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Biomedical subjects

A H Moss

Publications and source records attributed to A H Moss.

At least 19 recordsLinked to original sources
PubMed2001

Attitudes of patients toward cardiopulmonary resuscitation in the dialysis unit.

Some dialysis units have a policy of performing cardiopulmonary resuscitation (CPR) on all patients who experience cardiac arrest while undergoing dialysis. However, to perform CPR on patients who do not want it is contrary to ethics and the law. We interviewed hemodialysis patients in 12 units in Missouri, New York, and West Virginia to learn their attitudes about CPR. Four hundred sixty-nine of 830 patients (57%) agreed to be interviewed. Eighty-seven percent of patients wanted to undergo CPR if cardiac arrest were to occur while undergoing dialysis. Patients who had seen CPR on television were more likely to report that they knew what CPR was (94% versus 68%; P < 0.001) and to want CPR (88% versus 78%; P = 0.033). Thirteen percent of patients did not want CPR if cardiac arrest were to occur while undergoing dialysis. Compared with patients who wanted CPR, those who did not were older (69 versus 59 years; P = 0.026), had more comorbid conditions (2.0 versus 1.5 comorbid conditions; P = 0.016), and were more likely to have a living will (61% versus 43%; P = 0.01), be widowed (36% versus 20%; P = 0.026), and live in a nursing home (9% versus 3%; P = 0.017). Blacks were significantly more likely to want CPR than whites (adjusted odds ratio, 6.56; 95% confidence interval, 2.57 to 22.27). Only 20 of 58 patients (35%) who did not want CPR were certain they had a do-not-resuscitate order in their dialysis chart. Ninety-two percent of patients who wanted CPR agreed that patients who did not want CPR should have their wishes respected by the dialysis unit. We conclude that most dialysis patients want to undergo CPR, but also want other patients' preferences not to be resuscitated to be respected. Dialysis units need to do a better job of identifying patients who prefer not to be resuscitated and respecting their wishes in the event of cardiac arrest while undergoing dialysis. Most importantly, nephrologists and dialysis unit staff need to educate dialysis patients about the poor outcomes with CPR so that dialysis patients' decisions about CPR are informed.

Aged↗
PubMed2001

Improving advance care planning by accommodating family preferences.

CONTEXT: Family members often lack the knowledge of patients' values and preferences needed to function well as surrogate decision-makers. OBJECTIVE: To determine whether differences in values and preferences for the advance care planning process may be reasons family members are inadequately informed to act as surrogates. DESIGN: Face-to-face and telephone surveys using structured questionnaires. PARTICIPANTS: Two hundred forty-two pairs of dialysis patients and their designated surrogates. MAIN OUTCOME MEASURES: Content and number of end-of-life care discussions; patient and surrogate attitudes toward having patients express preferences explicitly; factors most important to surrogates in decision making; and within-pair agreement about the values of suffering and certainty. RESULTS: Ninety percent of patients designated a family member as their surrogate. In most cases, having more conversations about end-of-life issues did not increase surrogate knowledge of patients' values or preferences. Surrogates wanted written and oral instructions more often than patients wanted to provide them (62% vs. 39%, p < 0.001). Knowing the patient's wish to stop treatment in the present condition was more important to most surrogates than the physician's recommendation to stop treatment (62% vs. 45%, p < 0.001). Compared to patients, surrogates were less likely to want to prolong the patient's life if it entailed suffering (12% vs. 23%, p < 0.01) and were more concerned about being certain before stopping life-sustaining treatments (85% vs. 77%, p < 0.02). CONCLUSIONS: Differences in preferences for the advance care planning process between patients and their surrogates and failure to discuss specific end-of-life values and preferences may explain why surrogates often lack information needed to serve as surrogate decision-makers.

Adolescent↗
PubMed2001

New guideline describes nephrology community consensus on withholding and withdrawing dialysis. Recommendations regarding withdrawing dialysis. 2.

