Arch Intern Med
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Multicenter Study
Physicians' survival predictions for patients with acute congestive heart failure.
Current guidelines suggest that patients with low likelihoods of survival may be excluded from intensive care. Patients with new or exacerbated congestive heart failure are frequently but not inevitably admitted to critical care units. ⋯ Physicians have great difficulty predicting survival for patients with acute congestive heart failure and cannot identify patients with poor chances of survival. Current triage guidelines that suggest patients with poor chances of survival may be excluded from critical care may be impractical or harmful.
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The quality of discharge planning is an important determinant of patient outcomes following hospital discharge. Patients often report inadequate discussion prior to discharge regarding major elements of the postdischarge treatment plan, including medication and daily activities. ⋯ Physicians overestimate patients' understanding of the postdischarge treatment plan. Steps should be taken to improve communication about postdischarge treatment.
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Severe hemodynamic instability may occur during surgery for removal of pheochromocytoma, unless there is preoperative pharmacological treatment. ⋯ The combination of alpha-metyrosine and alpha-blockade results in better blood pressure control and less need for use of antihypertensive medication or pressors during surgery, compared with the classical method of single-agent adrenergic blockade. Preoperative treatment with metyrosine along with an alpha-blocker is a useful strategy for decreasing the surgical morbidity in patients with pheochromocytoma and assumes greater importance as long as the availability of phentolamine for intraoperative use is a problem.
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Palliative medicine is an emerging medical discipline in the United States, modeled after similar efforts in Great Britain, Australia, and Canada. Increasingly, academic medical centers are starting clinical programs in palliative medicine including inpatient consultation services. A description of the essential components of a palliative medicine consultation is presented, based on the author's experience of more than 600 patient encounters at the Medical College of Wisconsin in Milwaukee. A palliative medicine consultation consists of 6 features: assessment and management of physical symptoms; assisting patients to identify personal goals for end-of-life care; assessment and management of psychological and spiritual needs; assessment of the patient's support system; assessment and communication of estimated prognosis; and assessment of discharge planning issues.
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Some have suggested that advance directives elicit goals of care from patients, instead of or in addition to specific intervention preferences, but little is known about whether goals of care can be used in a meaningful way on documents or whether they can predict preferences for specific interventions. ⋯ Goals have a valid role in advance directives, since the goal choices had a logical relationship to scenarios and intervention choices. However, the 2 goals attempt cure and choose quality of life were not predictive in many instances. If these findings hold true for more general populations of patients, then advance directive documents will need to rely on more than these general goal statements if they are to adequately represent patient preferences.