Search PubMed⌕ Search

Biomedical subjects

P A Singer

Publications and source records attributed to P A Singer.

At least 91 records · Page 5Linked to original sources
PubMed1994

Evaluation of a multicenter ethics objective structured clinical examination.

The purpose of this study was to evaluate a six-station ethics objective structured clinical examination (OSCE) on a volunteer sample of 66 medical students and 33 residents from three Ontario medical schools. The internal consistency reliability was 0.46 and the median interrater reliability was 0.675 (range 0.30 to 0.89). The residents' scores were higher than those of the medical students (F = 2.24, 0.046). Also, the scores differed among the three schools (F = 3.19, p = 0.0004). The ethics OSCE has adequate interrater reliability and construct validity, but low internal consistency reliability. There are differences among the schools that may assist in ethics curriculum evaluation and development.

Brain Death↗
PubMed1994

Which advance directive do patients prefer?

This study examined patient acceptance of two different advance directives. Outpatients completed the two directives and a 12-item acceptability questionnaire for each, and then stated their directive preferences. Of 128 patients enrolled, 97 (76%) responded. Overall, 47% of the respondents were satisfied with the Let Me Decide directive and 53% with the Medical Directive (NS). Thirty-nine percent preferred the Let Me Decide directive, 37% preferred the Medical Directive, and 25% had no preference or were uncertain which they preferred. Although there was no difference in patient acceptance between the directives, 76% of the patients preferred one or the other. Therefore, different people like different directives, and a variety of directives should be available for patients to review before they complete one.

Adult↗
PubMed1994

Advance directives in dialysis.

A written advance directive (AD) is a document intended to indicate a person's preferences with respect to treatment decisions that may be necessary if and when that person becomes incompetent. Both in research and in practice, there are features of the dialysis population that make ADs potentially quite relevant and useful. An evolving body of empiric literature supports the use of these documents in this unique population. This article reviews this literature, discusses the philosophic foundations and legal status of ADs, provides some pilot data on a dialysis-specific living will being developed at the University of Toronto Centre for Bioethics, examines clinical considerations related to ADs, and finally suggests future research directions.

Advance Directives↗
PubMed1994

Long-term care facility policies on life-sustaining treatments and advance directives in Canada.

OBJECTIVE: To describe the prevalence and content of long-term care facility policies regarding the use of life-sustaining treatments (cardiopulmonary resuscitation (CPR), artificial hydration and nutrition, dialysis, antibiotics for life-threatening infections, transfer to acute care hospital) and advance directives in Canada. DESIGN: Cross-sectional mailed survey. SETTING: Canadian long-term care facilities with 25 beds or more listed in the 1991-92 Directory of Long Term Care Centres in Canada. Institutions listed as, "general hospitals," "psychiatric hospitals," "children's treatment centres," "group homes," or as purely residential facilities were excluded. PARTICIPANTS: Chief Executive Officers or their designates. MAIN OUTCOME MEASURES: Respondents' self-reports regarding the existence of life-sustaining treatment or advance directive policies and content analysis of the policies themselves. RESULTS: Of 1472 long-term care facilities, 1021 (69%) responded. Of these, 344 (34%) institutions had 397 policies regarding the use of life-sustaining treatments or advance directives. Three hundred twenty facilities (31%) had 349 do-not-resuscitate (DNR) policies (40% on CPR alone and 60% on CPR plus other life-sustaining treatments). Seventeen institutions (2%) each had one policy addressing life-sustaining treatments other than CPR, and 31 institutions (3%) each had one policy addressing advance directives. Of the 397 policies, 171 (43%) required routine discussion with all patients, 156 (39%) mentioned futility, 331 (83%) indicated that the competent patient had the right to make a decision about life-sustaining treatment, 265 (67%) indicated that the family of the incompetent patient had this right, 27 policies (7%) mentioned conflict resolution, 378 (95%) had an explicit requirement for recording the decision, 10 (3%) required explicit communication of the decision to the competent patient, 10 (3%) required such communication to the family of the incompetent patient, 260 (66%) required updating of the decision, and 213 (54%) mentioned rescinding or changing the decision. CONCLUSIONS: Only one-third of Canadian long-term care facilities have do-not-resuscitate policies, and even fewer have policies on advance directives or life-sustaining treatments other than CPR. The policies themselves could be improved by encouraging routine advance discussions, scrutinizing the use of the futility standard, stipulating procedures for conflict resolution, and explicitly requiring communication of the decision to competent patients or substitute decision makers of incompetent patients.

Advance Directives↗
PubMed1993

Canadian outpatients and advance directives: poor knowledge and little experience but positive attitudes.

