JAMA : the journal of the American Medical Association
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As patients approach the end of life, their disease process may create an immediate life-threatening emergency, yet invasive interventions may be less likely to provide benefit while carrying the same or greater risks. Knowing when it is time to shift from life-prolonging to more palliative approaches, focused on quality of life and comfort, is emotionally and clinically challenging for patients, families, and physicians. ⋯ A structured approach to decision making includes assessing the patient's physical, psychological, and spiritual needs; assessing the patient's support system; discussing prognosis; and assessing patient-specific goals. Physicians can best help patients decide which treatments are appropriate by taking the necessary time to explore all curative and palliative care options, providing honest and timely prognostic information, making clear recommendations, facilitating patient-family discussions, and affirming patient choices.
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Review
Accuracy of diagnostic tests read with and without clinical information: a systematic review.
Although it is common practice to read tests with clinical information, whether this improves or decreases the accuracy of test reading is uncertain. ⋯ At least for the tests examined, the common practice of reading diagnostic tests with clinical information seems justified. Future studies should be designed to investigate the best way of providing clinical information. These studies should also give an estimate of the accuracy of clinical information used, display ROC curves with identified data points, and include a wider range of diagnostic tests.
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Available data suggest that prospective research participants may frequently not understand information disclosed to them in the informed consent process. Little is known about how understanding can be improved. ⋯ Efforts to improve understanding through the use of multimedia and enhanced consent forms have had only limited success. Having a study team member or a neutral educator spend more time talking one-on-one to study participants appears to be the most effective available way of improving research participants' understanding; however, further research is needed.
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Comparative Study
Racial and ethnic differences in time to acute reperfusion therapy for patients hospitalized with myocardial infarction.
Nonwhite patients experience significantly longer times to fibrinolytic therapy (door-to-drug times) and percutaneous coronary intervention (door-to-balloon times) than white patients, raising concerns of health care disparities, but the reasons for these patterns are poorly understood. ⋯ A substantial portion of the racial/ethnic disparity in time to treatment was accounted for by the specific hospital to which patients were admitted, in contrast to differential treatment by race/ethnicity inside the hospital.