Must consent always be obtained for a do-not-resuscitate order?

Using cardiopulmonary resuscitation for cardiac or respiratory arrest unless there is an explicit do-not-resuscitate order is a policy adopted by all hospitals. Such a policy usually requires the patient's (or surrogate's) consent for a do-not-resuscitate order to be instituted. This article, however, presents the argument that consent need not always be obtained. In the case discussed, the well-being of the patient, other patients, and the health care providers all support a unilateral decision by the physician not to attempt resuscitation at the time of death. The medical community and society need to acknowledge that such cases exist and to develop policies that respect not only the interests of patients but also those of health care providers and society.

Will universal health insurance assure universal access to ongoing primary care for adults?

OBJECTIVE

To assess the impact of current public insurance status (Medicare and Medicaid) and hypothetical payment levels of a new insurance program on physician acceptance of adult primary care patients desiring continuing care.

METHOD

Survey of 175 primary care physicians in a medium-sized city and six surrounding counties in North Carolina.

MAIN OUTCOME MEASURE

Likelihood of accepting new continuing care patients covered by Medicare, Medicaid, or a hypothetical health insurance system mandated to cover the uninsured.

RESULTS

The response rate was 80%; 86% of the respondents were accepting new patients with private insurance. Of the remaining physicians, 72% were not accepting new continuing care patients covered by Medicaid and 55% were not accepting patients who paid via Medicare assignment alone. Seventy-nine percent of respondents were unlikely to accept new continuing care patients insured by a hypothetical public plan that reimbursed physicians at 60% of reimbursement levels provided by privately insured patients, compared with only 25% who were unlikely to accept patients if the reimbursement was 80% of the private level.

CONCLUSIONS

Medicaid and Medicare do not assure access to continuing primary care. Also, physician reimbursement is an important determinant in any new health care system designed to provide universal and consistent access to regular primary care services.