Pediatric asthma pathway in the emergency room

Asthma is one of the leading causes of hospital admission in the pediatric population. Standardization of asthma management guidelines for patients admitted to the emergency department has been suggested to improve care delivery and patient outcomes. Utilizing a multidisciplinary asthma task force at a single academic medical center, we sought to determine if a protocol-driven approach to implementation of care for patients with asthma could improve patient outcomes by reducing wait times for administration of steroids. A prospective cohort study examined the use of a standardized asthma pathway over a 2-year period compared to historical controls. Pathway use significantly decreased time to corticosteroid administration (45 vs. 29 min [year 1] and 20 min [year 2]; P < 0.0001). By implementing this standard of care at pediatric emergency departments, time to treatment can be decreased, therefore improving the morbidity and mortality of pediatric patients with asthma nationwide.

Therapeutic effect of flax-based diets on fatty liver in aged laying hens

This study examined the ability of flax-based ingredients to attenuate nonalcoholic fatty liver disease ( NAFLD: ) in aged laying hens-a novel and more physiologically relevant model of human disease. Our results showed only hens supplemented with whole flaxseed ( WFX: ) reduced steatosis and hepatocellular ballooning. Serum AST was also reduced in hens provided WFX and defatted flaxseed meal ( DFM: ). Hepatic ω-3 PUFA enrichment was improved with supplementation of WFX, DFM, and flaxseed oil ( FXO: ). However, this effect was more evident in the WFX group. In contrast, transcript abundance of genes linked to NAFLD were predominantly modified with FXO supplementation. Taken together, our data indicate a potential synergistic relationship between the fatty acid and lignan content in flaxseed which attenuated the progression of NAFLD in aged laying hens. Although more research is necessary, these findings demonstrate the potential use of whole flaxseed for the treatment and prevention of NAFLD in humans.

Dilated perivascular spaces in the Basal Ganglia are a biomarker of small-vessel disease in a very elderly population with dementia

BACKGROUND AND PURPOSE

Dilated perivascular spaces have been shown to be a specific biomarker of cerebral small-vessel disease in young patients with dementia. Our aim was to examine the discriminative power of dilated cerebral perivascular spaces as biomarkers of small-vessel disease in a very elderly population of patients with dementia.

MATERIALS AND METHODS

We studied healthy volunteers (n = 65; mean age, 78 ± 5.6 years) and subjects with vascular dementia (n = 39; mean age, 76.9 ± 7.7 years) and Alzheimer disease (n = 47; mean age, 74.1 ± 8.5 years). We compared white matter hyperintensity and 2 semiquantitative perivascular space scoring systems (perivascular space-1 and perivascular space-2). Intra- and interobserver agreement was assessed by using a weighted Cohen κ statistic. Multinomial regression modeling was used to assess the discriminative power of imaging features to distinguish clinical groups.

RESULTS

White matter hyperintensity scores were higher in vascular dementia than in Alzheimer disease (P < .05) or healthy volunteers (P < .01). The perivascular space-1 score was higher in vascular dementia and Alzheimer disease than in healthy volunteers (P < .01). The perivascular space-2 score in the centrum semiovale showed no intergroup differences. However, perivascular space-2 in the basal ganglia was higher in vascular dementia than in Alzheimer disease (P < .05) or healthy volunteers (P < .001) and higher in Alzheimer disease than in healthy volunteers (P < .001). Modeling of dementia versus healthy volunteers, Alzheimer disease versus healthy volunteers, and vascular dementia against Alzheimer disease demonstrated perivascular space-2basal ganglia as the only imaging parameter with independent significant discriminative power (P < .01, P < .01, and P < .05) with areas under the receiver operating characteristic curve of 0.855, 0.774, and 0.71, respectively. Modeling of vascular dementia versus healthy volunteers showed that perivascular space-2basal ganglia (P < .01) and the modified Scheltens score (P < .05) contributed significant, independent discriminatory power, accounting for 34% and 13% of the variance in the model respectively.

CONCLUSIONS

Dilated perivascular spaces remain a valuable biomarker of small-vessel disease in an elderly population.

