Arch Intern Med
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To assess the determinants of communication about resuscitation between persons with acquired immunodeficiency syndrome (AIDS) and their physician. ⋯ A majority of persons with AIDS in this study had not discussed their preferences for life-sustaining care with their physician, despite the desire to do so. Interventions to improve patient-physician communication about resuscitation for nonwhites and other groups at risk of inadequate discussion might lead to clinical decisions that are more consistent with patient preferences.
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The appropriate role of cardiopulmonary resuscitation in the hospital continues to be a topic of interest to physicians and patients alike. The use of do not resuscitate (DNR) orders reflects a growing expression of autonomy by patients to refuse medical treatment, and also a growing recognition of its futility in many circumstances by physicians. Although it has been suggested that wider use of advance directives will lead to a reduction in health care costs near the end of life, little empiric data exist to support this prediction. This study was designed to ascertain the rates of DNR orders and their associated costs. ⋯ This study demonstrates high variability in the use of DNR orders between various medical and surgical services. These range from a high of 98% on an oncology service to a low of 43% on cardiology. Most patients have a DNR order at the time of death, but these typically occur late in the course of the hospital stay. Death in the hospital is costly and total hospital and professional charges are significantly lower when a patient is admitted with an established nonresuscitation order compared with those for whom a DNR is established while in the hospital. This study provides a basis against which to measure the impact of efforts such as the Patient Self-Determination Act of 1990 to increase the use of advance directives, as well as monitor their effect on health care expenditures.
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Survival rates from out-of-hospital cardiac arrests due to ventricular fibrillation or pulseless ventricular tachycardia vary greatly. The majority of published reports indicate a survival range from 11% to 33%, depending on the area of observation. Two recent series from major metropolitan centers describe markedly less favorable outcomes and have led to speculation that dense urbanization may contribute to worse outcomes. ⋯ There is increasing evidence that previously recognized standards for resuscitation success may not be present in certain types of municipalities, including this northeastern city. A registry of outcomes from out-of-hospital cardiac arrests would help to clarify the true national experience.
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Editorial Comment
Variability in resuscitation rates for out-of-hospital cardiac arrest.