My aging mother-in-law was recently referred to a specialist for diagnosis of a sudden weakness in her arm. There was some foul- up, however, and it took several requests before her medical records reached the specialist’s office. Since we didn’t know about this delay, we had to go back a couple of times before he could examine her.

Then the report he sent to her regular doctor seemed to disappear, as well. Fortunately, she’s OK, and should recover from this weakness.

We wouldn’t say such delays and losses of medical records are normal. But neither are they entirely unknown.

In your case, you’re lucky. Her prognosis is good, so the only penalty resulting from the delay in transferring your mother-in- law’s medical records to the specialist’s office was the inconvenience and expense of having to go back more than once. But you’re right to be concerned. If her condition had been more acute, wasting a single day in diagnosing and treating her condition might have dramatically worsened her prospects for a full recovery.

That’s why we recommend that families keep their own copies of important medical records at home.

Most people are shy about asking for their medical records, and are easily deterred from obtaining a copy. But the law clearly establishes a patient’s right to receive copies of all medical reports and test results, as well as x-rays and other images. The provider is allowed to charge you a nominal fee for copying, but they rarely do.

We suggest you immediately submit a written request to your mother-in-law’s regular doctor, asking for a full copy of her medical records.

Once you obtain it, label it clearly, and store it in a safe place. Keep any films flat, so they don’t curl or crack as time goes by.

Remember to bring the records whenever your mother-in-law visits a new physician.

To keep your mother-in-law’s medical file up to date, always ask for copies of all new tests and specialist reports. If you make this request, face to face, at the beginning of each visit, you’ll find it quickly becomes a habit, and you’ll usually get very prompt compliance.

Most of the time, a specialist’s office staff will agree to send you the copies within a few days or a week, usually around the same time they send their report to the referring physician. But don’t forget that you’ve asked for the report. Write yourself a reminder, and if you haven’t received the additional medical paperwork within a reasonable time, ask again. Also, don’t be satisfied with just the interpretive or diagnostic report. Ask for copies of the original test results or images, too.

* * *

Dear Francine and Robert:

My husband and I have been helping his aging parents maintain a good quality of life for several months, now.

I’m happy to be of assistance to them, but they’re stubborn and secretive people. They won’t sign any of the paperwork that we’ve learned about, like a power of attorney or an organ donation form. They won’t even reveal whether they have a simple will.

Aren’t we right to insist they put all this paperwork in order?

Signed, Need Some Signatures

Dear Need Some Signatures:

Yes, you’re right to be interested in having them execute the proper paperwork. But just because you understand this simple reality does not mean your in-laws are going to accept the idea or sign on the dotted line.

In fact, you’ll probably create a family feud if you force your in-laws to reveal their secrets or sign any papers they think are suspicious.

The best way to proceed is to make sure your husband agrees with the idea of having them execute the appropriate legal documents. If he’s against it, there’s no chance they’ll give in. You’ll probably need the concurrence of his brothers and sisters, along with most other family members, as well.

Once you’re sure you’re not swimming against the tide, encourage the family to engage a lawyer who specializes in the needs and issues of aging parents. Get his advice on exactly what documents they ought to be executing.

But before the lawyer draws up any of these papers, the family should start having conversations with your in-laws about the important issues, such as: “What will happen if you get sick, Mom?” “Who would you want to make medical decisions for you, in case you can’t, Dad?” “What do you think about organ donations?”

Once you get Mom and Dad alerted to these matters, their friends and relatives will no doubt share lots of stories about real people who did, and who didn’t, execute the correct documents, complete with lurid details about the resulting impact of what they did.

After a period of time, your in-laws will begin talking about these matters, and will start make progress toward final decisions. As they do, write things down: how they feel about wanting to be resuscitated, kept on life support, donate their organs after death, and so forth.

To the Editors of American Demographics:

I work for a company that sells umbilical cord blood and stem cell collection services. From the information we gathered, we believe there are approximately 4 million births a year. It would be very helpful in our marketing efforts to expectant mothers if we knew what percentage of these births were to women over the age of 30, and even more helpful if we could further break down this group by household income levels. Thank you for your consideration.

