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Biomedical subjects

J A Tulsky

Publications and source records attributed to J A Tulsky.

25 records · Page 2Linked to original sources
PubMed1995

How do medical residents discuss resuscitation with patients?

OBJECTIVE: To describe how medical residents discuss do-not-resuscitate (DNR) orders with patients. DESIGN: Prospective observational study. SETTING: Inpatient medical wards of one university tertiary care center, one urban city public hospital, and one Veterans Affairs medical center. PARTICIPANTS: Thirty-one medical residents self-selected 31 of their English-speaking, competent patients, with whom they had DNR discussions. MEASUREMENTS: Three independent observers rated audiotaped discussions about DNR orders between the medical residents and their patients. Ratings assessed whether the physicians met standard criteria for requesting informed consent (e.g., disclosed the nature, benefits, risks, and outcomes), addressed the patients' values, and attended to the patients' emotional concerns. MAIN RESULTS: The physicians often did not provide essential information about cardiopulmonary resuscitation (CPR). While all the physicians mentioned mechanical ventilation, only 55% mentioned chest compressions and 32% mentioned intensive care. Only 13% of the physicians mentioned the patient's likelihood of survival after CPR, and no physician used a numerical estimate. The discussions lasted a median of 10 minutes and were dominated in speaking time by the physicians. The physicians initiated discussions about the patients' personal values and goals of care in 10% of the cases, and missed opportunities to do so. CONCLUSIONS: Medical ethicists, professional societies, and the public recommend more frequent discussions about DNR orders. Even when housestaff discuss resuscitation with patients, they may not be accomplishing the goal of increasing patient autonomy. Research and education must focus on improving the quality, as well as the quantity, of these discussions.

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PubMed1993

Amnesia in medical practice.

This discussion was selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from a transcription, it has been edited by Nathan M. Bass, MD, PhD, Associate Professor of Medicine, under the direction of Lloyd H. Smith Jr, MD, Professor of Medicine and Associate Dean in the School of Medicine.

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PubMedDate not supplied

Experts practice what they preach: A descriptive study of best and normative practices in end-of-life discussions.

BACKGROUND: Advance directives (ADs) are widely regarded as the best available mechanism to ensure that patients' wishes about medical treatment at the end of life are respected. However, observational studies suggest that these discussions often fail to meet their stated goals. OBJECTIVES: To explore best practices by describing what physicians who are considered expert in the area of end of-life bioethics or medical communication do when discussing ADs with their patients and to explore the ways in which best practices of the expert group might differ in content or style from normative practice derived from primary care physicians' discussions of ADs with their patients collected as part of an earlier study. DESIGN: Nonexperimental, descriptive study of audiotaped discussions. SETTING: Outpatient primary care practices in the United States. PARTICIPANTS: Eighteen internists who have published articles in the areas of bioethics or communication and 48 of their patients. Fifty-six academic internists and 56 of their established patients in 5 practice sites in 2 locations-Durham, NC, and Pittsburgh, Pa. Eligible patients were at least 65 years old or suffered from serious medical illness and had not previously discussed ADs with their physician. Expert clinicians had discretion regarding patient selection, while the internists chose patients according to a predetermined protocol. MEASUREMENTS: Coders applied the Roter Interaction Analysis System (RIAS) to audiotapes of the medical visits to describe communication dynamics. In addition, the audiotapes were scored on 21 items reflecting physician performance in specific skills related to AD discussions. RESULTS: Experts spent close to twice as much time (14.7 vs 8.1 minutes, P<.001) and were less verbally dominant (P<.05) than other physicians during AD discussions. When length of visit was controlled statistically, the expert physicians gave less information about treatment procedures and biomedical issues (P<.05) and asked fewer related questions (P<. 05) but tended toward more psychosocial and lifestyle discussion and questions. Experts engaged in more partnership building (P<.05) with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion (P<.001), and more positive talk (P<.05) than patients of community physicians. Expert physicians scored higher on the 21 items reflecting AD-specific skills (P<.001). CONCLUSIONS: Best practices as reflected in the performance of expert physicians reflect differences in measures of communication style and in specific AD-related proficiencies. Physician training in ADs must be broad enough to include both of these domains. Arch Intern Med. 2000;160:3477-3485.

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