JAMA : the journal of the American Medical Association
-
While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt with in diverse ways between different countries and cultures. ⋯ The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.
-
Comparative Study
Impact of Medicare coverage on basic clinical services for previously uninsured adults.
Uninsured adults receive less appropriate care and have more adverse health consequences than insured adults. Longitudinal studies would help to more clearly define the effects of health insurance on health care and health. ⋯ Previously uninsured adults substantially increased their use of covered basic clinical services but not medications after gaining Medicare coverage. An affordable option through which near-elderly uninsured adults could purchase Medicare coverage might have similar effects.
-
Recent advances in human immunodeficiency virus (HIV) therapy have significantly reduced HIV-related mortality in the developed world, but mortality rates have plateaued, and AIDS remains a leading cause of serious illness and death for young adults. The chronic nature of the HIV disease course and the increasing burden of cumulative HIV-related morbidity and treatment-related toxic effects pose new challenges to the care of patients over time. ⋯ As patients survive longer in the latter stages of progressive HIV disease, they may in fact have increasing need for comprehensive symptom management as well as wide-ranging need for psychosocial, family, and care planning support. In the HAART era, the false dichotomy of curative vs palliative care for patients with HIV/AIDS must be supplanted by a more integrated model to provide comprehensive care for patients with advanced HIV disease and their families.
-
Risk factors for perioperative mortality after coronary artery bypass graft (CABG) surgery have been extensively studied. However, which factors are associated with early readmissions following CABG surgery are less clear. ⋯ Readmission within 30 days following discharge is an important adverse outcome of CABG surgery. Continued attempts should be made to explore the potential of readmission as a supplement to mortality in assessing provider quality.