OBJECTIVE: To examine the knowledge of, previous experience with, attitudes toward and perceived barriers to completing advance directives among outpatients at two general medicine clinics. DESIGN: Cross-sectional questionnaire administered in face-to-face structured interviews. SETTING: General internal-medicine outpatient clinics at a university teaching hospital. PATIENTS: One hundred and five adult outpatients who could communicate in spoken English and who consented to be interviewed. RESULTS: Of 167 patients approached, 58 were excluded because they could not communicate in spoken English, and 4 refused to participate. Of the remaining 105 patients, 17 (16%) knew about living wills, 12 (11%) about durable powers of attorney for health care and 4 (4%) about advance directives. Twenty-three (22%) had thought about their preferences for life-sustaining treatment, 20 (19%) had discussed them, none had written them down, and 45 (43%) had thought about choosing a proxy. Sixty-one (58%) wanted to think about their preferences for treatment, 65 (62%) wanted to discuss them, 32 (30%) wanted to write them down, and 80 (76%) wanted to choose a proxy. The perceived barriers to completing an advance directive were inability to write, the belief that an advance directive was unnecessary, a fatalistic attitude, previous discussion of preferences, a desire to leave the decision to doctors, uncertainty about preferences, a desire to discuss preferences rather than document them, a desire to wait until the situation arose, a desire to write down preferences in the future and a desire to avoid thinking about preferences or advance directives. Respondents with more knowledge of life-sustaining treatments were more likely to want to complete an advance directive. CONCLUSIONS: Outpatients have positive attitudes toward advance directives, but their knowledge and experience are limited. These data underscore the need for patient education and for policies to eliminate the barriers to completing advance directives that patients face.

Adult↗
PubMed1993

What do gastroenterologists in Europe tell cancer patients?

This survey concerns the variation in attitudes among European gastroenterologists to truth telling in cases of cancer. Gastroenterologists in all parts of Europe were asked to consider a case of colonic cancer and to state what they would tell the patient and the patient's spouse. 260 replied. Gastroenterologists in northern Europe would usually reveal the diagnosis to both the patient and the patient's spouse, but some would inform only the spouse with the patient's permission. They would sometimes embellish the truth if the cancer had metastasised. Gastroenterologists in southern and eastern Europe would usually conceal the diagnosis from the patient, in many cases even when the patient asked to be told the truth. Most, however, would tell the spouse the full truth about both diagnosis and prognosis. The variation probably reflects differences in both doctors' attitudes and patients' expectations.

Attitude of Health Personnel↗
PubMed1993

Pneumocystis carinii thyroiditis. Report of three cases and review of the literature.

Pneumocystis carinii infection of the thyroid gland has previously been described in only four living patients with acquired immunodeficiency syndrome, three of whom had been receiving inhaled pentamidine prophylaxis against P carinii pneumonia. We treated three additional patients with P carinii thyroid involvement, all of whom were receiving aerosolized pentamidine. Two of our patients presented with clinical features suggestive of subacute granulomatous thyroiditis. The diagnosis of P carinii in our patients, as well as in the previously described patients, was established by thyroid fine-needle aspiration and Gomori's silver methenamine stains. The recent emergence of P carinii infection of the thyroid gland is likely related to the use of inhaled pentamidine prophylaxis, which appears to predispose to the development of extrapulmonary pneumocystosis. Clinicians need to be aware of the possibility of P carinii thyroiditis and should use aspiration and Gomori's methenamine silver staining in studying patients with the acquired immunodeficiency syndrome who have a painful (or other unexplained) thyroid mass so as to be able to initiate prompt and appropriate therapy.

AIDS-Related Opportunistic Infections↗
PubMed1993

The ethics objective structured clinical examination.

OBJECTIVE: To develop objective structured clinical examination (OSCE) stations to assess the ability of physicians to address selected clinical-ethical situations, and to evaluate inter-rater agreement in these stations. DESIGN: Two ten-minute OSCE stations were developed using video-taped encounters between attending physicians and standardized patients. One scenario involved a daughter requesting a do-not-resuscitate (DNR) order for her competent mother without the mother's knowledge; the other involved a competent elderly woman requesting not to be re-intubated if her congestive heart failure worsened. The scenarios were evaluated using foreign medical graduates taking an OSCE. Each candidate was scored on his or her interaction with a standardized patient in the two OSCE stations by two independent observers. PARTICIPANTS: Eight attending physicians from the Division of General Internal Medicine at the Toronto Hospital were used to develop the OSCE stations, and 69 foreign medical graduates taking the University of Toronto Pre-Internship Program OSCE were used to evaluate the stations. RESULTS: The inter-rater reliability coefficients for the DNR and intubation scenarios were 0.79 (95% CI 0.69-0.87) and 0.75 (95% CI 0.62-0.84), respectively. For the DNR station, the scores of the two examiners, on a scale of 0 to 10, agreed exactly for 34 candidates (50%), within one mark for 59 candidates (87%), and within two marks for 65 candidates (96%). For the intubation station, the scores of the two examiners agreed exactly for 27 candidates (40%), within one mark for 56 candidates (84%), and within two marks for 63 candidates (94%). CONCLUSIONS: The authors produced ethics OSCE stations with face and content validity and satisfactory inter-rater agreement. Ethics OSCE stations may be suitable for evaluating the ability of medical students and residents to address selected clinical-ethical situations.

