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Biomedical subjects

M R Gillick

Publications and source records attributed to M R Gillick.

16 recordsLinked to original sources
PubMed1995

A broader role for advance medical planning.

Advance planning for future illness should be broadened from medical care in the event of incompetence to all medical care for the elderly. To plan effectively, patients need an assessment of their overall medical condition: whether they are robust, frail, demented, or dying. They need to understand the kinds of complications often engendered by aggressive treatment, given their underlying status. Given information about their circumstances and their capacity to withstand medical interventions, patients, together with their physicians, need to formulate broad goals for medical care. There are significant barriers to implementing this scheme, but pressure from patients, structural changes in the practice of medicine that create incentives for planning, and educational strategies, including videotaped interviews and role-playing exercises, can facilitate this form of preventive medicine.

Advance Care Planning↗
PubMed1995

Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients with pneumonia.

OBJECTIVE: To determine factors associated with the decision to treat elderly long-term care patients with pneumonia in the hospital vs in the long-term care facility (LTCF) and factors associated with patient outcomes. DESIGN: Retrospective cohort study. SETTING: Hebrew Rehabilitation Center for Aged. PATIENTS: Nursing home residents who had an episode of pneumonia, defined as a new respiratory sign or symptom and a new infiltrate. MEASUREMENTS AND MAIN RESULTS: The majority of the 316 pneumonia episodes (78%) were managed in the LTCF, most (77%) with oral antibiotics. Both patient-related factors, such as elevated respiratory rate, and non-patient-related factors, such as evening evaluation, were associated with hospitalization. No patient who had a do-not-hospitalize (DNH) order was hospitalized. Equal proportions of patients given LTCF therapy (87%) and hospital therapy (88%) survived. Elevated respiratory rate was associated with dying from pneumonia in the LTCF but not in the hospital. Dependent functional status was associated with dying from pneumonia in both sites. CONCLUSIONS: Many episodes of pneumonia can be managed in the LTCF with oral antibiotics. Because, in the absence of DNH orders, both patient-related and non-patient-related factors are associated with hospital transfer, discussion regarding preferences for hospitalization should occur prior to the development of an acute illness. A high respiratory rate may be a good marker for those LTCF patients requiring hospitalization. Dependent functional status may be a good marker for those LTCF patients unlikely to benefit from hospital transfer.

Aged↗
PubMed1994

Medical decision-making in the last six months of life: choices about limitation of care.

OBJECTIVE: To characterize the limitation of care in routine geriatric practice in advance of and at the time of a patient's final episode of illness. DESIGN: A descriptive study performed by retrospective chart review. SETTING: An outpatient geriatric practice affiliated with a community teaching hospital. PATIENTS: Fifty-nine recipients of primary care who were community-dwelling and older than 65, died in the years 1988-1991, and were enrolled in the practice for at least 6 months prior to death. MEASUREMENTS: We recorded the type(s) of care patients (or, in the case of incompetence, their families) and their physicians chose to limit during the last episode of illness preceding death and during previous episodes of illness by examining those instances when therapy other than that considered "standard" was given. We also examined whether the presence of dementia, functional impairment, chronic disease, terminal illness, site of routine care (home vs hospital), and location of death were associated with the limitation of care. RESULTS: A choice to limit diagnostic tests or treatment was made by the patient or surrogate in 40% of the 59 patients during the 6 months before the patient's final episode of illness. Most frequently limited were diagnostic tests, surgery, and hospitalization for purposes other than surgery. Terminal illness and location of death were associated with the limitation of care, but dementia, functional impairment, chronic illness, and location of care were not. By comparison, 89% of the patients had limitation of care during the final episode of illness, and more aggressive therapies such as cardiopulmonary resuscitation and intubation constituted the majority of therapies withheld. CONCLUSIONS: In one geriatric practice, care is frequently limited before a patient's final illness in the course of routine practice. In contrast to recent discussion focusing on limitation of end-of-life interventions or interventions in the severely impaired, these results suggest that there are multiple points in the course of a community-dwelling elderly patient's illness at which choices about level of care can be made. Given this opportunity, a significant number of elderly patients of their surrogates will choose less intensive therapy.

Activities of Daily Living↗
PubMed1991

Influenza vaccination. Are we doing better than we think?