Directional limits on persistent gravitational waves using LIGO S5 science data

The gravitational-wave (GW) sky may include nearby pointlike sources as well as stochastic backgrounds. We perform two directional searches for persistent GWs using data from the LIGO S5 science run: one optimized for pointlike sources and one for arbitrary extended sources. Finding no evidence to support the detection of GWs, we present 90% confidence level (C.L.) upper-limit maps of GW strain power with typical values between 2-20×10(-50)  strain(2) Hz(-1) and 5-35×10(-49)  strain(2) Hz(-1) sr(-1) for pointlike and extended sources, respectively. The latter result is the first of its kind. We also set 90% C.L. limits on the narrow-band root-mean-square GW strain from interesting targets including Sco X-1, SN 1987A and the Galactic center as low as ≈7×10(-25) in the most sensitive frequency range near 160 Hz.

Soy protein isolate modified metabolic phenotype and hepatic Wnt signaling in obese Zucker rats

We have previously shown that soy protein isolate (SPI) with intact phytoestrogen content prevented obesity-related dysfunction. Recent data have suggested that soy ingredients may act as regulators of adipogenic programming in adipose tissue (AT) and liver. Thus, the current study was undertaken to determine whether the beneficial effects of SPI are linked to changes in adipogenic regulators, such as the Wnt signaling cascade. For this, lean (LZR) and obese Zucker (OZR) rats were provided isocaloric and isonitrogenous diets containing SPI, sodium caseinate, or dairy whey protein for 17 weeks. At termination, SPI increased body weight and total adiposity in rodents, which corresponded with an increase in both adipocyte size and number. Furthermore, markers of inflammation, hypercholesterolemia, and hepatic steatosis were all reduced in OZR rats provided SPI. Transcript abundance of several canonical and noncanonical Wnt signaling intermediates in liver, but not AT, was distinctly modified by SPI. Collectively, these data confirm the protective SPI attenuated obesity-related metabolic dysfunction conceivably through regulation of adipogenic programming, as evident by changes in AT morphology and hepatic Wnt signaling. Collectively, this study confirmed the potential utilization of soy protein and its bioactive ingredients for prevention and treatment of obesity-related comorbidities.

Design of novel melanocortin receptor ligands: multiple receptors, complex pharmacology, the challenge

The major pharmacophore for the melanocortin 1, 3, 4 and 5 receptors is the sequence -His-Phe-Arg-Trp-. There is a need for potent, biologically stable, receptor selective ligands, both agonists and antagonists, for these receptors. In this report we briefly examine the structural and biophysical approaches we have taken to develop selective agonist and antagonist ligands that can cross (or not) the blood brain barrier. Remaining questions and unmet needs are also discussed.

Barriers to human immunodeficiency virus testing of tuberculosis patients in Thailand, 2004-2007

SETTING

Tuberculosis (TB) clinics in five provinces and one national referral hospital in Thailand.

OBJECTIVE

To identify risk factors for TB patients not receiving human immunodeficiency virus (HIV) pre-test counseling and testing in Thailand.

DESIGN

We collected data on TB patients treated at participating facilities from 2004 to 2007. Patients with known HIV status at the time of TB diagnosis were excluded from the analysis. We performed multivariate logistic regression to determine patient and facility characteristics associated with HIV counseling and testing.

RESULTS

Of 15 903 TB patients, HIV pre-test counseling was provided to 13 604 (86%). HIV testing was provided to 11 702 (86%) of those counseled. Of 6141 patients with unknown HIV status, 2323 (38%) were treated in facilities that provide HIV testing in TB clinics compared with 6412 (58%) of 11 003 non-HIV-infected and 3814 (62%) of 6121 HIV-infected patients (P < 0.05). In multivariate analysis, patients treated in facilities in which HIV testing of TB patients was performed somewhere other than the TB clinic were significantly less likely to undergo HIV pre-test counseling (adjusted OR 1.55, 95%CI 1.28-1.86).

CONCLUSION

In Thailand, providing HIV testing directly in TB clinics, rather than in other settings, may increase the proportion of TB patients with known HIV status.

Biomarkers of cerebrovascular disease in dementia

There is increasing recognition that cerebrovascular disease contributes significantly to the development and progression of patients with dementia. The concepts of pure vascular and pure degenerative dementia have been replaced with a recognition that, in many patients, there is a spectrum of neurodegenerative and vascular processes. This is supported by preliminary studies showing response to vascular therapeutics and ventriculo-peritoneal shunting in patients with Alzheimer's disease. This article examines the imaging biomarkers that are available for the characterization of microvascular abnormality in the ageing brain, with particular reference to microvascular angiopathy, cerebral embolic disease, orthostatic hypotension and abnormalities of Monro-Kellie homeostasis.

