. The purpose of these guidelines is to provide a gauge for evaluating the amounts of service being delivered by managed care organizations. Three population-based guidelines (for attention-deficit/hyperactivity disorder, major depressive disorder, and schizophrenia) are compared to actual amounts of service delivered to enrollees in large behavioral health care systems.

Systematic home-based physical and functional therapy for older persons after hip fracture.

OBJECTIVE: To describe the development, implementation, and results of a home-based rehabilitation protocol for older persons after hip fracture. DESIGN: Demonstration study. SETTING: Community. PARTICIPANTS: One hundred forty-eight community-living, nondemented participants at least 65 years of age who underwent repair of a fractured hip at two local hospitals. INTERVENTION: A linked assessment-intervention, home-based rehabilitation strategy. The physical therapy (PT) component of the intervention was designed to identify and ameliorate impairments in balance, strength, transfers, gait, and stair climbing; the functional therapy (FT) component was designed to identify and improve unsafe and/or inefficient performance of specific activities of daily living (ADL). MAIN OUTCOME MEASURES: The percentage of participants able to complete each component and the extent of progress noted in strength, balance, transfers, gait, and daily functioning. RESULTS: A total of 104 of the 148 participants (70%) completed the 6-month PT and FT program; 4 completed only PT and 6 refused both PT and FT. The remaining 32 participants (22%) received partial PT and FT that was terminated by death, hospitalization, or institutionalization. Seventy-seven percent of participants reported performing at least half of the recommended daily exercise sessions. Ninety-four percent and 96% of participants progressed in upper and lower extremity conditioning respectively; 33% progressed to the highest level in the graduated resisted exercise program. All participants progressed in the competency-based graded balance program, with 55% progressing to the fifth (most difficult) level. Similarly, the majority progressed in transfer maneuvers, stair climbing, and outdoor gait. One repetition maximum (RM) elbow extension increased from a mean of 5.8 (SD 4.6) pounds at baseline to 7.2 (SD 3.8) pounds at 6mo (t 2.22; p < .02). One RM knee extension increased from 5.8 (SD 5.8) pounds to 10.8 (SD 5.4) pounds (t = 8.06; p < .0001). The number of gait deviations decreased from 2.1 (SD 1.3) to 0.6 (SD 0.9) (p < .0001), while the mean modified Berg Balance Scale Score increased from 13.0 (SD 4.8) to 20.5 (SD 6.8) (t = 16.6; p < .0001). Finally, the Total ADL Score increased from a mean of 48.2 (SD 15.0) to 77.7 (SD 18.8) (t = 17.03; p = .0001). CONCLUSIONS: This systematic assessment and intervention protocol, targeting impairments and ADL, was feasible, safe, and effective. Protocols such as the one presented should enhance the ability to implement rehabilitation programs for the increasing number of multiply impaired older persons receiving home-based therapy and to document the process and outcomes of this care.

The credibility of nonprofit boards: a view from the 1990s and beyond.

The wrongdoings of nonprofit organizations have become grist for the media mill. The authors explore five of the more recently publicized cases of nonprofits gone wrong: the United Way of America, National Association for the Advancement of Colored People, Foundation for New Era Philanthropy, Jewish Community Center of Greater Washington, and Upsala College, and their significance in regard to the role and functioning of the board. Discussion focuses on the implications of these cases in regard to nonprofits' credibility and strategic options for enhancing accountability. Unless governing boards address some of their deficiencies, tighter government regulations, increased donor skepticism, and greater demands and expectations upon them will result.

The role of psychiatrists in community mental health centers: a survey of job descriptions.

There is little data about the role of psychiatrists within CMHCs. To gain perspective on this issue, job descriptions for medical directors and staff psychiatrists were collected from 214 CMHCs. The data demonstrated that most CMHCs want fully trained psychiatrists involved in a variety of activities in addition to prescribing medication. Policy development was specifically included as part of the medical director's job for 69% of the CMHCs, and 50% mentioned training as part of the staff psychiatrist's job. Although job descriptions may not accurately reflect the actual roles of the psychiatrist in all cases, these data suggest that CMHCs support a multifaceted role for their psychiatrists.

Altered patterns of retinoblastoma gene product expression in adult soft-tissue sarcomas.

Altered expression of the retinoblastoma (RB) tumour-suppressor gene product (pRB) has been detected in sporadic bone and soft-tissue sarcomas. Earlier studies, analysing small cohorts of sarcoma patients, have suggested that these alterations are more commonly associated with high-grade tumours, metastatic lesions and poorer survival. This study was designed to re-examine the prevalence and clinical significance of altered pRB expression in a large and selected group of soft-tissue sarcomas from 174 adult patients. Representative tissue sections from these sarcomas were analysed by immunohistochemistry using a well-characterised anti-pRB monoclonal antibody. Tumours were considered to have a positive pRB phenotype only when pure nuclear staining was demonstrated, and cases were segregated into one of three groups. Group 1 (n = 36) were patients whose tumours have minimal or undetectable pRB nuclear staining (< 20% of tumour cells) and were considered pRB negative. Patients with tumours staining in a heterogeneous pattern (20-79% of tumour cells) were classified as group 2 (n = 99). The staining of group 3 (n = 39) was strongly positive with a homogeneous pRB nuclear immunoreactivity (80-100% of tumour cells). pRB alterations were frequently observed in both low- and high-grade lesions. Altered pRB expression did not correlate with known predictors of survival and was not itself an independent predictor of outcome in the long-term follow-up. These findings support earlier observations that alterations of pRB expression are common events in soft-tissue sarcomas; nevertheless, long-term follow-up results indicate that altered patterns of pRB expression do not influence clinical outcome of patients affected with soft-tissue sarcomas. It is postulated that RB alterations are primary events in human sarcomas and may be involved in tumorigenesis or early phases of tumour progression in these neoplasias.