State statutes limiting advance directives: death warrants or life sentences?

The compliance of doctors and nurses with do-not-resuscitate orders in Germany and Sweden

A questionnaire based on a case-scenario offering three levels of available information about the patients' wishes was circulated with the objective to evaluate compliance with do-not-resuscitate orders (DNR) and advance directives (AD) from a cross-cultural perspective. Replies from 191 doctors and 182 nurses from Germany and 104 doctors and 122 nurses from Sweden were studied. The frequency of cardiopulmonary resuscitation (CPR) performed against the patients wishes varied between 32.5% (German doctors for DNR-scenario) and 8.3% (Swedish nurses for AD-scenario). The variance regarding the CPR decision could be explained by the help obtained by increasing information regarding the patients wishes and preferred treatment options. Since compliance is related to detailed information given by the patient the use of DNRs and ADs should be encouraged to a larger extent.

Advanced lung disease. Palliation and terminal care

Considering that lung disease is the fourth leading cause of death in the United States, remarkably little has been written about palliative care for patients who die of respiratory disease. Because most such deaths are anticipated, palliative care should begin with advance medical planning, ideally in the form of a prescheduled meeting among the physician, the patient, and the patient's proxy for health affairs. Home hospice care should be considered when a patient with progressive lung disease is largely confined to the bedroom because of dyspnea. Medical attention during the terminal phase of a respiratory illness should focus on the experience of the patient. Common symptoms amenable to counseling and pharmacotherapy include dyspnea, pain, anxiety, insomnia, and depression. If initiated to no benefit, mechanical ventilation can be terminally withdrawn with the concurrence of the patient or family. The withdrawal process should be family centered, and followed by continued supportive care until the patient dies.

Medical care of nursing home residents

OBJECTIVE

To present an overview of the special challenges of providing medical care for nursing home residents.

DESIGN

After researching the current medical literature, we summarized information on nursing home demographics, government regulations, and specific care issues for medical practice in nursing homes.

RESULTS

Almost 2 million Americans currently live in more than 20,000 nursing homes nationwide, and these nursing home residents are increasingly older and more frail than in the past. Most nursing home residents receive multiple prescription medications, and many are cognitively and functionally impaired. Nursing home-acquired infections are a frequent occurrence, as are falls and fall-related injuries. Recent federal laws have had a major effect on medical care in the nursing home and have made physicians more accountable for the care provided. The use of physical restraints and psychotropic drugs has been severely restricted.

CONCLUSION

The medical care of nursing home residents presents many challenges to primary-care physicians. Nevertheless, nursing home residents are among those patients in greatest need of competent, compassionate care. Despite numerous disincentives, provision of medical care for nursing home residents can be gratifying.

Living and dying in the Jewish way: secular rights and religious duties

This article compares and contrasts the modern American secular emphasis on individual rights and autonomous decision making in the "right to die" context with the traditional emphasis on obligation to others and to God found in Orthodox Judaism. The approach of Conservative and Reform Judaism to decision-making about life-sustaining medical treatments also is explicated and used as the basis for posing a variety of questions regarding the proper balance and relative influence of religious and secular values for modern American Jews in grappling with the difficult ethical dilemmas posed by "right to die" scenarios.