Enhanced visual experiences and seeing hardware for reduced vision: a pilot study

BACKGROUND

Persons with vision loss may have limited ability to experience visual arts and difficulty navigating unfamiliar environments. The Center for Advanced Visual Studies at Massachusetts Institute of Technology developed a Retinal Imaging Machine Vision System (RIMVS) "seeing machine" to project "word-images" onto the retina and permit navigation through virtual architectural environments.

METHODS

Ten subjects with visual acuity < or = 20/70 in the better-seeing eye were recruited. Subjects viewed word-images that were projected on the retina of the better-seeing eye and asked to interpret the images. Subsequently, they were asked to recall as many images as possible. Participants also practiced navigation through a computer-modeled building that was projected onto the retina. A survey elicited subject response to the RIMVS.

RESULTS

Six subjects correctly interpreted all 10 word-images; no subject interpreted fewer than 8 correctly. Seven subjects felt that the word images afforded easy recall, and 7 subjects responded that the technology might assist subsequent navigation in unfamiliar environments.

CONCLUSIONS

Responses reflect a general interest and potential with the RIMVS. Further studies are warranted to explore the value of the RIMVS as a tool to enable visually compromised persons to experience and appreciate visual arts and as a navigation aid.

A retrospective comparison of remifentanil versus methohexital for anesthesia in electroconvulsive therapy

The electroconvulsive therapy (ECT) service at West Virginia University conducted a retrospective analysis of 24 patients who received bilateral ECT between November 1998 and December 2003. Patients were treated with a standard methohexital-based anesthetic. Twenty-four patients became completely or relatively refractory to maximum settings on the ECT device and were then switched to remifentanil as the sole induction agent. Seizure threshold was established by stimulus dose retitration. Stimulus dose in total charge (mC) and dynamic energy (J) was significantly lower with the remifentanil anesthetic versus methohexital. (P < 0.0001) Resulting motor and EEG seizure duration in patients was significantly longer receiving the remifentanil anesthetic versus methohexital. (P < 0.0001) Previous reports describe a rise in seizure threshold in patients for repeated ECT. Although this rise occurred during the treatment course using a methohexital anesthetic, this effect was greatly diminished when remifentanil was used as the sole anesthetic agent. We conclude that remifentanil can provide improved seizure response to ECT in patients who are refractory to seizure induction after a standard methohexital anesthetic. We also conclude that the increase in stimulus dose typically required with repeated treatments is related to the anesthetic regimen.

Goal setting & Network 9/10 efforts to improve care

TRN, through its Medical Review Board, has developed, endorsed, and articulated goals for two aspects of dialysis treatment. These goals promote the use of continuous quality improvement by encouraging dialysis programs to perform internal examinations of their own data in the context of regional and national data. TRN believes that this combination of data feedback, CQI, and goal setting will impact positively on patient outcomes for all dialysis patients within The Renal Network.

Laparoscopic surgical simulator and port placement study

We have developed a virtual laparoscopic surgical simulator and gathered data during student trial runs. The students performed simulated surgical dissections from 3 pairs of port positions with angles between the cutting and grasping instruments set to 60, 90, and 120 degrees. Preliminary data indicates improved performance at the 90 degree angle. Study updates can be found at http:¿www.hitl.washington.edu/research/lss

Contraceptive requirements for clinical research

OBJECTIVE

To survey the type and frequency of use of contraceptive requirements for entry into clinical trials.

METHODS

We reviewed 410 protocols submitted between January 1994 and January 1997 to one Institutional Review Board.

RESULTS

Contraception or sterility for women was required in 171 (41.7%) protocols without explanation and 146 (35.6%) based on study drug. Eight and one half percent hd no exclusions. Signature certification of contraceptive use was required in 138 protocols; 230 required certification of understanding requirements; and 101 required two signatures. Signature certification documenting no pregnancy at enrollment was required in 234 protocols. There were no requirements for signatures from male subjects. Celibacy or sexual orientation were not recognized as reasons for waiver from signature requirements.

CONCLUSION

The broad application of contraceptive requirements potentially creates disproportionate burdens and access by gender to participation in clinical research. Careful elucidation of methods, timing, and the consent process in order to avoid potential fetal risk and encourage inclusion of hormonally intact women will improve research and access.

