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At least 19 recordsLinked to original sources
PubMed1992

Factors associated with veterans' decisions about living wills.

Most states have adopted legislation that allows patients to designate by advance directives the type of health care they would like to receive if they should become incompetent while suffering from a terminal illness. The living will is one of the most common of these legal instruments. Unlike most studies that have examined very sick or hospitalized patients' preferences regarding life-sustaining treatments, our study explores the concerns of 70 ambulatory veterans from a general medical clinic regarding living wills. Before the interview, 43% of patients reported never having heard of living wills. At interview, 4% of the patients had a living will, 33% intended to sign a living will but had not done so (INTEND), 54% were undecided about living wills (UNDECIDED), and 9% did not want a living will. Compared with UNDECIDED patients, all other patients did not differ in the use of health care services during the previous year or in diagnoses. INTEND patients, however, were significantly more likely to be white, to express poorer health status, to know someone with a living will, and to have previously discussed the topic. UNDECIDED patients were more likely than INTEND patients to report that religious beliefs about living wills affected their decision. Virtually all (91%) of the respondents believed that signing a living will would not affect their treatment. These data suggest that many patients may not know that they can have a living will and that discussions with those who already have a living will may be helpful in educational programs designed to promote informed patient decision-making.

Aged↗
PubMed1991

Knowledge, attitudes, and behavior of elderly persons regarding living wills.

The knowledge, attitudes, and behavior of elderly persons regarding living wills were explored in a rural county in eastern North Carolina. A questionnaire was administered to 75 ambulatory elderly persons by personal interview at community dining sites. Fifty-two percent (39) of these subjects said they were familiar with living wills and 64% (48 persons) correctly summarized what the North Carolina living will says. When asked about preferences for medical care in the setting of a terminal illness, 86% (65 persons) stated a desire to receive basic medical care or comfort care only. Although their preferences were consistent with the provisions of a living will, none had signed the living will document provided by the state of North Carolina, and only two (3%) had discussed a living will with their physician. Seventy (93%) wanted their family or spouse to make decisions about terminal care if they themselves were unable to participate, and discussions between these persons and their chosen proxies actually occurred 45% (34/75) of the time. Eighty-one percent (61 persons) stated a desire to discuss end-of-life care with their physicians, but a minority (eight [11%]) had actually talked with their physicians, and these discussions were usually initiated by the patient (five of eight). We conclude that living will legislation is congruent with the desire of many elderly persons to limit medical care in terminal illness. However, this elderly population did not make use of living wills as a means of indicating their wishes. Recommendations are made to improve physician-patient and patient-proxy communication regarding preferences for medical care at the end of life and living wills. Alternatives to the living will should also be explored.

Aged↗
PubMed1991

Willed action and the prefrontal cortex in man: a study with PET.

We used positron emission tomography to contrast changes in cerebral blood flow associated with willed and routine acts. In the six tasks used, volunteers had to make a series of responses to a sequence of stimuli. For the routine acts, each response was completely specified by the stimulus. For the willed acts, the response was open-ended and therefore volunteers had to make a deliberate choice. Willed acts in the two response modalities studied (speaking a word, or lifting a finger) were associated with increased blood flow in the dorsolateral prefrontal cortex (Brodmann area 46). Willed acts were also associated with decreases in blood flow, but the location of these decreases was modality dependent.

Acoustic Stimulation↗
PubMed1990

Should living wills be legalized?

Living wills allow patients to state their wish to die and not be kept alive through the use of medications, artificial means or "heroic" measures. They have been made legal documents in 38 states in the United States. Living wills permit advance expression of a patient's wishes, promote effective communication and demonstrate respect for the patient as a person. Problems with legal recognition of such wills include the need for agreement on fundamental terms, possible restriction of patients' rights, limitation of options in decision-making and possible negative effects on the physician-patient relationship. Before legislation is enacted, public and professional attitudes toward the care of terminally ill patients should be assessed. All health care professionals should receive better education in this area, and palliative care services should be made more widely available. Only if these measures fail should living wills be made legal documents in Canada.

