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Biomedical subjects

A H Moss

Publications and source records attributed to A H Moss.

At least 37 records · Page 2Linked to original sources
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↗
PubMed1996

Working with noncompliant and abusive dialysis patients: practical strategies based on ethics and the law.

The patient population in dialysis facilities today reflects common societal problems such as human immunodeficiency virus infection, illicit drug use, distrust of and disrespect for authority, and a propensity toward violence. An increase in calls from dialysis units for guidance in dealing with noncompliant and abusive patients prompted ESRD Network 5 to examine this problem and develop an educational program, "Working with Noncompliant and Abusive Patients." This article provides an overview of the ESRD Network 5 study of the ethical, legal, psychosocial, and administrative aspects of this problem, presents practical strategies for working with such patients, and demonstrates the application of these strategies in three cases. It emphasizes the importance for dialysis units of four elements in the successful treatment of such patients: instruction for all levels of dialysis staff; a team approach; written policies; and patient education at the time of admission about these policies, including the consequences of verbal and physical abuse and the circumstances under which patients will be discharged from the dialysis unit.

Aggression↗
PubMed1996

Residents' ethical disagreements with attending physicians: an unrecognized problem.

PURPOSE: To evaluate the frequency and nature of ethical disagreements over patient care between housestaff and attending physicians. METHOD: During the spring of 1994, a cross-sectional survey about ethical disagreements was conducted of all 42 internal medicine housestaff at the West Virginia University Hospitals and all 51 faculty in the Department of Medicine at the West Virginia University School of Medicine. Chi-square analysis was used to compare categorical variables. RESULTS: Thirty-six (86%) of the residents and 41 (80%) of the faculty responded. The housestaff recounted 127 ethical disagreements between attending physicians and housestaff in the previous year; the attending physicians reported 19. A total of 32 residents reported at least one ethical disagreement with an attending physician during the previous year. When asked about their most troubling disagreement, 27 (84%) of these residents reported they had been distressed because they considered the treatment ordered by the attending physician to be futile. Only 11 residents (34%) had discussed their most troubling disagreement with the attending physician. Of the 24 residents who correctly identified that a formal process to resolve ethical disagreements with a physician did not exist, 17 desired one. CONCLUSION: The residents' disagreements with attending physicians over ethical aspects of patient care were common and usually concerned issues of overtreatment. Since most of the housestaff did not express their concerns, the attending physicians were largely unaware of them. The findings suggest that residency directors need to encourage housestaff to discuss their ethical conflicts with attending physicians.

Attitude of Health Personnel↗
PubMed1996

Patients with amyotrophic lateral sclerosis receiving long-term mechanical ventilation. Advance care planning and outcomes.

OBJECTIVE: To examine advance care planning and outcomes of patients with amyotrophic lateral sclerosis (ALS) receiving long-term mechanical ventilation (LTMV). DESIGN: Case series. SETTING: Population-based study in homes and chronic care facilities in four states, and Home Ventilator Program of California Kaiser Permanente. PATIENTS: Seventy-five ALS patients receiving LTMV were identified; 11 died prior to interview, and 6 were totally locked in; 50 of 58 (86%) who were able to communicate consented to structured interviews, of whom 36 lived at home and 14 in an institution. RESULTS: Thirty-eight patients (76%) had completed advance directives, and 96% wanted them. Thirty-eight patients wished to stop LTMV in certain circumstances, of whom 30 had completed advance directives. Those who had completed advance directives were more likely to have communicated their preference, to stop LTMV to family and physician than those who had not (76 vs 29%; p = 0.05). Patients living at home rated their quality of life on a 10-point scale better than those in an institution (7.2 vs 5.6; p = 0.0052), and their yearly expenses were less ($136,560 vs $366,852; p = 0.0018). CONCLUSIONS: Most ALS patients receiving LTMV would want to stop it under certain circumstances, and the process of advance care planning enhances communication of patient preferences to family and physicians. Home-based LTMV is less costly and associated with greater patient satisfaction.

Adult↗
PubMed1996

Issues in ethics.

Explore the source record for details and available documents.

Ethics, Medical↗
PubMed1995

To use dialysis appropriately: the emerging consensus on patient selection guidelines.

When the United States Congress established the Medicare End-Stage Renal Disease (ESRD) Program in 1972, they did not specify patients for whom dialysis would be appropriate. The ESRD program has grown beyond expectation in patient numbers and in costs, partly because patients who were not initially considered by the dialysis community to be candidates are now routinely accepted. The appropriateness of dialysis for some of these patients has been questioned. Recognizing that practice guidelines are a means to promote appropriate health care, the Institute of Medicine Committee to Study the Medicare ESRD Program recommended the development of practice guidelines for ESRD patient selection. This article reviews the arguments for and against guideline development for dialysis patient selection and the guidelines that have been proposed. It describes what appears to be an emerging consensus on the appropriate use of dialysis and recommends a process for the establishment of dialysis patient selection guidelines based on this consensus.

