When Too Much is Too Little

Abstract

The patient was admitted to the neurology service. A chest radiograph revealed a density in the right lung apex. Radiographs of the spine The New England Journal of Medicine Downloaded from nejm.org at STOCKHOLMS UNIVERSTITETSBIBL on August 11, 2015. For personal use only. No other uses without permission.

Barriers to Obtaining Consent in Dementia Research: Implications for Surrogate Decision‐Making

“…Although living wills were designed for situations such as these, none of the subjects who had no surrogate in our study had evidence of such documents. In an era when external forces such as cost and length of stay constraints are playing an increasing role in medical decision‐making, and where substantial numbers of patients have no care providers to coordinate their care, 9 it is disturbing that 16% (22 of 146) of all patients with advanced dementia admitted over a 2‐year period to the hospital in this study did not have a surrogate decision‐maker. Although some authors have begun to address the issue of care for incapacitated subjects without surrogates, 10–12 there are currently no guidelines aimed at protecting this vulnerable population of patients from either over‐ or undertreatment.…”

End-of-Life Decision-Making in the Hospital

“…1 All too often hospitalized patients are deprived of a peaceful and digni-fied death, owing to unwanted, prolonged aggressive life-sustaining treatment and lack of adequate relief of suffering. 2, 3 A variety of interventions to improve the care of hospitalized dying patients have not achieved notable success. 2,4 To better understand how end-of-life decisions are made and guide programmatic reforms, we examined end-of-life practice patterns at a large teaching hospital.…”

End-of-Life Assessment Within a Holistic Bio-Psycho-Social-Spiritual Framework.

“…Realistically, there is little need for normative assessment tools or standardized interviews near the end of life (but see McClain, Rosenfeld, & Breitbart, 2003). Even the assessment of cognition relevant to medical decision making capacity may initially be conversational in an effort to identify the thought processes and level of comprehension demonstrated by the patient (Morrison et al, 1996). Essentially, the process of psychological assessment advocated here depends critically on relationship, conversation, and inquiries concerning issues of particular concern or relevance to the dying patient and his or her family (for relevant content domains, see Table 5.1).…”

“…Engaging in conversation and listening to the personal story the patient tells (e.g., life experiences, beliefs, hopes, fears) may permit the assessment of adaptive resources and perspectives on dying and death and may provide important insight into cognitive and linguistic competencies necessary for working through social, emotional, and spiritual concerns. The ability to communicate is essential for addressing nearly every issue deemed relevant to those who are dying, including conversations with family (e.g., Lynn, 1997;Stewart et al, 1999), assessing medical information and treatment decision making (e.g., Lynn, 1997;Morrison et al, 1996), finding meaning in the process of illness and dying (Exley, 1999;Kaut, 2002;Patrick et al, 2001), and discussing spiritual and existential concerns (Anbar, 2001;Kaut, 2002;Koenig, 2002;Smith, 1993;Walter, 1996). Therefore, knowing how a patient's physiological status may influence her or his cognitive and language skills at the present, or in the future, is extremely valuable when planning important conversations, considering cognizance of decisions, and managing details near the end of life.…”