Attitude of Health Personnel↗
PubMedDate not supplied

Physicians' attitudes towards living wills and cardiopulmonary resuscitation.

OBJECTIVE: To determine whether a physician's familiarity with the living will directly relates to an expressed willingness to discuss resuscitation issues with patients. DESIGN: Survey of selected primary care and medical sub-specialist physicians most likely to care for seriously or terminally ill patients. SETTING: Private-practice clinicians practicing in an urban county. PARTICIPANTS: Internists, family practitioners, cardiologists, oncologists, and neurologists in private practice. INTERVENTIONS: None. RESULTS: Almost all responding physicians (97.2%) knew of the living will, although few (13.5%) had executed one for themselves. Most were willing to keep a copy of their patients' living wills with their office records. However, only a few physicians (20%) indicated they routinely discussed extraordinary care issues with their patients. In fact, most (70%) reported they rarely or never discussed cardiopulmonary resuscitation (CPR) with their patients. With terminally ill patients, physician initiative was greater: 69% reported discussing resuscitation preferences. Comparable discussions with elderly patients were undertaken only if the physician believed they would be warranted by the clinical circumstances. When questioned about their own sentiments towards resuscitation, most physicians indicated they would not want CPR if they were terminally ill (86%) or mentally incompetent (93%). A similar number (92%) would refuse artificial feeding if permanently comatose. CONCLUSIONS: Many physicians recognize the importance of living wills as an expression of patient treatment preferences. Nevertheless, discussion of patient preferences is unlikely because of physicians' reluctance, except in limited circumstances, to initiate a dialogue about life-sustaining measures. Because patients also are often unwilling to begin such discussions, better methods of facilitating discussion of CPR and other extraordinary health care measures must be sought.

Adult↗
PubMed1990

Technical difficulties with the Brooker-Wills nail in acute fractures of the femur.

In this series of 41 cases of acute fractures of the femur treated with the Brooker-Wills nail, 20 technical problems with insertion or removal of the nail occurred in 19 of the total. Final outcomes were determined in 33 cases followed for 1 year or more. Technical difficulties had a deleterious effect on the outcome in three of these 33 cases. Mechanical failure seems to be a significant problem with the Brooker-Wills system in this and other series. We found that bending of the proximal nail during the insertion, breaking of the tip of the distal fixator inserter, and detachment of the blades from the fixator shaft had occurred. Although satisfactory results were obtained in this series, comparable to other "start-up" series, it is our opinion that the advantages of the Brooker-Wills nail over other interlocking nails are outweighed by the disadvantages of difficult insertion and removal.

Adolescent↗
PubMedDate not supplied

Will outpatients complete living wills? A comparison of two interventions.

OBJECTIVE: To test the efficacy of two intervention methods that aimed to increase the percentage of adult clinic patients who completed living wills and placed them on file with their physicians within a four-month period. DESIGN: There were one control and two intervention groups. Surveys were separated by age and gender categories and randomly selected for the final sample. SETTING: The internal medicine outpatient clinic of a large tertiary hospital. PARTICIPANTS: All patients who visited the clinic were asked whether they would be willing to fill out a survey. The final sample included 167 adult patients who comprised three study groups. INTERVENTIONS: The first intervention relied solely on a booklet that described the Minnesota Living Will Act, general information concerning advance directives, and medical interventions that could be considered extraordinary if used for a patient in a terminal condition. The second intervention relied on both the booklet and repeated physician-initiated discussions with the patient about the probable value of a living will. MAIN RESULTS: The booklet/physician intervention was found to be significantly more effective than either the booklet-only intervention or no intervention (p less than 0.05 and 0.01, respectively). CONCLUSIONS: The physician intervention used in this population could be undertaken in any primary care clinic. Time spent in discussion before a crisis may be significantly shorter and qualitatively better than time spent in discussion with families who must make decisions during a crisis.