Humans↗
PubMed1994

Stopping dialysis of an incompetent patient over the family's objection: is it ever ethical and legal?

Decisions to stop dialysis or other life-sustaining treatments for incompetent patients are among the most difficult ethical problems faced by physicians and families. This observation is verified by the large number of court cases and the increasing frequency of ethics consultations on these issues. In such instances, in the absence of an advance directive, the usual practice for physicians is to turn to the patient's family for direction on whether to start, continue, or withdraw the treatment. They do so on the presumption that the family best represents the patient's interests. This presumption may not always be correct. A case is presented in which the family's insistence on continued dialysis was contrary to the patient's previously expressed wishes and the treating physician's assessment of the patient's best interests. It is asserted that, in such situations, after thorough conversation with the family, consultation, documentation, and an unsuccessful attempt to transfer the patient's care to another physician, nephrologists have an ethical obligation and legal right to override the family's decision and to stop dialysis. The ethical obligation is supported by the principles of respect for persons, beneficence, and nonmaleficence. The legal right is grounded in common law and state statutes.

Aged↗
PubMed1994

Dialysis decisions and the elderly.

It is ironic that the patients who were specifically excluded from dialysis at its inception, the elderly, are now the fastest growing segment of the dialysis population. Just because it is possible to dialyze elderly patients does not mean that it should be done. This article reviews the following topics as they relate to decisions about dialysis treatment in elderly people--medical outcomes, age as a selection criterion, allocation of scarce resources, and withholding and withdrawing dialysis--and presents an approach to reaching decisions about treatment of renal failure in the elderly.

Advance Directives↗
PubMed1993

Home ventilation for amyotrophic lateral sclerosis patients: outcomes, costs, and patient, family, and physician attitudes.

We conducted this study to better inform amyotrophic lateral sclerosis (ALS) patients about home ventilation and to assist them in decision-making. We gathered data on the prevalence of ALS patients on home ventilation in northern Illinois and the percentage who chose it, and we asked identified subjects, their families, and physicians for their attitudes toward home ventilation. Fewer than 10% of ALS patients had chosen home ventilation, and fewer than 5% were still on it. Seventeen patients (90%) were glad to have chosen home ventilation and would choose it again. Family caregivers reported major burdens, and only half would choose it for themselves. The mean yearly cost of home ventilation was $153,252. Home ventilation is effective for ALS patients had desired by the small number who undergo it, but it imposes significant burdens on families.

Adult↗
PubMed1993

Variation in the attitudes of dialysis unit medical directors toward decisions to withhold and withdraw dialysis.

Increasingly, physicians who treat patients with renal failure are deciding with patients and families whether to withhold or withdraw dialysis. These decisions as well as those concerning whether medical directors of dialysis units felt prepared to make them were studied using three hypothetical scenarios. A questionnaire survey of 524 physician medical directors of adult chronic dialysis units throughout the United States was conducted. They were asked about decisions to withdraw dialysis from a competent patient and a patient with severe dementia, about decisions to withhold dialysis from a permanently unconscious patient, and also about their use of ethics committees to reach these decisions. Three hundred eighteen (61%) responded. Most, 92%, indicated that their units would usually honor a competent patient's request to stop dialysis. There was less agreement about whether to start dialysis in permanently unconscious patients; 83% would withhold dialysis, and 17% would provide it. There was the least agreement about continuing dialysis in patients with dementia; 32% would stop dialysis, and 68% would continue it. Ninety-four percent of medical directors reported that they felt prepared to decide about withholding and withdrawing dialysis. Eighty percent said they might consult a Network ethics committee for difficult decisions. Almost all medical directors of dialysis units believe that they are prepared to make decisions to withhold and withdraw dialysis. Nevertheless, this study revealed significant variation in their attitudes toward these decisions. Practice guidelines and consultation with ethics committees might assist dialysis unit medical directors in making these decisions more uniformly and in a way that promotes patient benefit.

Attitude of Health Personnel↗
PubMed1993

A proposal for guidelines for patient acceptance to and withdrawal from dialysis: a follow-up to the IOM report.

The Institute of Medicine Committee for the Study of the Medicare End Stage Renal Disease Program recommended that the nephrology community, patients, and families develop guidelines for decisions to accept patients to and withdraw them from dialysis. This article rebuts the arguments that have been voiced against such guidelines, presents arguments for them, and proposes a mechanism for their development should general agreement to draft such guidelines be reached.

Decision Making↗