Highlights of this issue
Long-term tube-feeding
Making decisions for cognitively impaired elderly people
See also:
- Evidence: Decision-making for long-term tube-feeding in cognitively impaired elderly people
- Editorial: Substitute decision-making for cognitively impaired older people
Susan Mitchell and Fiona Lawson interviewed 46 substitute decision-makers of cognitively impaired tube-fed patients over 65 years old in chronic care facilities, most of whom had not given advance directives. Just over half of the substitute decision-makers were confident that the patient would want to be tube-fed (56.5%) and felt that they had received adequate support from the health care team in making the decision (52.2%). Although most felt that they understood the benefits of tube-feeding (84.8%), less than half (45.7%) felt that they understood the risks. A physician spoke with the substitute decision-maker about tube-feeding for 15 minutes or less in 17 cases (37.0%) and not at all in 13 cases (28.3%). Twenty (43.5%) of the substitute decision-makers did not feel that tube-feeding improved the patient's quality of life, and less than half (45.7%) said that they would choose tube-feeding for themselves. In an accompanying editorial Margaret Brockett explores the ethics and misconceptions surrounding tube-feeding and the challenges of substitute-decision making in our technological age.
Assessing medical fitness to drive
Physician knowledge and training lacking
See also:
- Evidence: Saskatchewan physicians' attitudes and knowledge regarding assessment of medical fitness to drive
Shawn Marshall and Nathalie Gilbert surveyed 935 Saskatchewan physicians involved in assessing patients' medical fitness to drive. Of the 523 (55.9%) who completed the questionnaire, 57.6% indicated that they do not hesitate to report patients medically unfit to drive, although 59.5% felt that their relationship with the patient is negatively affected by reporting. The availability of restricted licensing positively influenced the decision to report for 60.3% of the respondents. However, physicians rated their knowledge regarding assessment of medical fitness as poor and training as inadequate. Most of the respondents (71.1%) reported using the CMA's Physicians' Guide to Driver Examination as a resource.
A simple way to shorten hospital stay
Checklist improves physician efficiency
See also:
Length of stay in hospital is known to be influenced by patient and institutional characteristics, but no studies have attempted to intervene in the practice patterns of physicians. In their pilot study, John Setrakian and colleagues compared length of stay on 2 general medical wards before and after providing physicians with a checklist for planning management and discharge. Length of stay was significantly shorter during the intervention period than during the control period on one ward (11.0 v. 14.7 days respectively, p = 0.02). Readmission rates did not increase, and house staff found the checklist useful.
Pregnancy and Accutane
Physicians and patients fail to comply with Pregnancy Prevention Program
See also:
- Research Letter: Fetal exposure to oral isotretinoin: failure to comply with the Pregnancy Prevention Program
- Editorial: Oral isotretinoin: prescribers beware
Oral isotretinoin (Accutane™) is effective for the treatment of recalcitrant, cystic acne but is also a potent teratogen. The Pregnancy Prevention Program, used in Canada and the US, provides printed material to prescribing physicians, requires a negative pregnancy test result and informed consent from the patient before initiation of therapy and stresses the need for 2 concurrent forms of contraception. Nonetheless, the Motherisk Program in Toronto continues to receive reports of fetal exposure to oral isotretinoin. Gordana Atanackovic and Gideon Koren describe 4 recent cases. In an accompanying editorial, Neil Shear explains why and how we should improve the current rate of 3.4 pregnancies per 1000 courses of oral isotretinoin.
© 1999 Canadian Medical Association
