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Biomedical subjects

J M Luce

Publications and source records attributed to J M Luce.

At least 19 recordsLinked to original sources
PubMed1998

Acute lung injury and the acute respiratory distress syndrome.

OBJECTIVE: To review acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) in light of recent information about the definitions, epidemiology, pathophysiology, management, and outcome of these conditions. DATA SOURCES: The author's personal files as well as the computerized MEDLINE database. STUDY SOLUTION: Studies were selected for their relevance to the conditions of ALI and ARDS. DATA EXTRACTION: The author extracted all applicable data. DATA SYNTHESIS: The diagnostic criteria for ALI and ARDS include a) acute onset; b) bilateral chest radiographic infiltrates; c) a pulmonary artery occlusion pressure of < or =18 mm Hg or no evidence of left atrial hypertension; and d) impaired oxygenation manifested by a PaO2/FIO2 ratio of < or =300 torr (< or =40 kPa) for ALI and < or =200 torr (< or =27 kPa) for ARDS. The incidence of ALI and ARDS are approximately 70 and 7 patients out of 100,000 of the total U.S. population per year, respectively. The conditions result from direct or indirect injury to the pulmonary epithelium and endothelium that causes edema, atelectasis, inflammation, and fibrosis. This "diffuse alveolar damage" is actually patchy in many patients. Therapy of ALI and ARDS is largely supportive, although new approaches in mechanical ventilation, patient positioning, and pharmacologic therapy have been introduced. The mortality rate of ARDS has improved to <50%, but the reasons for this improvement are unclear. CONCLUSION: ALI and ARDS are better defined and understood than ever before, and their outcome has improved for unclear reasons.

Humans↗
PubMed1998

A national survey of end-of-life care for critically ill patients.

In some intensive care units (ICUs), fewer patients who die now undergo attempts at cardiopulmonary resuscitation (CPR), and many more have life support actively withdrawn prior to death than did a decade ago. To determine the frequency of withdrawal of life support, we contacted every American postgraduate training program with significant clinical exposure to critical care medicine, asking them prospectively to classify patients who died into one of five mutually exclusive categories. We received data from 131 ICUs at 110 institutions in 38 states. There were 6,303 deaths, of which 393 patients were brain dead. Of the remaining 5,910 patients who died, 1,544 (23%) received full ICU care including failed cardiopulmonary resuscitation (CPR); 1,430 (22%) received full ICU care without CPR; 797 (10%) had life support withheld; and 2,139 (38%) had life support withdrawn. There was wide variation in practice among ICUs, with ranges of 4 to 79%, 0 to 83%, 0 to 67%, and 0 to 79% in these four categories, respectively. Variation was not related to ICU type, hospital type, number of admissions, or ICU mortality. We conclude that limitation of life support prior to death is the predominant practice in American ICUs associated with critical care training programs. There is wide variation in end-of-life care, and efforts are needed to understand practice patterns and to establish standards of care for patients dying in ICUs.

Brain Death↗
PubMed1997

[Decrease of supercooling capacity during embryogenesis and larval growth in Coleoptera].

Potential cold resistance of non-diapause eggs and first instar larvae of Osmoderma eremita (Coleoptera, Cetoniidae, Trichiinae) during embryogenesis and post-embryonic growth was assessed by measuring individual supercooling points (SCP): sterile eggs had a mean SCP of -24.3 +/- 2.0 degrees C; fertilized newly laid eggs a mean SCP of -23.4 +/- 3.2 degrees C and eggs about to hatch a mean SCP of -9.2 +/- 2.9 degrees C. Water absorption by fertilized eggs is a necessary requirement for the development of the embryo and results in an increase in weight and water content: fertilized newly laid eggs had a mean fresh weight of 10.687 +/- 1.072 mg and a mean water content (expressed as a percentage of the dry weight) of 79.5 +/- 10.83%; eggs about to hatch had a mean fresh weight of 19.127 +/- 3.183 mg and a mean water content of 250.10 +/- 74.15%. The ex-ovo larvae, hatched 30 days after oviposition, had a mean SCP of -10.1 +/- 3.6 degrees C (no significant difference with eggs about to hatch) and had gained in weight (24.845 +/- 3.911 mg) and in water content (499.72 +/- 55.49%). Feeding 1st instar larvae had a decreased supercooling ability (mean SCP = -5.7 +/- 0.4 degrees C) whereas their mean fresh weight (99.858 +/- 53.091 mg) and mean water content (665.83 +/- 82.74%) increased. The eggs and larvae of O. eremita are freezing intolerant. Before overwintering, all larvae switch to being freezing tolerant and can survive ice formation in their tissues and body fluids, whereas their mean SCP stays at around -5 degrees C. However, recent experiments in the winter of 1996 have shown that frozen larva mortality does occur at temperatures lower than about -12 degrees C.