Patients who were candidates for influenza vaccination seen in the primary care center of a community teaching hospital were studied to determine whether there is a differential immunization rate depending on risk level. The immunization rate was as follows: moderate risk group, 44%; high risk group, 59%; and very high risk group, 81%. The immunization rate was also closely associated with the frequency of clinic visits, ranging from 34% for those with low visit frequency to 73% for those with high visit frequency. The highest vaccination rates were thus found in the groups at highest risk for influenza-associated morbidity and mortality. Although influenza complication rates are lower in the healthy elderly, this group is so large that the public health impact of a low vaccination rate will be significant. The healthy elderly should be the special targets of future influenza vaccination campaigns.

Adolescent↗
PubMed1987

The impact of health maintenance organizations on geriatric care.

Increasing numbers of health maintenance organizations (HMOs) are contracting with the federal government to permit enrollment of Medicare beneficiaries, and increasing numbers of the elderly are joining HMOs. A review of past HMO performance suggests that, although these organizations will try to effect a decrease in the rate and duration of hospitalization to control costs, a high rate of functional disability and acute illness in elderly patients will make it impossible to accomplish this significantly. Also, although HMOs will attempt to provide more comprehensive coverage, the demand for prescription drugs, eyeglasses, and medical devices will make such coverage very expensive. Attempts to ration the services of primary-care physicians will impede case management and continuity of care. If HMOs are to provide high-quality medical care at a reasonable cost, they will need to consider making use of geriatric assessment units, geriatric consultants, geriatric nurse practitioners, and special geriatric hospital wards.

Consumer Behavior↗
PubMed1984

Health promotion, jogging, and the pursuit of the moral life.

Individual lifestyle was held accountable for health and disease throughout much of American history. Since the advent of the germ theory of disease, the focus on the etiology of disease has shifted to factors beyond individual control. But in the past two decades, there has been a resurgence of interest in the role of personal habits in producing sickness. This paper examines the history of one facet of the health promotion movement--aerobic exercise, primarily jogging. Initially, concepts in exercise physiology were adapted from non-medical fields--such as competitive sports and the military--for use in cardiac rehabilitation. Subsequently, a few physicians generalized their experience with cardiac patients to the general population, concluding that aerobic exercise could prevent heart attacks. This idea of exercise as a prophylaxis was seized upon by the public, who were receptive because of the political climate of the sixties. Once the popular movement was underway, researchers began studying the role of exercise in preventing coronary heart disease, confirming that exercise does confer some benefit. In the seventies, exercise attracted a new, wider audience--not because of the justification for its use provided by the scientific community, but because of the appeal of upright living as a means to personal and social redemption. The case of aerobic exercise provides an instructive example to social scientists and policymakers seeking to understand or to encourage widespread behavioral change.

Attitude of Health Personnel↗
PubMed1982

Adverse consequences of hospitalization in the elderly.

This study prospectively examines 502 general medical patients for evidence of side-effect of hospitalization unrelated to diagnosis or therapy of acute illness. Symptoms of depressed psychophysiologic functioning (confusion, falling, not eating, and incontinence) unrelated to acute medical diagnoses were found in 8.8% of the patients under 70 and in 40.5% of the elderly population (P less than 0.0001). The rate of medical intervention secondary to these symptoms (psychotropic medications, restraints, nasogastric tubes, and foley catheters) was 37.9% among the young patients and 47.1% in the elderly group (P = 0.4). The sample was too small to permit adequate empirical determination of the complication rate from medical intervention (thrombophlebitis, pulmonary embolus, aspiration pneumonia, urinary tract infection, septic shock) but estimates from the literature indicate that each of the interventions studied entails a complication rate of 25-30%. Combining the observed rate of functional symptoms development and intervention, and the literature rates of complications, yields a risk of complications of 1.0% for the young and 5.7% for the elderly (P less than 0.0001). These data indicate that hospitalized elderly patients are at high risk of developing symptoms of depressed psychophysiology functioning and of sustaining medical intervention as a result of these symptoms, with attendant medical complications. We suggest that in incidence of depressed psychophysiologic function needs to be assessed in patients treated outside the hospital, along with efficacy of treatment outside the hospital, to determine whether there are patients for whom hospitalization is not optimal therapy.

Aged↗