The New England journal of medicine
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BACKGROUND. Advance directives for medical care and the designation of proxy decision makers to guide medical care after a patient has become incompetent have been widely advocated but little studied. We investigated the attitudes of patients toward planning, perceived barriers to such planning, treatment preferences in four hypothetical scenarios, and the feasibility of using a particular document (the Medical Directive) in the outpatient setting to specify advance directives. ⋯ When people are asked to imagine themselves incompetent with a poor prognosis, they decide against life-sustaining treatments about 70 percent of the time. Health, age, or other demographic features cannot be used, however, to predict specific preferences. Advance directives as part of a comprehensive approach such as that provided by the Medical Directive are desired by most people, require physician initiative, and can be achieved during a regular office visit.
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The use of advance directives is recommended so that people can determine the medical care they will receive when they are no longer competent, but the effectiveness of such directives is not clear. ⋯ In an analysis of 96 outcome events (hospitalization or death in the nursing home), care was consistent with previously expressed wishes 75 percent of the time; however, the presence of the written advance directive in the medical record did not facilitate consistency. Among the 24 events in which inconsistencies occurred, care was provided more aggressively than had been requested in 6 cases, largely because of unanticipated surgery or artificial ventilation, and less aggressively than requested in 18, largely because hospitalization or cardiopulmonary resuscitation was withheld. Inconsistencies were more likely in the nursing home than in the hospital. CONCLUSIONS. The effectiveness of written advance directives is limited by inattention to them and by decisions to place priority on considerations other than the patient's autonomy. Since our study was performed in only one nursing home and one hospital, other studies are necessary to determine the generalizability of our findings.
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Randomized Controlled Trial Multicenter Study Comparative Study Clinical Trial
Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.
In the Cardiac Arrhythmia Suppression Trial, designed to test the hypothesis that suppression of ventricular ectopy after a myocardial infarction reduces the incidence of sudden death, patients in whom ventricular ectopy could be suppressed with encainide, flecainide, or moricizine were randomly assigned to receive either active drug or placebo. The use of encainide and flecainide was discontinued because of excess mortality. We examined the mortality and morbidity after randomization to encainide or flecainide or their respective placebo. ⋯ There was an excess of deaths due to arrhythmia and deaths due to shock after acute recurrent myocardial infarction in patients treated with encainide or flecainide. Nonlethal events, however, were equally distributed between the active-drug and placebo groups. The mechanisms underlying the excess mortality during treatment with encainide or flecainide remain unknown.