The American journal of medicine
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Review
Acquired immunodeficiency syndrome and the Americans with Disabilities Act: a legal duty to treat.
The emergence of the human immunodeficiency virus (HIV) as a serious public health threat has rekindled long dormant debate about individual physicians' duty to treat potentially contagious patients. Because of the widely accepted common-law tenet of the "no duty [to treat] rule," previous work on a duty to treat focused on historical reviews, medical society position statements, and the ethical arguments upon which the statements are based. The passage of the Americans with Disabilities Act has rendered these discussions moot by creating, through federal civil rights mechanisms, a legal duty to treat patients with HIV, enforceable under considerable penalties. The paper also concludes that there has been inadequate attention paid to similar civil rights concerns of infected physicians.
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This study was designed to describe the cerebrospinal fluid (CSF) findings and neurologic diagnoses observed in human immunodeficiency virus (HIV)-infected adults undergoing diagnostic lumbar puncture (LP) and to correlate the results of LP with indications and CD4 counts. ⋯ CSF abnormalities were common at all stages of disease. LP was diagnostic in 22% of cases, but fewer than half of the diagnoses were of treatable secondary complications. Patients with a CD4 count higher than 0.200 x 10(9) have a very low incidence of opportunistic complications. The relatively low yield of LP in patients with altered mental status suggests that other testing modalities should be used prior to LP.
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The medical futility debate is usually framed as a conflict between physician and patient (or surrogate) over the right to decide whether a particular life-saving treatment is futile and should not be attempted. Arguments on behalf of physician-determined futility emphasize the limits of physicians' obligations; arguments on behalf of patient-determined futility reflect concerns over the potential erosion of recent gains in patient autonomy against medical paternalism. ⋯ Often overlooked in this debate, both at the bedside and in public commentary, is the ethical duty of the physician to redirect efforts from life-saving treatments toward the conscientious pursuit of treatments that maximize comfort and dignity for the patient and the grieving family. To supplement the limited terms of the futility debate with an ethic of care, physicians should lead in advocating greater awareness of the ethics of care in doctor-nurse interactions, institutional facilities, insurance policies, and public education.
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Review
Infection with the human immunodeficiency virus in prisoners: meeting the health care challenge.
The magnitude and the scope of health care problems posed by human prison inmates seropositive for the human immunodeficiency virus (HIV) are enormous. Prisoners represent a substantial proportion of HIV-infected individuals in North America. A high proportion of prisoners are intravenous drug users who often have not received appropriate health care or HIV-directed services prior to incarceration. ⋯ The Brown University medical community, in conjunction with the Rhode Island Department of Health and Corrections, has developed an effective program for the health care of such prisoners, both during incarceration and after release from prison. Academic medical centers are uniquely poised to assume the leading role in meeting this obligation. We believe that this general approach, with region-specific modifications, may be effectively applied in many correctional institutions in North America.
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To assess the association between implementation of the Patient Self-Determination Act (PSDA) and (1) the use of formal, written advance directives, (2) the use of informal advance care arrangements, and (3) discussions between patients and their physicians and proxies an advance care planning and end-of-life treatment preferences. ⋯ The PSDA was associated with significant effects on general advance care planning issues, increasing the proportion of patients who had (1) some kind of advance care arrangements and (2) general discussions of end-of-life issues with their proxies. However, the PSDA did not appear associated with significant increases (1) in the use of formal, written advance care documents, (2) in the frequency of discussions between patients and their physicians on advance care documents or end-of-life issues, or (3) in the frequency of discussions about specific treatment preferences between patients and their proxies.