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Biomedical subjects

T E Quill

Publications and source records attributed to T E Quill.

At least 37 records · Page 2Linked to original sources
PubMed1994

Physician-assisted death: progress or peril?

Physician-assisted death poses a unique challenge to those devoted to the understanding and prevention of suicide. Though suicide driven by desperation that could be relieved must be prevented whenever possible, our responsibilities to those who are seeking death as a last resort to escape intolerable, unrelievable suffering are less clear. We currently acknowledge that requests to stop life-sustaining therapy can be rational, but we delegitimize the potential rationality of similar requests made by patients who have no such treatment to stop. Though modern palliative methods can ameliorate much of the suffering that accompanies dying, there are still some cases where disintegration and humiliation of the person occurs before death in spite of our best efforts. This manuscript explores a range of personal stories of unrelieved suffering experienced by incurably ill patients who have no escape other than death, and considers potential physician responses.

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PubMed1992

The effects of a hospital policy and state legislation on resuscitation orders for geriatric patients.

In 1983, The Genesee Hospital, Rochester, NY, enacted a do-not-resuscitate (DNR) policy that was revised in 1988 because of complex state legislation. Using a retrospective chart review, we studied DNR ordering for all patients older than 79 years who died in the hospital during the 6 months before the policy and compared it with two 6-month intervals after the policy and three 6-month intervals after the law. The hospital policy was associated with an increase in explicit ordering of DNR from 21% in 1982 to 76% for the 2 years thereafter. A further nonsignificant increase to 84% was seen in the 3 years after the law. When cardiopulmonary resuscitation (CPR) was ordered, it was performed in 29% before the policy, 56% in the 2 years after, and 92% for the 3 years after the law. We reviewed all CPR attempts for 1988 and found that the overall survival rate for patients older than 79 years was 39% and probably was the result of careful patient selection. Our hospital policy was not adversely affected and may even have been enhanced by the New York State legislation. Despite this progress, we found that less than 25% of decisions about CPR or DNR were the result of informed decision making by patients themselves.

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PubMed1991

"The facts concerning the recent carnival of smoking in Connecticut" and elsewhere.

The behavior of health care practitioners toward their patients can greatly affect the patients' motivation for change. Mark Twain's story, "The Facts Concerning the Recent Carnival of Crime in Connecticut," is used to illustrate how traditional strategies for motivating patients to change can have the paradoxic effect of inhibiting change and growth. We use a theory of human motivation, referred to as self-determination theory, to explain this effect and suggest alternative strategies for facilitating patient motivation. Empirical tests of the theory have shown that people will accept more responsibility for behavior change when motivated internally rather than externally. In the doctor-patient relationship, this internal motivation for change can be facilitated when doctors allow choice, provide relevant information, and acknowledge the patient's perspective. We propose a simple, three-question model, consistent with self-determination theory, for physicians to use with patients who smoke and are not yet ready to try quitting.

Counseling↗
PubMed1991

Bad news: delivery, dialogue, and dilemmas.

The narrative from a real patient encounter is used to illustrate the powerful effect that delivering bad news can have on both patient and physician. The meaning of bad news to the patient may be quite different than the medical or the personal meaning to the physician. Differences in perception must be explored and understood before the common ground necessary for joint decision making is established. Initial patient responses can be divided into three categories: (1) basic psychophysiologic (fight-flight or conservation-withdrawal), (2) cognitive, and (3) affective. Responses vary considerably depending on the meaning of the diagnosis to the patient, the degree of immediate threat, and the patient's previous experience with illness. Desired outcomes of the initial meeting include (1) minimizing aloneness and isolation for both patient and physician; (2) achieving a common perception of the problem; (3) giving information tailored to the immediate needs of the patient; (4) addressing immediate medical needs, including the risk of suicide; (5) responding to immediate discomforts; and (6) ensuring a basic plan for follow-up. Though all clinicians deliver bad news, few have had formal training or open exploration of the profound potential impact of the experience.

Acquired Immunodeficiency Syndrome↗
PubMed1990

Healthy approaches to physician stress.

Many studies demonstrate that physicians in training and in practice experience considerable distress, with a high incidence of dysfunction and dissatisfaction. Little is known about the strategies employed by practicing physicians who find enjoyment and satisfaction in their work. We conducted an open-ended survey about how a group of physicians cope with common dilemmas they face today such as mistakes, death, self-care, uncertainty, patient demands, and time demands. We describe the techniques employed by those who felt they were effectively coping. Responses were organized into five general requirements for personal growth: (1) self-awareness, (2) sharing of feelings and responsibilities, (3) self-care, (4) developing a personal philosophy, and (5) nontraditional coping skills of reframing and limit setting. General descriptions of these requirements are followed by tables of specific examples from the survey. The application of these strategies to the dilemmas cited above are presented. These descriptive findings emphasize the need for training programs and governing bodies to incorporate strategies for physicians' personal growth into their priorities. The five basic areas described herein can provide a framework for formal attention to physicians' personal development.

