Annals of internal medicine
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The decision to use bedside pulmonary artery catheterization for managing patients must involve a careful assessment of the risks compared to the benefits. Complications can be minimized by following specific guidelines for catheter insertion and maintenance. Pulmonary artery catheterization has been shown to be more accurate than clinical assessment alone in critically ill patients for determining the cause of shock (hypovolemic, cardiogenic, or septic) or for assessing the cause of severe pulmonary edema (cardiogenic or noncardiogenic). ⋯ Similarly, although clinical management of hemodynamic instability in septic shock is facilitated by pulmonary artery catheterization, the mortality remains very high because of the lack of specific therapy to reverse the sepsis syndrome. Adequate volume resuscitation and improved tissue oxygenation are universally accepted goals, but specific hemodynamic endpoints are controversial and direct measurements of tissue oxygenation are not possible. Prospective studies to define the clinical value of pulmonary artery catheterization are needed, but must be designed very carefully in order to identify unequivocally the effect of pulmonary artery catheterization on outcome in critically ill patients.
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To understand the factors that distinguish terminally ill, incompetent patients who are given do-not-resuscitate status by physicians against the wishes of the patient's family, I reviewed the charts of 20 such patients (cases) seen in consultation by the ethics committee at the Massachusetts General Hospital over 10 years. I also compared this group of patients with 105 patients who received do-not-resuscitate status with family consent over 3 months in 1986. Socioeconomic factors were similar between cases and controls. ⋯ Eighty percent of the ethics committee cases died in the hospital. The control do-not-resuscitate patients were much less sick and received much less invasive support. This research suggests that the ethics committee at the study hospital was not redefining the principles of medical ethics that underlie decisions not to resuscitate when it recommended limited care in the absence of family consent, but rather was recommending such limitations only for patients in whom it appeared further care was futile.
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To evaluate the appropriateness of diagnostic coding of acute myocardial infarction across teaching and nonteaching hospitals. ⋯ Cases with an inappropriate discharge diagnosis of acute myocardial infarction may be concentrated in teaching hospitals. This finding could have implications for Medicare's diagnosis-related group payment system and governmental and other research efforts that use these data for such purposes as drawing inferences about the quality of hospital care.