The mentor effect in student evaluation

OBJECTIVE

To determine if faculty mentors rate their mentored students higher than do nonmentors, and to ascertain if gender is a factor.

METHODS

All third-year students (n = 101) from academic years 1996-1998, who performed their obstetrics and gynecology clerkship at the Milton S. Hershey Medical Center in the Penn State Geisinger Health System and were evaluated by full-time faculty (n = 18), were included in the study (total observations = 545). Students were rated by faculty on an ordinal scale in five categories. Generalized estimating equation methodology was used to fit proportional odds models for ordinal data to assess whether there were statistically significant mentor or faculty/student gender effects.

RESULTS

Student evaluations from mentors were more likely to have better scores than student evaluations from nonmentoring-faculty for all five categories (all P <.01). The odds ratios (OR) for the mentor effect ranged from 2.1 (95% confidence interval [CI] 1.4, 3.2) for fund of knowledge to 3.2 (95% CI [2.1, 4. 8]) for attitude. For problem-solving and technical skills, male faculty were more likely than female faculty to give male students better scores (problem-solving skills: odds ratio [OR] = 1.7, 95% CI [1.0, 2.7]; technical skills: OR = 2.2, 95% CI [1.1, 4.6]). Mentoring-faculty evaluations were not strongly correlated with the students' objective examination scores.

CONCLUSION

Overall, mentors score their mentored students statistically higher than do nonmentors. Gender differences in evaluation, while present, are less consistent and smaller than the mentor effect.

The value of acute care simulation

Simulation of crises has long been a component of training in the aviation and nuclear industries. This technology has been successfully transferred and adapted to acute care medicine and allied health care. In this article, we describe the capabilities and uses of human acute care simulation at West Virginia University Hospital.

Recommendations for incorporating palliative care education into the acute care hospital setting

This article presents recommendations for improving the education of physicians about end-of-life care in the acute care hospital setting. The authors, who have a variety of backgrounds and represent several types of institutions, formulated and reached consensus on these recommendations as members of the Acute Care Hospital Working Group, one of eight working groups convened at the National Consensus Conference on Medical Education for Care Near the End of Life in May 1997. A recently published literature review on the status of palliative care education, a summary of recent research on education about end-of-life care, and expert opinion were helpful in developing the recommendations. The authors emphasize that the acute care setting offers many opportunities for education about care at the end of life. Faculty should support learners' appreciation of the importance of end-of-life care, and convey the meaning and privilege of attending to patients and families at this difficult time. Faculty should teach students and residents to provide care that embodies attention to the control of distressing physical, physiologic, and spiritual symptoms, appropriate awareness of patients' differing cultural backgrounds and their impact upon the experience of dying, excellent communication skills, the application of bioethical principles, timely referral and smooth transition to other care settings that meet patient and family goals, and the role of the interdisciplinary team in meeting the diverse needs of dying patients and their families.

Ciliated hepatic foregut cyst: a study of six cases and review of the literature

Ciliated hepatic foregut cyst (CHFC) is a rare, benign, solitary cyst consisting of ciliated pseudostratified columnar epithelium, subepithelial connective tissue, a smooth muscle layer, and an outer fibrous capsule. We studied six previously unreported cases of CHFC and 50 cases from the literature. The literature search revealed that Friedreich first described the lesion in 1857 and hypothesized its congenital origin. The cyst generally is found incidentally on radiologic imaging or during surgical exploration, although one case presented with portal vein compression. It occurs more frequently in men and is found most commonly in the medial segment of the left hepatic lobe, unlike most other solitary cysts that show a female predominance and greater occurrence in the right hepatic lobe. Two of the 56 cases were multilocular. There has been an increase in the number of reports of CHFC during the past 15 years. This may reflect the increased availability and use of various radiologic imaging modalities. A large number of cases have been reported in the Japanese population, but the significance of this is unclear. CHFC should be considered in the differential diagnosis of other solitary liver cysts, including simple cysts, hepatobiliary cystadenomas, and parasitic cysts.

Oocyte donors as gynecologic teaching associates

OBJECTIVE

To fulfill the need for gynecologic teaching associates for an expanded pelvic examination module for third-year medical students, we sought women who were able to provide feedback to medical students. Oocyte donors were hypothesized as a useful potential pool of gynecologic teaching associates.