Adaptation, Psychological↗
PubMed1989

Recognizing and adjusting to barriers in doctor-patient communication.

Barriers frequently develop in physician-patient encounters. If they go unrecognized, they can severely limit the therapeutic potential of the doctor-patient relationship. Because barriers are not always explicit, a strategy is presented for recognizing implicit signs such as verbal-nonverbal mismatch, cognitive dissonance, unexpected resistance, and physician discomfort. Once a potential barrier is identified, its source can be defined and explored using standard clinical reasoning techniques such as hypothesis generation and testing. Patients can often share in the process of generating hypotheses about the nature and sources of barriers. Once defined and understood, most barriers can be lessened and sometimes resolved using the basic communication skills of acknowledgment, exploration, empathy, and legitimation. When conflict exists, common interests and differences must be clarified. Conflict might involve disagreement about the presence of a barrier, its nature or source, its relevance to the physician-patient relationship, or about strategies for approaching it. Negotiation need not be limited to the initial positions, but can include creative solutions whereby both parties gain. The decision to confront a barrier depends on both doctor and patient readiness, as well as how critical the barrier is to the therapeutic process, and how amenable it is to change. By effectively uncovering and addressing barriers, the physician can often turn roadblocks to effective communication into means for enhancing the therapeutic relationship.

Communication↗
PubMed1989

Utilization of nasogastric feeding tubes in a group of chronically ill, elderly patients in a community hospital.

Physician practice patterns and attitudes about the use of nasogastric (NG) feeding tubes in a group of elderly patients with severe chronic illness were explored in a community-based teaching hospital in Rochester, NY, using a physician questionnaire and a chart review. The physician questionnaire showed considerable divergence in beliefs about whether this treatment is extraordinary (42%), ordinary (21%), or comfort oriented (37%). Physicians who believed it was extraordinary treatment said they would recommend it less often than those who believed it to be ordinary or comfort oriented in the abstract scenario of a chronically ill, elderly patient who was not maintaining adequate nutrition. Most physician-respondents believed that the patient's wishes should guide the decision. Independently, medical records were retrospectively reviewed for all patients admitted to the hospital in the previous year who had an NG feeding tube placed, who were over the age of 70 years, and who had primary diagnoses of cerebrovascular accident, organic brain syndrome, or metastatic cancer. Contrary to the questionnaire responses, oral or written consent was documented in only 2 of 51 insertions of NG tubes. Of the 7 charts where a surrogate gave consent, only one expressed consideration of the patient's actual wishes. The clinical reasoning leading to the decision documented in the chart emphasized biomedical concerns much more than the patient's quality of life (8:1 ratio). Sixty-four percent (35/55) of patients in the study group died in the hospital, including 90% (19/21) of those who were to be treated with a comfort orientation. In only 2 of 55 patients was medical improvement cited as the reason for discontinuing use of the NG feeding tube. Restraints were used in 53% of the patients to keep the tube in. Recommendations are made that emphasize the need for active patient and family participation in the decision to use an NG feeding tube, requiring a balanced presentation of potential benefits, burdens, and limitations in patients with severe irreversible illnesses.

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PubMed1987

Medical resident education. A cross-sectional study of the influence of the ambulatory preceptor as a role model.

A teaching practice of a residency program in primary care internal medicine was used for a cross-sectional study of the record-keeping habits of ambulatory preceptors and the residents they supervise. A retrospective review of 12 charts per physician over a six-month period was used to compare the charting behavior of three practice groups. Each group was comprised of an attending preceptor and a resident in each of the first, second, and third years of residency. Compared with the other two ambulatory preceptors, one ambulatory preceptor had significantly fewer charts with problem lists, medication lists, and health maintenance records as well as a lower ratio of psychosocial problems to total problems noted on his problem lists. The medical records of the residents supervised by this ambulatory preceptor were also significantly more deficient in each of these areas than the medical records of the other two resident groups. The fact that poor medical record keeping by an ambulatory preceptor was similarly deficient for the residents he supervised across each major area studied suggests that the ambulatory preceptor's actual practice behavior may exert a broad influence on the behavior of his residents. Future educational efforts in primary care internal medicine should be partially directed toward the ambulatory preceptors who serve as potent role models.

Cross-Sectional Studies↗
PubMed1985

Somatization disorder. One of medicine's blind spots.

Patients with somatization disorders are frequently unrecognized and misdiagnosed. The diagnosis depends on recognizing a long-standing pattern of seeking medical intervention for vague, multisystemic symptoms, often without clear physical cause. These patients use symptoms as a way to communicate, express emotion, and be taken care of. Instead of recognizing the disorder and exploring psychosocial contributors to illness, nonpsychiatric physicians tend to repeatedly pursue organic possibilities through multiple tests, procedures, medications, and operations. In patients with somatization disorders, the dollar costs of this strategy are only exceeded by its potential for iatrogenic harm. More productive treatment strategies are presented, emphasizing the need for a long-term relationship with a primary care provider who will treat the patient and his symptoms seriously and respectfully but who is not compelled to invasively evaluate all symptoms.

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