Analysis of Variance↗
PubMed1993

Graphical display of categorical data.

Categorical data are usually displayed in medical publications with pie graphs and bar graphs. We here consider some of the problems that occur in displaying the rank, magnitude, width, and spacing of categorical data. A solution to some of these problems is offered by the dot chart, which has been used in other scientific literature, but not in medical publications. The dot chart can be a preferred alternative to pie graphs and offers a useful alternative to bar graphs. Dot charts can also be helpful in displaying categorical data for two groups.

Data Display↗
PubMed1993

Public opinion regarding consent to treatment.

OBJECTIVE: To examine public opinion regarding certain elements of consent: disclosure, advance directives, substitute decisions, emergency treatment, and advocacy. DESIGN: Cross-sectional random-digit-dialing telephonic survey. SETTING: General public. PARTICIPANTS: One thousand randomly-selected adults living in Ontario. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Self-reported attitudes and behaviors. RESULTS: Of 5,708 telephone numbers drawn, 641 were non-valid or non-residential, 1,283 were not in service, 1,068 had no answer, a busy line, or an unavailable respondent, 147 subjects had a language barrier, 1,497 subjects refused, 72 interviews were incomplete, and 1,000 interviews were completed. With regard to disclosure, 33% of respondents said that a doctor should withhold information from a patient if asked to do so by the patient's family. With regard to advance directives, 36% of respondents had had advance discussions with their families, and 12% had completed a living will. With regard to substitute decisions, 77% of respondents said that they would went their wishes followed if they were unable to make medical decisions for themselves; 58% wanted their spouse or partner to make such decisions for them. With regard to emergency treatment, 48% of respondents stated that a doctor should give a life-saving blood transfusion to an unconscious adult carrying a card stating that blood transfusion was against his or her religious beliefs. With regard to advocacy, 78% of respondents supported mandatory advocacy services for serious health decisions such as whether to have heart surgery; 33% supported advocacy services for less serious decisions such as whether to have a dental filling. CONCLUSIONS: These data highlight the need to reconsider legislative provisions regarding and/or target public education programs toward specific consent-related issues including disclosure, advance directives, substitute decisions, emergency treatment, and advocacy.

Adult↗
PubMed1993

Continuing problems with patient self-determination.

Cruzan v. Director, Missouri Department of Health, the first "right to do die" case to be decided by the United States Supreme Court, constitutionalizes the principle of patient self-determination. The case encourages competent patients to reflect thoughtfully about the possibility that one day they may be incapacitated just as Nancy Beth Cruzan was and to prepare for that possibility by completing an advance directive. Furthermore, the recently enacted Patient Self-Determination Act requires hospitals to ask adult patients upon admission whether they have advance directives. However, a number of practical concerns arise for physicians about operationalizing these patient self-determination principles within their states and their scopes of practice. Will physicians be prosecuted for "assisting suicides" if they withdraw feeding tubes or forgo other life-sustaining treatments? Will physicians be liable in medical malpractice for "undertreatment" or "overtreatment" in such cases? Will physicians be asked to violate their own moral codes in treating patients? Will others intrude into the traditional physician-patient relationship and decision-making process? Will physicians be caught in the middle of troublesome family, staff, and institutional disputes? How will physicians learn of patients' advance directives? Will physicians be asked to continue care in futile cases? Will Cruzan's self-determination doctrine be improperly extended? Successful implementation of patient self-determination principles will require consideration and discussion of these practical physician concerns.

Attitude of Health Personnel↗
PubMed1993

Advance directives in family practice.

Family physicians can play an important role in helping patients and their families to discuss life-sustaining treatments and to complete advance directives. This article reviews the legal status of, and empirical studies on, advance directives and addresses some important clinical questions about their use relevant to family practice.

Advance Directives↗