Biomedical subjects
M Gillick
Publications and source records attributed to M Gillick.
A patient-centered approach to advance medical planning in the nursing home.
OBJECTIVE: The objective of this study is to determine whether nursing home residents or their surrogates are willing and able to prioritize their goals for care and to demonstrate how these rankings can form the basis of a specific pattern of medical care. DESIGN: A prospective, descriptive study. SETTING: A 40-bed nursing unit for residents with mild to moderate impairments in a 725-bed teaching nursing home. RESULTS: Overall, 78% of patients or their families were willing to prioritize their goals, allowing the investigators to infer a pattern of care. The goals were interpreted as implying an intensive pattern in 21%, a comprehensive pattern in 16%, a basic pattern in 18%, palliation in 18%, and comfort only in 6% of residents. Goals chosen by residents who were able to select for themselves translated into more aggressive care than did the goals selected by surrogates. CONCLUSION: Goal-centered advance medical planning can be initiated in nursing homes by asking residents or their surrogates to prioritize their goals of care. These prioritizations can form the foundation for specific patterns of care.
The high costs of dying. A way out.
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Referral of patients from long-term to acute-care facilities.
Medical care available to residents of nursing homes and chronic-care hospitals was assessed by studying transfers of such persons to the emergency room of an acute-care hospital. One hundred patients transferred from nursing homes and 16 patients transferred from chronic-care hospitals were compared with 338 elderly patients from home (control group). Elevated temperature (greater than or equal to 102 degrees F) was found in 17.3 per cent of nursing home patients and 30.0 per cent of chronic-case hospital patients, compared with 1.8 per cent of controls (P less than .05); mental status abnormalities were found in 66.1 per cent of patients from nursing homes and in 90.9 per cent of those from chronic-care hospitals, compared with 36.2 per cent of controls (P less than .025). In addition, patients from chronic-care hospitals, but not those from nursing homes, often showed substantial abnormalities of blood pressure and pulse. Thus, the patients from nursing homes tended to be slightly sicker than controls, and those from chronic-care hospitals considerably sicker. The probability of requiring admission to the hospital was the same for residents of nursing homes and persons living at home (44.0 per cent and 43.2 per cent, respectively), but was higher for persons from chronic-care hospitals (81.3 per cent, P less than .005). It was also determined whether a disproportionately large percentage of transfers from extended-care facilities occurred at night or on weekends. Among nursing home patients, 12.6 per cent of emergency room visits occurred on weekends, compared with 20.0 per cent of chronic-care hospital patients and 24.3 per cent of controls. Thus, no evidence for "dumping" of patients was found. It was concluded that utilization of a hospital emergency room by nursing home patients is very similar to that by home residents, suggesting an inadequacy of on-site medical services, whereas that by chronic-care hospital patients is restricted to major illness, which is entirely appropriate.
Effect of propranolol on platelet function.
Excessive reactivity of blood platelets may contribute to atherosclerotic vascular disease. Hence drugs which alter platelet function may be protective. Prompted by findings that propranolol therapy normalized hyperactive platelet aggregation in patients with coronary artery disease, we studied propranolol in vitro to assess its action on platelets. At concentrations similar to those achieved in vivo (0.1-1 muM), propranolol raised the thresholds for aggregation of some normal paltelets by adenosine diphosphate (ADP). At higher concentrations (10-50 muM), propranolol abolished the second wave of platelet aggregation induced by ADP and epinephrine, and inhibited aggregation induced by collagen, thrombin, and the ionophore A23187. Propanolol blocked the release of 14C-serotonin from platelets, inhibited platelet adhesion to collagen, and interfered with clot retraction. Propranolol blocked ionophore-induced uptake of 45Ca by platelets. Inhibition appeared unrelated to beta-adrenergic blockage, as d(+) propranolol (which lacks beta-blocking activity) was equipotent with 1(-) propranolol. Moreover, practolol, a beta-blockading drug which is nonlipophilic, did not inhibit platelet function. These studies suggested that propranolol, like local anesthetics, decreased platelet responsiveness by a direct action on the platelet membrane, possibly by interfering with calcium availability. Modulation of platelet function by propranolol may occur at concentrations achieved at usual clinical doses of the drug.
When the nursing home resident with advanced dementia stops eating: what is the medical director to do?
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