Advance directives promise patients a say in their future care but actually have had little effect. Many experts blame problems with completion and implementation, but the advance directive concept itself may be fundamentally flawed. Advance directives simply presuppose more control over future care than is realistic. Medical crises cannot be predicted in detail, making most prior instructions difficult to adapt, irrelevant, or even misleading. Furthermore, many proxies either do not know patients' wishes or do not pursue those wishes effectively. Thus, unexpected problems arise often to defeat advance directives, as the case in this paper illustrates. Because advance directives offer only limited benefit, advance care planning should emphasize not the completion of directives but the emotional preparation of patients and families for future crises. The existentialist Albert Camus might suggest that physicians should warn patients and families that momentous, unforeseeable decisions lie ahead. Then, when the crisis hits, physicians should provide guidance; should help make decisions despite the inevitable uncertainties; should share responsibility for those decisions; and, above all, should courageously see patients and families through the fearsome experience of dying.

OBJECTIVE: Culture may have an important impact on a patient's decision whether to perform advance care planning. But the cultural attitudes influencing such decisions are poorly defined. This hypothesis‐generating study begins to characterize those attitudes in 3 American ethnic cultures. DESIGN: Structured, open‐ended interviews with blinded content analysis. SETTING: Two general medicine wards in San Antonio, Texas. PATIENTS: Purposive sampling of 26 Mexican‐American, 18 Euro‐American, and 14 African‐American inpatients. MEASUREMENTS AND MAIN RESULTS: The 3 groups shared some views, potentially reflecting elements of an American core culture. For example, majorities of all groups believed “the patient deserves a say in treatment,” and “advance directives (ADs) improve the chances a patient's wishes will be followed.” But the groups differed on other themes, likely reflecting specific ethnic cultures. For example, most Mexican Americans believed “the health system controls treatment,” trusted the system “to serve patients well,” believed ADs “help staff know or implement a patient's wishes,” and wanted “to die when treatment is futile.” Few Euro Americans believed “the system controls treatment,” but most trusted the system “to serve patients well,” had particular wishes about life support, other care, and acceptable outcomes, and believed ADs “help staff know or implement a patient's wishes.” Most African Americans believed “the health system controls treatment,” few trusted the system “to serve patients well,” and most believed they should “wait until very sick to express treatment wishes.” CONCLUSION: While grounded in values that may compose part of American core culture, advance care planning may need tailoring to a patient's specific ethnic views.

No abstract

No abstract

No abstract

An ektacytometer was used to measure red blood cell deformability during blood storage for 42 days at different degrees of cell packing in citrate-phosphate-dextrose preservative. Observed changes in deformability were studied in relationship to red blood cell adenosine triphosphate (ATP) levels, lipid content, osmotic fragility, and hematocrit during storage. Decrease in whole cell deformability as measured in isotonic medium did not occur until cellular ATP levels were reduced to less than 30 percent of initial values. The rate of deformability loss during storage increased with increased degrees of cell packing because of more rapid substrate depletion. The loss in isotonic deformability was further magnified when deformability measurements were carried out in hypotonic media, suggesting that a reduction in surface area-to-volume ratio was the dominant cause of the reduced deformability of stored red blood cells. Marked spherocytosis, decreased membrane lipid content and increased osmotic fragility confirmed loss of membrane surface area during storage. The significantly higher rate of deformability loss observed in packed red blood cells suggests that careful control of storage hematocrit may be necessary to avoid loss of cellular deformability and possibly posttransfusion viability.

No abstract

A 52-yr-old multiparous white female was found to have Rh null blood type. She had macrocytic anemia, with reticulocytosis (15%-20%), of long duration. Although stomatocytes in peripheral blood were numerous and osmotic fragility was increased, suggesting increased cell water, the RBC cation content, and thus cell water, was decreased. Cell dehydration was confirmed by an increased proportion of high density RBC on Stractan density gradients. The deformability of RBC from four gradient subpopulations was measured in the ektacytometer as a function of suspending medium osmolality. Analysis of these measurements showed an abnormal reduction in cell surface area with increasing cell density, thus explaining the increased osmotic fragility of whole blood. This was confirmed by a density-dependent reduction in cell cholesterol content, suggesting membrane instability in vivo. Rh null subpopulations showed a twofold increase in both ouabain-sensitive and - insensitive Na-K ATPase activity and 86Rb transport, even in the dense fraction with the fewest reticulocytes. No membrane protein or glycoprotein abnormality was detected by SDS-PAGE. The associated deficiencies of both membrane surface area and cation content in Rh null cells, as well as increased Na-K pump activity, suggest a pleiotropic functional interrelationship among Rh antigen, membrane stability, and cation regulation.