This article reviews two of the recommendations in the RPA/ASN clinical practice guideline that are particularly relevant to making decisions to stop dialysis. The final article in the series will review the recommendations in the RPA/ASN clinical practice guideline regarding resolving conflicts with patients and families and making decisions about whether to dialyze patients who are terminally ill from non-renal causes or who are unable to cooperate with the dialysis process. In all, the guideline makes nine recommendations regarding the treatment of patients with either acute renal failure or end-stage renal disease, and each recommendation is supported by a rationale. The guideline includes 25 prognostic tables and 302 references. The goal of the guideline was to improve patient care by promoting medically and ethically sound decisions about starting and stopping dialysis.

Ethics, Medical↗
PubMed2001

Recommendations regarding conflict resolution and forgoing dialysis in special patient populations.

The Institute of Medicine defines a clinical practice guideline as "a systematically developed statement to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances." The goal of the RPA and ASN in developing this guideline was to help nephrologists and other members of the renal care team with challenging dialysis decisions regarding starting, continuing, and stopping dialysis.

Aged↗
PubMed1999

Dialysis patients' preferences for family-based advance care planning.

BACKGROUND: Most patients do not participate in advance care planning with physicians. OBJECTIVE: To examine patients' preferences for involving their physicians and families in advance care planning. DESIGN: Face-to-face interviews with randomly selected patients. SETTING: Community-based dialysis units in one rural and one urban region. PARTICIPANTS: 400 hemodialysis patients. MEASUREMENTS: Questions about whom patients involve in advance care planning, whom patients would like to include in this planning, and patients' reactions to state legislation on surrogate decision makers in end-of-life care. RESULTS: Patients more frequently discussed preferences for end-of-life care with family members than with physicians (50% compared with 6%; P < 0.001). More patients wanted to include family members in future discussions of advance care planning than wanted to include physicians (91% compared with 36%; P < 0.001). Patients were most comfortable with legislation that granted their family end-of-life decision-making authority in the event of their own incapacity (P < 0.001). CONCLUSION: Most patients want to include their families more than their physicians in advance care planning.

Adult↗
PubMed1999

Failure of advance care planning to elicit patients' preferences for withdrawal from dialysis.

Although withdrawal from dialysis is relatively common among dialysis patients, little is known about the patients' consideration of withdrawal during advance care planning. We studied a stratified random sample of 400 hemodialysis patients in two geographic areas (all six dialysis units within 75 miles of Morgantown, WV, and all nine dialysis units in Rochester, NY) by reviewing responses to a questionnaire addressing issues of advance care planning. Interviews were performed by trained interviewers during a routine hemodialysis treatment. Fifty-one percent of the patients had completed an advance directive (29% had a living will and a health care proxy, 22% had a living will or proxy). Patients who had completed advance directives were more likely to have notified their decision makers of their roles (91% with a living will and health care proxy, 81% with a living will or proxy v 55% who had no advance directive; P < 0.01). Most patients had not discussed their wishes for specific interventions in the event of permanent coma: 41% had discussed mechanical ventilation; 35%, tube feedings; 25%, cardiopulmonary resuscitation; and only 18% had discussed stopping dialysis. Patients who had completed a living will and proxy were most likely to have discussed end-of-life care, but stopping dialysis was the least often discussed intervention, even in this patient subset. Sixty-nine percent had discussed mechanical ventilation; 55%, tube feedings; 43%, cardiopulmonary resuscitation; and only 31% had discussed stopping dialysis (all P < 0.001). Although withdrawal from dialysis is relatively common, it is rarely discussed in advance care planning by dialysis patients. Dialysis unit staff and nephrologists should address issues involving withdrawal from dialysis with their chronic dialysis patients.

Adult↗
PubMed1999

A review of alternative approaches in the management of iatrogenic femoral pseudoaneurysms.

