The Milbank quarterly
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Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. ⋯ The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
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The Milbank quarterly · Jan 1996
What is the moral authority of family members to act as surrogates for incompetent patients?
Policy and practice regarding the proper role of family members in acting as surrogate decision makers for incompetent patients often suffer from an incomplete understanding of the diverse grounds of families' moral authority to act as surrogates. The different, sometimes conflicting, grounds of family surrogacy are explored: (1) its establishment by democratic decision processes; (2) the self-determination of the incompetent patient; (3) the fact that a family member usually acts according to the patient's wishes and interest; (4) the reality that family members are usually most affected by the patient's decisions; (5) consideration of these effects; (6) a recognition that the family is a moral unit, responsible for its members. Each of these grounds must be considered when selecting a surrogate or deciding on the proper scope of the surrogate's decision-making authority.
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In the United States today, major forces in society and within medicine are uniting in support of an enlarged pool of primary care physicians and a heightened status for primary care in medical practice. In the unsettled contemporary medical world, it is little noticed that, during its rise to prominence, primary care has changed from what was basically an administrative concept into one of a sophisticated generalism; the pressure for its new form arises from difficulties in current health care delivery and subspecialty medicine. Generalism takes as its theme the patient rather than the disease and is most appropriate for the contemporary world of chronic disease. It requires new forms and places of training, including postgraduate didactic teaching, so that doctoring is as specifically taught as medical science.
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This review of the literature of the past decade on medical care costs at the end of life finds that the data do not support the often-voiced hypothesis that the rise in medical care costs is due largely to the disproportionate use of high-technology medical care by persons who die. It also shows that although the intensity of care, as indicated by hospital expenditures, declines with age, any savings on hospital costs of very old decedents are offset by nursing-home costs. Studies of hospice care and advance directives are reviewed for their effectiveness in reducing end-of-life costs, but these strategies are not promising at this time, largely because of the difficulty of predicting when an individual patient will die. It is suggested that curbing the rise in medical care costs will require basic changes in the physician-patient relationship and in our attitude to death.