Adult↗
PubMed1992

Living wills and orders not to resuscitate: what is the difference?

There is confusion about the meaning of living wills and orders not to resuscitate. Both are very important concepts which allow patients to control some of the decisions at the end of life. Living wills are valid until revoked, have the same meaning throughout Louisiana, and are implemented when a patient becomes incompetent and qualified (certified in writing as having a terminal and irreversible condition). Orders not to resuscitate are policy matters in each hospital, thus they vary throughout the state. They are implemented at the time of cardiac arrest.

Cardiopulmonary Resuscitation↗
PubMed1988

Early use of the Brooker-Wills interlocking intramedullary nail (BWIIN) for femoral shaft fractures in acute trauma patients.

During a 33-month period, 40 multiply injured patients underwent 43 Brooker-Wills interlocking intramedullary nailings (BWIIN) for femur fractures in the setting of a Level I trauma unit. There were 12 open fractures (28%), 66% of the closed fractures underwent BWIIN within the first 24 hours of injury, and 33 fractures (77%) had comminution of Winquist-Hansen Type II or greater, and either static or dynamic locking techniques were used in 38 (88%) of the cases. There were three intraoperative technical problems. The estimated blood loss and operative times were consistent with other reported series for interlocking nailing techniques. The average followup was 65 weeks. Only one fracture went on to nonunion. There were no problems with angulation or rotation. One patient had 1.5 cm of shortening. There were four major (9%) and four minor (9%) complications. Rod removal was successful in 17 of 18 cases. Mechanical failure (deformation and/or fracture) of the proximal end of the rod was found in four (22%) of the extracted nails and caused failure of removal in one. The Brooker-Wills nail is a versatile device which can be used to treat complex fractures of the entire femoral shaft in acutely injured patients.

Adolescent↗
PubMed1989

Living wills: the ethical dilemmas.

Advanced technology has created various means to prolong life, along with the supposed obligation to use those technologies. Often costly, these technologies may have little or no impact on the outcomes of illness. When and how that technology should be used may result in conflict. By writing a living will, some persons have said "Thanks, but no thanks" to the use of these technologies. Many healthcare professionals, however, are reluctant, because of misinformation or fear of litigation, to respect consumers' rejection of the offer of prolonged life at all costs. An examination of the legal, ethical and emotional aspects of NDAs and living wills may provide some guidelines for dealing with the conflicts encountered in practice. In addition, an awareness of personal feelings may clarify some of the gray areas involved in living wills and assist healthcare professionals to make decisions about Natural Death Acts.

Attitude of Health Personnel↗
PubMedDate not supplied

Second thoughts on living wills.

Advance directives such as living wills are attractive in that they give us a sense of control over our futures. But they also tend to obscure conflicts between a patient's competent wishes and later, incompetent interests. They allow caregivers to avoid evaluating quality of life in assessing the best interests of incompetent patients.

Caregivers↗
PubMed1991

Of dead brains, living wills, and autonomy.

Recent court decisions have clarified many important bioethical and medicolegal issues. Brain death, living wills, and patient autonomy are being defined by the rulings.

Adult↗
PubMed1990

Living wills in Michigan. Why the time is right.

This issue of Michigan Medicine marks a turning point in MSMS posture regarding advance directives ("living wills"). For many years, MSMS has discussed the issue and has supported legislation, more or less behind the scenes. We are now involved in a more proactive stance, trying to encourage more discussion and wider use of these devices, whether or not legislation is enacted. In this article I will: 1) review some basic terms and ethical principles; 2) recount the deliberations of the MSMS Committee on Bioethics on this topic; and 3) indicate why the time is now ripe for more action by Michigan physicians.

Advance Directives↗
PubMed1989

Are people willing and able to pay for health services?