Animals↗
PubMed1997

Increasing incidence of withholding and withdrawal of life support from the critically ill.

To determine whether limits to life-sustaining care are becoming more common, we attempted to quantify the incidence of recommendations to withhold or withdraw life support from critically ill patients, to describe how patients respond to these recommendations, and to examine how conflicts over these recommendations are resolved. In 1992 and 1993 we prospectively enrolled 179 consecutive patients from two intensive care units (ICUs) for whom a recommendation was made to withhold or withdraw life support. Where possible, we compared results with data collected in the same units over a similar time period in 1987 and 1988. Recommendations to withhold or withdraw life support preceded 179 of 200 deaths (90%) in 1992 and 1993, compared with 114 of 224 deaths (51%) in 1987 and 1988 (chi2 = 73.76, p < 0.001]. Cardiopulmonary resuscitation was initiated in 10% of deaths in 1992 and 1993 as compared with 49% in 1987 and 1988. Ninety percent of patients agreed within less than 5 d, and only eight patients (4%) refused physicians' recommendations to limit life support. In cases of conflict, physicians in 1992 and 1993 deferred to patients with one exception: physicians were willing to refuse surrogate requests for resuscitation of patients they considered hopelessly ill. We conclude that 90% of patients who die in these ICUs now do so following a decision to limit therapy, that this represents a major change in practice in these institutions over a period of 5 yr, that most patients and surrogates accept an appropriate recommendation to withhold or withdraw life support, and that physicians will refuse surrogate requests in certain circumstances.

Adolescent↗
PubMed1997

Making decisions about the forgoing of life-sustaining therapy.

The incidence of withholding and withdrawal of life support from critically ill patients has increased to the extent that these practices now precede well over half of all deaths in many intensive care units (ICUs). Although the forgoing of life-sustaining therapy is ethically acceptable and clinically desirable in certain instances, and although physicians do not have a responsibility to provide futile care even if a patient or surrogate insists on it, they must be cautious in exercising their influence, if not authority, over patients and surrogates in prompting the withholding and withdrawal of life support. Such caution is particularly indicated because managed care has made patients suspicious of healthcare institutions and physicians who are rewarded for restricting access to care. Most patients and surrogates agree with reasonable physician recommendations to forgo life-sustaining therapy. When they do not agree, physicians should not limit care on the basis of their own personal notions of futility, but should instead rely on institutional or multiinstitutional futility policies. Such policies should be developed by health professionals, patients, community leaders, and, when appropriate, participants in managed-care organizations. They should specify which ICU interventions are beneficial, address potential conflicts of interest, and be available to persons who could use such information in selecting the source of their care.

Attitude of Health Personnel↗
PubMed1997

Withholding and withdrawal of life support: ethical, legal, and clinical aspects.

The withholding and withdrawal of life support are processes by which various medical interventions either are not given to or are taken away from patients, with the expectation that they will die as a result. The propriety of withholding and withdrawal of life support has been supported by ethical statements from groups such as the Task Force on Ethics of the Society of Critical Care Medicine, and by a series of legal decisions beginning with the Quinlan case. Surveys of healthcare professionals indicate that most ICU physicians withhold and withdraw life support on a regular basis, that they consider these processes ethically equivalent, that they recommend withholding and withdrawal of life support based upon prognosis (which may be expressed as futility), and that they consider patient and surrogate wishes to be most important in deciding to forego life-sustaining treatment, but place these wishes in the context of their own assessment of prognosis. Observational studies show that: withholding and withdrawal of life support occur frequently, the frequency has increased over the past several years in some ICUs, patients and families generally agree with physician recommendations to limit care or request such limitation, disagreements sometimes occur on this issue, withdrawal of life support occurs more commonly than withholding of life support in most ICUs, cardiopulmonary resuscitation is the therapy most frequently withheld, mechanical ventilation is the therapy most frequently withdrawn, this withdrawal process usually is gradual, and it usually is facilitated by the administration of sedatives and analgesics. Clinical information such as this is helping to define a standard of care in the area of withholding and withdrawal of life support.

Critical Care↗
PubMed1996

Physician responses to a hospital policy allowing them to not offer cardiopulmonary resuscitation.

