The Journal of the American Board of Family Practice / American Board of Family Practice
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J Am Board Fam Pract · Mar 1992
Informed consent: law, clinical reality, and the role of the family physician.
Informed consent is typically seen as most relevant to surgical and other invasive specialties. Although family physicians perform fewer high-risk procedures, they are nonetheless extensively involved in the informed consent process because of the comprehensive and continuing nature of the family physician-patient relationship. ⋯ Legal rules that require disclosure of alternatives to the patient by the treating physician are examined in the context of the family physician's role as a coordinator of patient care. Practical suggestions regarding discussion of alternatives, extent of disclosure, coordination with consulting physicians, and encouragement of patients' participation in discussions are offered.
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J Am Board Fam Pract · Mar 1992
ReviewBenzodiazepine dependence and withdrawal: identification and medical management.
Primary care physicians prescribe benzodiazepines for the treatment of anxiety. Although most patients use the benzodiazepines appropriately, some patients experience benzodiazepine abuse, addiction, or physical dependence, each one of which is a distinct syndrome. Benzodiazepine dependence, which relates to the development of tolerance and an abstinence syndrome, can be produced by three disparate benzodiazepine use patterns. These distinct benzodiazepine use patterns can in turn create distinct withdrawal syndromes. High-dose benzodiazepine use between 1 and 6 months can produce an acute sedative-hypnotic withdrawal syndrome. In contrast, low-dose therapeutic range benzodiazepine use longer than 6 months can produce a prolonged, subacute low-dose benzodiazepine withdrawal syndrome. Daily, high-dose benzodiazepine use for more than 6 months can cause a combination of an acute high-dose benzodiazepine withdrawal and a prolonged, subacute low-dose withdrawal syndrome. In addition, patients may experience syndrome reemergence. ⋯ Medical management for acute benzodiazepine withdrawal includes the graded reduction of the current benzodiazepine dosage, substitution of a long-acting benzodiazepine, and phenobarbital substitution. However, the medical management of benzodiazepine dependence does not constitute treatment of benzodiazepine addiction. Primary care physicians can accept complete, moderate, or limited medical responsibility regarding patients with substance use disorders. However, all physicians should provide diagnostic and referral services.
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J Am Board Fam Pract · Jan 1992
Review Case ReportsAmputation: preoperative psychological preparation.
More than 90 percent of all amputations are now due to the complications of chronic disease. Because most amputations can be anticipated, the preoperative period allows the opportunity for psychological preparation of the patient. This article highlights the important contribution family physicians can make before patients undergo amputation. ⋯ Our experience and review of the literature suggest that psychological intervention during the preoperative period is associated with a less complicated postoperative adjustment and grieving experience. The family physician can promote patient adjustment by providing accurate information, eliciting unspoken fears, and encouraging the involvement of the patient's family. By emphasizing the patient's enduring characteristics and his or her past coping ability, we believe that family physicians can lessen the psychological distress of amputation and facilitate adaptation.
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Advance medical directives (the living will and the durable power of attorney) provide a means for competent persons to influence treatment decisions in the event of serious illness and loss of competence. Advance directives among elderly homebound patients. ⋯ Advance directives are important mechanisms whereby patients can extend autonomy over the circumstances of dying. Physicians and patients should consider and discuss the issues that surround treatment in the event of terminal illness or permanent unconsciousness.
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J Am Board Fam Pract · Sep 1991
Comparative StudyA rural-urban comparison of prehospital emergency medical services in Nebraska.
Provision of emergency medical services (EMS) in the rural United States presents a unique challenge. While rural and urban EMS outcomes have been compared, differing urban-rural population characteristics and roles for rural ambulance teams can confound such comparisons. ⋯ Prehospital EMS in this rural location involved a predominantly elderly population with a large number of routine transfers linking the nursing home and community hospital. Further comparisons of rural and urban EMS outcomes should account for possible differences in type and severity of illness and type and location of service.