The management of iatrogenic pseudoaneurysms (IPAs) demands close co-operation between radiologist, vascular surgeon and plastic surgeon. Ideally, each patient should be reviewed employing a team approach. Many IPAs require only observation; those with a volume greater than 6 cm3 will require treatment as spontaneous thrombosis is uncommon. Radiological treatment options include ultrasound guided compression repair (UGCR), embolisation, and covered stenting. Occasionally, these are unsuccessful or contra-indicated, and the vascular surgical approach is discussed in detail. Finally, the role of the plastic surgeon in dealing with skin ischaemia is detailed.

Aneurysm, False↗
PubMed1998

Rationing dialysis in the United States: possible implications of capitated systems.

The application of managed care to dialysis raises concerns that dialysis will be rationed in the United States. Rationing means the implicit or explicit denial of beneficial or marginally beneficial medical treatment as a result of insufficient resources to provide treatment to all. In this era of cost containment and budget cutting, rationing appears inevitable in the end-stage renal disease program because of its continued growth in numbers and cost and because many are questioning the benefit of dialysis to certain groups of patients. Rationing according to social worth, ability to pay, or age is not ethically justifiable, but it is justified to ration according to medical benefit. There is an important role for guidelines developed with broad input from patients, families, health care professionals, ethicists, health policy experts, and payers. Consensus statements exist in the literature, and the nephrology community is in the process of developing practice guidelines that will be available for future use. In the meantime, managed care companies should look to broader community input in the form of consensus statements and community dialogue. Managed care companies will need ethics committees to ensure that their policies and procedures for rationing are fair, principled, and subject to review and appeal.

Ethics, Medical↗
PubMed1998

Dialysis decision making in Canada, the United Kingdom, and the United States.

This study was designed to determine the extent to which differences in criteria for dialysis patient selection and availability of financial resources cause the wide variation in acceptance rates for dialysis in Canada, the United Kingdom, and the United States. We also sought to determine whether there is agreement among nephrologists in the three countries on which patients should not be offered dialysis. We used a cross-sectional survey of all members of the Canadian Society of Nephrology and the Renal Association of Great Britain, and a randomized sample of 800 members of the American Society of Nephrology. Five case vignettes were presented asking for yes/no decisions on offering or not offering dialysis, together with ranking of factors considered important. We also inquired about dialysis resources and physician demographics. We compared responses by country. More nephrologists from the United Kingdom returned responses (83%) than Canadian (53%) or American (36%) nephrologists. American nephrologists offered dialysis more than Canadian or British nephrologists (three of five cases; P < 0.04 to P < 0.001) and ranked patient/family wishes (three of five cases; P < 0.057 to P < 0.0001) and fear of lawsuit (P < 0.04 to P = 0.0012) higher than British or Canadian nephrologists. Canadian and British nephrologists reported their perception of patients' quality of life as a reason to provide (P = 0.0019) or not provide (P = 0.068 to P = 0.0026) dialysis more often than their American counterparts. Despite these differences, nephrologists from each country did not differ by more than 30% on any decision and ranked factors almost identically. Ten percent and 12% of Canadian and British nephrologists, respectively, but only 2% of American nephrologists, reported refusing dialysis due to lack of resources (P < 0.0001). We conclude that the wide variation in dialysis acceptance rates in the three countries is somewhat influenced by differences in patient selection criteria and withholding of dialysis by nephrologists based on financial constraints, but that other factors, such as differences in rates of patient nonreferral for dialysis, contribute more significantly to the variation. Generally agreed on practice guidelines for dialysis patient selection appear possible.

Adult↗
PubMed1998

Withholding and withdrawing dialysis: the role of physician specialty and education and patient functional status.