OBJECTIVE: To determine whether physicians followed a hospital policy permitting them to not offer cardiopulmonary resuscitation (CPR) to patients considered unlikely to benefit from this therapy. DESIGN: Prospective series. SETTING: San Francisco General Hospital, a university-affiliated public hospital. PATIENTS: Attending physicians were interviewed about patients admitted over a period of 5 consecutive months for whom do-not resuscitate (DNR) orders were written. Only the first patient for whom each physician wrote a DNR order was included. MAIN OUTCOME MEASURES: Responses of physicians to questions regarding their initiation of DNR orders for these patients. RESULTS: Sixty-nine physicians responded to questions about DNR orders written for 69 patients. Fifty-seven of these physicians said that they were aware of the hospital policy, and 49 of the 57 physicians said that they generally agreed with it. Thirty-three physicians felt that CPR should be offered only to patients likely to benefit from it. In contrast, 36 physicians said that CPR should be offered to all patients, regardless of benefit. CPR was offered to 41 patients and 15 surrogates; 27 of these patients were considered to be unlikely to benefit from CPR. CONCLUSION: Despite a policy that allows them to do otherwise, physicians usually offered CPR to patients, regardless of benefit. Most physicians believed that CPR should be offered to all patients. These findings suggest that policies such as that of San Francisco General Hospital may not be compelling because physicians hold attitudes that are inconsistent with the policies.

Attitude of Health Personnel↗
PubMed1996

Use of risk-adjusted outcome data for quality improvement by public hospitals.

In 1993 the California Office of Statewide Health Planning and Development (OSHPD) began public release of risk-adjusted monitoring of outcomes (RAMO) under the California Hospital Outcomes Project. We studied how 17 acute are public hospitals in California used these RAMO data for quality improvement purposes following their initial distribution, first by analyzing the outcome data for San Francisco General Hospital Medical Center as recommended by OSHPD and, second, by querying the departments at the other 16 public hospitals to determine how their own analyses compared. We found that the hospitals generally did minimal analyses of the OSHPD RAMO data and considered the data of little value to them. Only 3 hospitals initiated quality improvement activities based on their data review. The major reasons given by the hospitals for not using the RAMO data were that their outcomes were adequate, as verified by a comparison of their observed outcomes and those expected after risk-adjustment; that the hospitals had too few patients in the diagnostic categories; that they had too few resources; and that they were not concerned with the data's public release. Other possible explanations were that awareness of the California Hospital Outcomes Project was not widespread at the time of the study, that the RAMO data were not distributed in a way that encouraged their use, and that public hospitals were not inclined to use the outcome data because the project was imposed on them. Whatever the explanation, our study suggests that the California Hospital Outcomes Project has had little effect on quality improvement in public hospitals.

California↗
PubMed1995

Cost and outcome of intensive care for patients with AIDS, Pneumocystis carinii pneumonia, and severe respiratory failure.

OBJECTIVE: To determine the costs and outcomes associated with intensive care unit (ICU) admission for patients with acquired immunodeficiency syndrome (AIDS)-related Pneumocystis carinii pneumonia (PCP), and severe respiratory failure. DESIGN: Survival and cost-effectiveness analysis. SETTING: A large municipal teaching hospital serving an indigent population. PATIENTS: Consecutive patients intubated and mechanically ventilated for AIDS, PCP, and respiratory failure from 1981 through 1991 (n = 113). The cohort was separated into three groups for analysis: patients admitted to the ICU in 1981 through 1985 (era I, n = 43), those admitted in 1986 through 1988 (era II, n = 33), and those admitted in 1989 through 1991 (era III, n = 37). MAIN OUTCOME MEASURES: Hospital charges and survival time; cost per year of life saved, using a zero-cost, zero-life assumption. RESULTS: Twenty-eight (25%) of the 113 patients mechanically ventilated for PCP and respiratory failure survived to hospital discharge: six (14%) of 43 in era I, 13 (39%) of 33 in era II, and nine (24%) of 37 in era III (P = .04). Post-ICU admission charges averaged $57,874 for the entire cohort, remaining relatively stable across the three eras. Cost of care for survivors was significantly more expensive than for those dying before discharge. The cost of ICU admission and subsequent hospitalization averaged $174,781 per year of life saved; $305,795 in era I, $94,528 in era II, and $215,233 in era III. Improved survival rates and shorter lengths of ICU stay led to the improved cost-effectiveness in era II, while the opposite trends resulted in worsening cost-effectiveness in recent years. The strongest predictors of hospital mortality in era III were low CD4 cell counts on hospital admission and the development of pneumothorax during mechanical ventilation. CONCLUSIONS: The cost-effectiveness of intensive care for patients with PCP and severe respiratory failure improved during the first 8 years of the AIDS epidemic but fell in recent years such that it is now below that of many accepted medical interventions.

