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Biomedical subjects

S H Miles

Publications and source records attributed to S H Miles.

At least 37 records · Page 2Linked to original sources
PubMed1992

Deaths caused by physical restraints.

A retrospective analysis of 122 deaths caused by vest and strap restraints found that most victims were women (78%) and a median age of 81. Victims were found suspended from chairs (42%) or beds (58%); 83% were in nursing homes. Detailed analysis of 19 cases showed that all were demented, 13 had impulsive or involuntary movements, and 14 had recently tried to escape from a restraint or been found in a dangerous position while restrained. Restraints are an underrecognized, underreported, avoidable, and proximate cause of at least 1 of every 1,000 nursing home deaths.

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PubMed1992

Empowerment of the older patient? A randomized, controlled trial to increase discussion and use of advance directives.

OBJECTIVE: To see if an educational intervention directed at older outpatients would lead to increased use or discussion of advance directives and to characterize patients' reasons for not obtaining advance directives. DESIGN: Randomized, controlled trial of an educational intervention versus usual care. SETTING: Outpatient geriatrics clinic of a university hospital. PATIENTS: One hundred and thirty-one non-demented patients over the age of 65 who did not have an advance directive documented in their record at the start of the study. Forty-eight patients were in the trial arm and 83 in the control. MAIN OUTCOME MEASURES: All patients had their charts reexamined 6 months after enrollment to look for the presence of a living will, a durable power of attorney for health care, or a physician's note describing a discussion of advance directives. Trial patients were also re-interviewed to examine their reasons for not executing an advance directive. MAIN RESULTS: Six months after the intervention, only seven of the 48 trial subjects (15%) had an advance directive or note describing discussion of advance directives in their charts compared to eight of the 83 controls (10%) (P greater than 0.05). When asked to give reasons for not obtaining an advance directive, many patients' responses pointed to procrastination as a significant barrier. CONCLUSIONS: Promoting advance directive use is a complicated task. Barriers other than information and access to documents appear to be involved and need to be addressed in future efforts.

Advance Directives↗
PubMed1992

Attitudes toward discussing life-sustaining treatments in extended care facility patients.

OBJECTIVE: To determine nursing home residents' attitudes toward discussing life-sustaining treatment plans with their physicians and the factors associated with these attitudes. DESIGN: Random-sample, interviewer-administered survey. SETTING: Forty-one nursing homes in which some residents were cared for by house-staff physicians of the Hennepin County (Minnesota) Medical Center Extended Care Department. PATIENTS: Random sample of 150 nursing home residents receiving primary care from Extended Care Department physicians, 131 (87%) of whom completed the interview. RESULTS: Older individuals were less likely to have spoken with physicians and family members about treatment plans (p < 0.05), and to have felt that they had more say than necessary in their treatment (P < 0.05). Only 19 (14.5%) residents had formal treatment plan discussions about limiting life-sustaining treatment. Although perceived current health status did not differ between residents with and without treatment plans, those residents who had discussions about advance directives were more likely to report health improvement over the past 6 months (P < 0.05). Residents with formal advance directives were, on average, 8.4 years younger than those without them (P < 0.05). CONCLUSIONS: Younger patients are more likely to have had discussions about life-sustaining treatment and are also more frequently involved in plan development. Preferences for level of involvement should be considered during advance directive planning, and it should be recognized that these preferences may vary with age. Future research should evaluate whether this age relationship is a true age or a cohort effect.

Adult↗
PubMed1992

Interpersonal issues in the Wanglie case.

The case of Helga Wanglie involved a conflict between the medical team, which concluded that a respirator was providing no medical benefit to the 87-year-old woman and should therefore be discontinued, and Ms. Wanglie's family who did not want the respirator removed. Most published commentary on the case has analyzed the medical team's conclusion. In contrast, this article examines the impact of the conflict on the conduct of the clinical case, and on the relationships among the various parties involved.

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PubMed1992

From data to policy ... to politics. The Minnesotans health care plan for universal access to care.

Calls for major reform of the health care delivery system have been sounded at both the state and federal level. However, given the lack of consensus on health care reform at a federal level, more than half of the states are developing initiatives for universal access to care. In 1989, the Minnesota legislature created the Health Care Access Commission to develop a blueprint for universal access in Minnesota. To assist this effort, we studied the extent and nature of uninsurance and underinsurance within the state. In this article we report the findings of that study and discuss how the findings were first used to develop recommendations for universal access legislation. We then describe the fate of the legislation. Finally, we describe the veto and the creation of HealthRight, the recently enacted plan for health care reform bill in Minnesota. This plan simultaneously expands access to care and aims to contain health care costs.

Adult↗
PubMed1991

Limiting resuscitation: emerging policy in the emergency medical system.

Patients, families, and physicians frequently decide that a hospitalized patient will forgo cardiopulmonary resuscitation and document this decision with a do-not-resuscitate (DNR) order. In community settings (home, nursing home, hospice), these orders may conflict with paramedics' standing orders to provide cardiopulmonary resuscitation whenever it is medically indicated. We did a nationwide telephone survey of state offices for coordination of emergency medical services (EMS) to see how the states deal with this potential conflict. We identified eight states that have specific policies enabling EMS personnel to accept DNR orders for patients being transported by ambulance. State officials identified administrative complexities and legal concerns as the primary barriers to enacting prehospitalization DNR policies. We also identified 21 local EMS systems that have developed policies for accepting orders to withhold life-sustaining treatment. Four types of policy models, characterized according to procedure for validating DNR orders and telephone accessing the EMS system, show that regulatory reform can address policy barriers in the absence of enabling legislation.

Attitude of Health Personnel↗
PubMed1991

Autonomy's responsibility. A gloss on the Wanglie affair.

In 1990, 87-year-old Helga Wanglie suffered cardiac arrest while being treated for lung disease at a chronic care facility. When she failed to regain consciousness after being resuscitated, a physician suggested the possibility of discontinuing treatment. At this point, her family requested that she be transferred to a hospital for evaluation. After a variety of procedures failed to improve her condition, the attending physician told the family he was no longer willing to prescribe the respirator because it could not serve her personal medical interests and that her unconscious state precluded the possibility of her appreciating life. However, the family insisted that the hospital provide Ms. Wanglie care, and she remained in treatment until she died 13 months later. The dispute between the hospital and the Wanglie family brings into focus the fundamental premises of the doctor-patient-family relationship. The rules for these relationships-described by such terms as "rights," "responsibilities," and "informed consent"--have both private and public dimensions. Mr. Wanglie had a clear right to be fully informed of all medically reasonable treatments and a right to choose or refuse any therapy the physician prescribed. He did not, however, have a right to demand any treatment he wanted.

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