Withholding and withdrawing dialysis are subjects of major concern to nephrologists, because both result in a significant number of end-stage renal disease (ESRD) patient deaths. The medical literature on withholding dialysis is extremely limited, and that on withdrawing dialysis consists mainly of retrospective studies from the 1980s. The present study was conducted to identify ways to improve dialysis decision making by providing a current understanding of how decisions to withhold or withdraw dialysis are being made and by examining whether some patients who might benefit from dialysis are not being referred. In 1995, 22 of 27 (82%) nephrologists practicing in West Virginia agreed to participate in a year-long prospective study in which they completed forms on each patient from whom they withheld or withdrew dialysis. Seventy-six of a random sample of 214 (36%) primary care physicians returned questionnaires describing their practice experience in 1995 with patients with advanced chronic renal failure. The nephrologists withdrew dialysis from 60 of 822 (7%) patients. Academic nephrologists who had received education in the ethics and law of stopping dialysis withdrew it from a greater percentage of patients than those in private practice (12% v 6%; P = 0.009). Patients who were withdrawn more often resided in nursing homes (37% v 2%; P < 0.0001). Twenty-one patients (37%) lacked decision-making capacity at the time the decision was made to withdraw dialysis. Advance directives were available for 13 of the 21 (62%) patients: eight of the 10 treated by academic nephrologists and five of the 11 treated by private practice nephrologists. Academic nephrologists found advance directives to be helpful in decision making to withdraw dialysis of incapacitated patients more often than nephrologists in private practice (70% v 9%; P = 0.004). Nephrologists withheld dialysis from 25 of 357 (7%) ESRD patients compared with 42 of 193 (22%) withheld by primary care physicians (P < 0.001). In deciding not to refer a patient for a dialysis evaluation, 25% of primary care physicians did not consult a nephrologist; 60% cited age as a reason not to refer. These findings suggest that dialysis decision making might be improved by educating nephrologists about the ethics and law of withdrawing dialysis and about how to implement successfully advance care planning so that advance directives will be present and helpful when decisions need to be made for incapacitated dialysis patients. Education of primary care physicians about when to refer patients with chronic renal failure for a dialysis evaluation might also result in more referrals for patients who will benefit from dialysis.

Adult↗
PubMed1998

Inadequate self-care knowledge among elderly hemodialysis patients: assessing its prevalence and potential causes.

OBJECTIVE: The purpose of this study was to determine how well informed elderly hemodialysis patients (EHP) are about information needed for self-care and to identify factors that might lead their self-care knowledge to be inadequate. SAMPLE/SETTING: The sample included 142 patients over the age of 65 in 17 outpatient hemodialysis units in three Eastern states. METHODS: Interviews were conducted to test factual knowledge of dialysis and to assess how well informed EHP thought they were about self-care related issues. Interviewers also asked demographic questions and administered the Mini-Mental State Exam (MMSE) to assess cognitive capacity. RESULTS: Seventy-five percent of patients believed they were well informed; however, only 14% answered all three questions correctly. The average number correct on a three-question, self-care knowledge measure was only 1.67. Knowledge was lowest for older, poorly-educated patients with diminished cognitive capacity (DCC) who had recently begun dialysis (mean correct score 1.1). Thirty-nine percent of our sample had DCC. CONCLUSIONS: Because a majority of EHP lack information needed for self-care and many have DCC, nurses should not unquestioningly accept EHP claims that they are well informed. EHP with DCC, less than a high school education, and advanced age require extra educational efforts closer monitoring, and more family involvement in decision making. Using the MMSE to identify patients with DCC is one of six recommendations we offer to improve EHP self-care.

Aged↗
PubMed1997

To dialyze or not to dialyze: an ethical and evidence-based approach to the patient with acute renal failure in the intensive care unit.

Patients with acute renal failure in the intensive care unit have high in-hospital mortality. In this setting, decision making with regard to the initiation or discontinuation of dialysis by physicians, patients, and families is challenging because of the desire of all for the patient to recover while sparing unnecessary suffering. Decision making can be facilitated by knowledge of outcomes of the treatment of such patients in the medical literature. This knowledge assists nephrologists to distinguish those patients whose clinical situation indicates a more favorable prognosis from those whose prognosis is uncertain or definitely poor even with dialysis. This information, combined with consideration of relevant ethical guidelines, provides a framework for nephrologists to make decisions that are evidence based and ethically sound. We present and discuss two cases to show the application of evidence-based medicine and ethical considerations to decision making for patients with acute renal failure in the intensive care unit.

Acute Kidney Injury↗