Following a nationwide increase in user fees for health services in Swaziland, this paper analyzes the effect of the fee increase on overall patient use of health services, on which types of services, curative vs preventive, were most affected, and on changes in utilization by higher paying and lower paying groups. Patient attendance data from a 71% sample of government and mission health facilities, suggests that the 'people are willing and able to pay for health services' assertion is not supported by the Swaziland case. Following the fee increase, average attendance decreased at government facilities by 32.4%, increased at mission facilities by 10.2%, leading to a combined decline of approx. 17%. Patient visits designed to protect against childhood diseases, BCG and DPT immunizations, or against dehydration in children, show average attendance declines of -16, -19, and -24%, respectively, while visits for musculoskeletal diseases, a less serious disease, declined 1.2%. The analysis also suggests that up to 34% of the overall decline in attendance was among patients who previously had paid the least for health care with part of this decline likely including fewer multiple visits.

Eswatini↗
PubMed1988

Inability to deploy the distal fixator fin of a Brooker-Wills nail.

While a Brooker-Wills nail was being placed in an osteotomized femur during the course of a closed femoral shortening procedure, the slot holding the distal fixator fin was deformed as it was driven across the fracture/osteotomy site (approximately 50% apposition), and the fin could not have been deployed had it been needed for stabilization of the fracture. This case illustrates the importance of maintaining a meticulous closed reduction and of obtaining oblique image intensifier views of the distal portion of this nail while it is being inserted.

Adolescent↗
PubMed1986

Usefulness of a statewide referral directory of dentists found willing to treat disabled persons.

Referral directories of dentists willing to treat disabled individuals have been used as an expeditious means of improving access to care for this group. The purpose of this survey was to assess the usefulness of one such statewide referral directory. Agencies, individual field workers, and organizations to which the directory had been sent 18 months earlier were surveyed to determine the usefulness of the directory. Of the 77 groups and individuals surveyed, 46 (59.7 percent) reported that they had received the directory. The directory was considered "useful" or "very useful" by 58.7 percent of the acknowledged recipients. An additional 19.6 percent considered it to be "marginally useful." The directory was estimated to be used at least once per month by 59.1 percent of the recipients. Referral directories address only one aspect of access to dental care for disabled individuals; the effectiveness of such directories depends on their appropriate use by referring agencies.

Dental Care for Persons with Disabilities↗
PubMed1989

The future prospects for living wills.

Following the first enactment of living will legislation in California in 1976 the majority of the states of the USA have now passed similar laws. However, flaws have been identified in the way they work in practice and many states are considering reviewing their legislation. In Britain there is no legislation but the subject is currently commanding considerable interest. This paper assesses the future prospects for living wills in both the USA and Britain, analysing the different options available and comparing the two countries. If patients who become permanently incompetent are to have their previous autonomous decision-making respected, there is general agreement that advance directives for health care must be introduced. The difficulty is in deciding how to implement them, and especially whether this should be by statutory or non-statutory means, the traditions in the two countries being very different in this respect. It is concluded that whichever route is taken, promoting respect for patient autonomy is as much a matter for education and persuasion of doctors as of the adoption of particular instruments. Doctors should therefore be trained in what constitutes good medical practice in this area and, to ensure that it can be carried out properly, the general level of medical facilities for these patients must also be protected and promoted.

Forecasting↗
PubMed1992

Approaching families for organ donation: physicians are willing.

While current literature documents a critical disparity between the increasing demand for organs for transplantation and the relatively static supply, reasons for the shortage of donors are not well understood. Public opinion surveys describe a population willing to donate, but consent rates reported by organ procurement organizations suggest problems in the process of approaching families. This study of Texas physicians regarding their knowledge of laws related to brain death and to routine inquiry for organ donation and their attitudes toward the critical step of seeking consent from families indicates that physicians need more information about questions asked by families, would benefit from more structured hospital policies on routine inquiry, feel that physicians rather than nurses should approach families, and believe that the public is not well informed about donation.

Brain Death↗