METHODS

Gynecologic teaching associates were recruited from a pool of women who were involved in our oocyte donor program. Students were evaluated on a scale of 1 (best) to 5 (worst) on their performance on the pelvic examination by themselves (n = 91), by the gynecologic teaching associate (n = 10), and by the supervising faculty (n = 6). Students were shown their evaluations, and these were reviewed at the end of the session to provide students with immediate feedback.

RESULTS

Students consistently ranked their skills lower than either the gynecologic teaching associate or supervising faculty member for all four categories evaluated (communication skills, technical skills, professional demeanor, and overall performance) (P < .001). Students gave their communications skills the highest mean rankings, whereas gynecologic teaching associates gave them the lowest. The highest correlation and agreement between pairs of evaluators were between the gynecologic teaching associate and the supervising faculty member. Gynecologic teaching associates and faculty members also were more likely to praise the students' performance in written comments (chi2 58.2, P < .001), whereas no student found anything praiseworthy in his or her performance.

CONCLUSION

Oocyte donors represent a useful pool of potential gynecologic teaching associates. They provide important feedback to students. Their evaluation of the proficiency of the student correlates well with that of the supervising faculty member.

Uterine papillary serous carcinoma: evaluation of long-term survival in surgically staged patients

OBJECTIVE

Earlier studies have demonstrated that the uterine papillary serous carcinoma (UPSC) variant of endometrial carcinoma has a high recurrence rate, even when disease is apparently confined to the uterus. The current study evaluated survival in patients with surgically staged UPSC.

METHODS

Patients with UPSC were identified from surgical pathology files and charts were retrospectively reviewed. Only patients who had undergone a TAH-BSO, lymph node dissection, and peritoneal cytology were included.

RESULTS

The FIGO stages of the 36 patients were 12 Stage I (4 IA, 4 IB, 4 IC), 2 Stage IIB, 13 Stage III (5 IIIA, 8 IIIC), and 9 Stage IV. Of the 14 Stage I/II patients, 6 did not receive adjuvant therapy, 5 received whole pelvic radiation (WPXRT), and 3 received whole abdominal radiation therapy (WART); after a median follow-up interval of 50 months only 2 (14%) of these Stage I/II patients have developed a recurrence. Both of the recurrences were in Stage IC patients who received radiation; 1 recurred in the radiation field. Of the 5 Stage IIIA patients, 3 patients declined therapy and 2 were treated with WART; 3 patients, including the 2 who received radiation therapy, are alive without disease. Of the 8 Stage IIIC patients, 2 declined postoperative therapy, 2 received WART, and 4 received WPXRT with an extended field to include paraaortic nodes. Four of the 6 Stage IIIC patients treated with curative intent are without evidence of disease and 1 died of unrelated causes after a median follow-up interval of 48 months. Both of the Stage IIIC patients who declined treatment recurred. Of the 9 patients with Stage IV disease, 8 have died of disease.

CONCLUSION

Women with UPSC have a good prognosis when surgical staging confirms that disease is confined to the uterus (Stage I/II). Surgical findings can also be used to tailor adjuvant radiation treatments. Further study is required to define the optimal treatment for women with metastatic UPSC.

The effects of nefazodone on sleep architecture in depression

A polysomnographic study was conducted on 10 outpatients with major depression at baseline and during 4 to 8 weeks of open-trial treatment with nefazodone (400 to 600 mg/day). All 10 patients were treatment responders as evidenced by at least 50% reduction from baseline scores on the Hamilton Depression Rating Scale. Nefazodone was associated with significantly decreased wake and movement time and increased minutes and percentage of stage 2 sleep at the expense of light stage 1 sleep. Nefazodone did not increase rapid-eye-movement (REM) latency and it did not suppress REM sleep. In fact, a trend toward increased REM in the second REM period was observed, although decreased REM in the third REM period was also noted. In summary, nefazodone, an effective antidepressant, decreases arousals and wakefulness during sleep and reduces light non-REM sleep. This agent does not appear to suppress REM sleep or prolong REM latency in patients who respond to treatment.

A phase I trial of a rhenium 186-labeled monoclonal antibody administered intraperitoneally in ovarian carcinoma: toxicity and clinical response

OBJECTIVES

To determine the maximum tolerated dose, spectrum of toxicity, and response of persistent and recurrent ovarian carcinoma to intraperitoneal injection of a conjugate of rhenium 186 (186Re) and a monoclonal antibody; to measure the radiation distribution to normal structures; and to establish the fate of the infused isotope.

