JAMA : the journal of the American Medical Association
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The homeless mentally ill have become one of the greatest problems of present-day society. The American Psychiatric Association's Task Force on the Homeless Mentally Ill concluded that this is not the result of deinstitutionalization per se but of the way it has been carried out; homelessness among the chronically and severely mentally ill is symptomatic of the grave problems facing them generally in this country. Thus, the problem will not be solved until the basic underlying problems are addressed and a comprehensive and integrated system of care for the chronically mentally ill is established. Specific recommendations of the Task Force include an ample range of graded, supervised community housing; comprehensive and accessible psychiatric care and rehabilitation; the availability of general medical assessment and care, crisis services, and a dependable source of income; a system of case management in which one mental health worker is responsible for each patient; changes in commitment laws to make them more responsive to clinical needs; coordination between the various community resources; and ongoing asylum and sanctuary for that small proportion who require it.
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Eight patients with chronic severe and refractory hypoxemia were treated with a new transtracheal oxygen catheter. All patients demonstrated an arterial oxygen partial pressure of less than 55 mm Hg on high-flow nasal cannula therapy. Refractory hypoxemia was successfully treated in all eight patients following initiation of transtracheal oxygen therapy at 2.5 to 6.0 L/min. ⋯ There were no complications related to the procedure and oxygen flow rates up to 6 L/min were well tolerated. Although four patients died, four remain clinically stable with adequate oxygenation at up to 20 months' follow-up. All eight patients experienced an improvement in quality of life with transtracheal oxygen.
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We studied compliance with do-not-resuscitate (DNR) orders at a university hospital where a DNR protocol has existed since 1979. Documentation of DNR status in patient progress notes and chart orders increased through 1983. During a 12-month period (March 1983 through April 1984), we studied in detail the medical records of 521 patients who had a cardiopulmonary arrest in the hospital. ⋯ The decision to designate a patient DNR occurred late in the course of a patient's illness, often when the patient was in coma. For 28% of patients, some form of medical care was withdrawn or withheld after they were designated DNR. These data suggest that use of the DNR protocol requires changes if patients are to participate in the decision not to undergo cardiopulmonary resuscitation.