AIDS-Related Opportunistic Infections↗
PubMed1995

Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists.

OBJECTIVE: This article was written to argue that physicians are not ethically obligated to provide care which they consider futile, unreasonable, or both, either voluntarily or in response to patient or surrogate demands. DATA SOURCES: Data used to prepare this article were drawn from published articles, including original investigations, position papers and editorials in the author's personal files. STUDY SELECTION: Articles were selected for their relevance to the subjects of medical ethics, the concepts of futility and medical reasonableness, case law, and healthcare reform. DATA EXTRACTION: The author extracted all applicable data. DATA SYNTHESIS: Physicians may feel obligated to provide care in all clinical circumstances due to the single master view of medicine and the ethical principle of autonomy. However, care may be considered futile according to several definitions of that word, including that which describes futile treatment as something that does not benefit the patient as a whole. Furthermore, care may be considered unreasonable if it is excessive and not generally agreed upon. Physician refusal to provide futile or unreasonable care is supported by the ethical principles of nonmaleficence, beneficence, and distributive justice. The last principle is particularly relevant in the current climate of healthcare reform. CONCLUSIONS: Although the issue of physician refusal of requested care has not been resolved by case law or legal statute, it is supported by compelling ethical principles. Physicians are not ethically required to provide futile or unreasonable care, especially to patients who are brain dead, vegetative, critically or terminally ill with little chance of recovery, and unlikely to benefit from cardiopulmonary resuscitation.

Adult↗
PubMed1995

Withholding and withdrawing of life support from patients with severe head injury.

OBJECTIVE: To characterize the withholding or withdrawing of life support from patients with severe head injury. SETTING: San Francisco General Hospital, a city and county hospital with a Level I trauma center. DESIGN: A standardized questionnaire was used to collect data on demographics and functional outcome of severely head-injured (Glasgow Coma Score of < or = 7) patients admitted to the medical-surgical intensive care unit, and to interview the patients' physician and family members. PATIENTS: Forty-seven patients who were admitted to a medical-surgical intensive care unit over a 1-yr period. INTERVENTIONS: Twenty-four patients had life support withheld or withdrawn, and 23 patients did not. MEASUREMENTS AND MAIN RESULTS: Physician and family separately assessed patient's probable functional outcome, degree of communication between them, reasons important in recommending or deciding on discontinuation of life support, and the result of action taken. Six months later, the families reviewed the process of their decision, how well physician(s) had communicated, and what might have improved communication. Of 24 patients with life support discontinued, 22 died; two were discharged from the hospital. Twenty-three of the 24 patients had a poor prognosis on admission. Of the 23 patients who were continued on life support for the duration of their hospitalization, ten had a poor (p < .001) prognosis on admission. Prognosis improved for two patients from the first group and five from the latter. Family's assessment of prognosis agreed with physician's assessment in 22 of the 24 patients from whom life support was discontinued (p < .001). Physicians' ability to convey the prognosis appeared to influence families' assessments. Physicians' considerations in recommending limitation of care and families' considerations in making decisions were the same, primarily an inevitably poor prognosis. Neither physician nor families cited cost or availability of care as a deciding factor. Two families disagreed with the recommendation to limit care after initial agreement because the patients' prognosis improved from "likely death" to "vegetative." Care was therefore continued, and both patients remained vegetative 6 months after admission to the hospital and discharge to chronic care facilities. CONCLUSIONS: Life support is commonly withheld or withdrawn from patients with severe head injury at San Francisco General Hospital, and usually it is accompanied by death. A reciprocal consideration exists in most cases between the physician and family making the difficult decision to limit care. Care is provided for patients whose families request it despite physician recommendations.

Adolescent↗
PubMed1994

The changing physician-patient relationship in critical care medicine under health care reform.

American society and the medical profession have historically been dominated by a "single master" view that emphasizes unrestrained advocacy for individual patients and prohibits physicians, including those who work in critical care units, from being providers and rationers of health care services simultaneously. With its emphasis on universal access and cost containment, health care reform requires that society and the medical profession balance this individualistic ethic with a communitarian ethic that stresses proportional advocacy for all patients and encourages physicians and patients to help define the scope of services their health care institutions provide. Ideally, this balance will allow the transition from a "rule of rescue" in which large sums of money are spent on therapies that may have only marginal benefit to a "rule of reason" in which this money can be used for primary and preventive care.

Beneficence↗