METHODS

Rhenium 186 was conjugated to murine monoclonal antibody NR-LU-10, which binds to a cell surface antigen present on ovarian carcinoma. In a dose-escalating phase I trial, a single dose of 25 mg/m2 of antibody complexed with 25-150 mCi/m2 of 186Re was administered intraperitoneally to 17 women with ovarian carcinoma that was recurrent or persistent after platinum-based chemotherapy.

RESULTS

Severe myelosuppression was observed at 150 mCi/m2 of 186Re in two evaluable patients. Other clinically significant toxicities included low-grade fever and transient skin rash. Hepatic enzyme elevation was seen in 12 of 17 patients, but was not clinically significant. No chronic enteric toxicity was observed. Decreased tumor size was demonstrated by repeat operation in four of seven patients with disease measuring less than 1 cm at the time of treatment (four of 17 total). All four responders had serum CA 125 levels of 35 U/mL or less at the time of treatment and had received only one regimen of chemotherapy.

CONCLUSION

This immunoconjugate can be administered intraperitoneally with acceptable toxicity and produces objective responses after a single dose in patients with minimal objective disease.

Combined radiotherapy and chemotherapy in the management of local-regionally advanced vulvar cancer

PURPOSE

To determine, in a retrospective single institutional study, the role of concurrent radiotherapy and chemotherapy in the treatment of local-regionally advanced vulvar cancer.

METHODS AND MATERIALS

From 1984 to 1991, 20 patients with locally extensive primary or recurrent carcinoma of the vulva were treated with initial combined radiotherapy and chemotherapy. Seven patients had Federation Internationale de Gynecologie et d'Obstretrique Stage III disease, 10 had Stage IV disease, and three were treated for recurrent disease. None of these patients were considered candidates for primary radical vulvectomy and groin node dissection. Median radiation doses to regions of microscopic disease and gross tumor were 40 Gy (range 30-54 Gy) and 54 Gy (34-70.4 Gy), respectively. All patients received 2 or 3 cycles of 5-Fluorouracil concurrently with radiotherapy. In addition, five patients received Cis-platinum, and one Mitomycin-C. Median at-risk follow-up interval was 37 months.

RESULTS

Ten patients had complete resolution of tumor to initial chemoradiotherapy, and eight of these have remained free of tumor relapse. Eight other patients had partial responses, with tumor bulk reduced by > 50%, while the remaining two patients had local-regionally progressive disease. Six of the patients with partial responses had residual tumor successfully resected, although four subsequently recurred. For the entire group of 20 patients, the actuarial 3- and 5-year local control rates were 48% each, and the corresponding disease-specific survival rates were 59% and 49%. There was a suggestion that better local control was obtained in patients who received gross tumor radiation doses > or = 50 Gy. Skin reaction was the major acute toxicity and responded well to conservative management. Long-term sequalae were limited to skin and subcutaneous atrophy.

CONCLUSION

These results indicate that initial combined radiotherapy and chemotherapy is effective in the management of advanced vulvar cancer.

Myelodysplastic syndromes: a review for nurses

The Myelodysplastic Syndromes (MDS) are a group of hematologic disorders that resemble hematologic malignancies but are often treated much differently. These syndromes result from a clonal disorder of certain stem cells in the bone marrow. Treatment can range from simple supportive care to new and innovative approaches such as immunotherapy. In general, treatment is dictated by the severity of the presenting disease. Oncology nurses, because of their familiarity with the manifestations of cancer, are particularly qualified to intervene for the patient and family experiencing MDS. Nursing interventions, based on a firm understanding of the underlying disease, include patients and family education. In addition, emotional support and symptom management are important nursing roles.

The quality of dying: financial, psychological, and ethical dilemmas

The quality of life of terminally ill patients depends on the information base and psychosocial skills of their health care team. Patients have the right to choose to forego medical care, and it is important to learn the who, what, when, and where of informing a patient and supporting their decisions. Planning for care outside the hospital must include psychological support for the patient and family during the initial transition to issues involving the terminal phase of an illness. Although there is a remarkable array of potential care choices--home hospice, hospital-based hospice, and varying nursing home coverage--the access of an individual patient to these may vary widely. The impoverishment of the family, monetarily and physically; the denial of alternatives, even though potentially more cost-effective; and lack of coverage for a significant portion of the patient population can make humane care at the end of life impossible. Physicians have an ethical responsibility to inform themselves about terminal care and to advocate improved coverage at the end of life.