Your inquiry could not have come at a more newsworthy time. In fact, it arrived just as President Bush was calling for more funding of scientific research using stem cells from sources other than human embryos, such as umbilical cord blood.

Now, to answer your question: In July, the Centers for Disease Control (CDC) released preliminary birth data for 2000, which confirms your figure for the number of new births. Indeed, last year there were 4.1 million births, about 106,000 more births than in 1999. Women ages 30 and older gave birth to 36.3 percent of the babies born in 2000, up slightly from 35.7 percent in 1999. Moreover, the CDC reports that in 2000, birth rates (the number of births per 1,000 women) for women ages 30 and older rose to their highest levels in 30 years. Currently, there are 94.2 births per 1,000 women age 30 to 34; 40.3 for women 35 to 39; 7.9 for women age 40 to 44; and 0.5 for women age 45 to 54.

For the income breakdown, we turned to the 2000 Current Population Survey’s (CPS) Fertility of American Women study. Of course, the numbers you desire are not available in a nice, easy-to-read report, so we got crunching. According to American Demographics’ analysis of CPS data on women ages 30 to 44 who gave birth in the past year, 10 percent came from families with an annual income of less than $15,000; 14 percent had incomes between $15,000 and $29,999; 19 percent earned between $30,000 and $49,999; and 23 percent took home between $50,000 and $74,999. The largest share of this population (34 percent) had a combined annual household income of $75,000 or more. That’s what you would call a “sugar mommy.”

John Fetto

Research Editor

Tune In

To the Editors of American Demographics:

I am looking for a comprehensive source that compares the demographics of the major U.S. TV networks (ABC, CBS, NBC and Fox).

Scott Lucas

Research Specialist

Bain & Company

Chicago, Ill.

Dear Scott,

A few companies provide this data to researchers. Naturally, there’s Nielsen Media Research, which has had a virtual monopoly on TV ratings and audience estimates since the medium’s inception. But there are some additional suppliers of this information that you may want to consider. Two of those sources - regularly used by our own research team - are Mediamark Research, Inc. (MRI) and Simmons Market Research Bureau (SMRB).

MRI and SMRB collect their data through surveys of 30,000 individuals, while Nielsen collects its data primarily through “people meters,” electronic devices connected to the television sets of 5,000 U.S. households. Of course, if you’re looking for immediate ratings and audience measures, Nielsen is the way to go. It has ratings reports available on a daily basis, while SMRB and MRI publish new data only twice a year. However, if you’re looking for more details, check out MRI and SMRB. Both companies are able to link behavioral, psychographic and spending data to media consumption. Nielsen primarily provides only basic demographics. Best of luck in your search.

“COMPETENT, CARING NURSING FOR THE PEOPLE OF SASKATCHEWAN”

On April 11. 2003 Saskatchewan RN(NPJs were given the authority to “diagnose and treat common medical disorders” (RN Act. 1988). Since that time, the most frequently asked question in relation to the practice of the RN(NP) is “what are common medical disorders?”

The SRNA RN(NP) Standards and Core Competencies, 2003. defines “common as “conditions, diseases or disorders that RN(NPJs see regularly within the particular context of their own practices” (p. 23).

After consultation with stakeholders and SRNA legal council, the need to further interpret the phrase ‘common medical disorders became apparent. Therefore. SRNA Council passed an interpretation on September 15. 2005 which describes the RN(NP) scope of practice in relation to common medical disorders.

This interpretation includes the original definition of common and then expands upon that definition by referencing the approved program curriculum as a guideline for the determination of appropriate problems, conditions, diseases or disorders assessed, diagnosed and/or treated by the RN(NP). RN(NPJs will also only practice within their chosen area of practice and may only assess, diagnose or treat common medical disorders for which they are currently competent.

The following are situations that are not within the RN(NP) independent (versus collaborative) scope of practice.

1. Independently initiate and manage treatment of atypical or complex health problems (examples only: Diabetes TYPE 1, Hypertension. Chronic Inflammatory Bowel Disease (Ulcerative Colitis and Crohn’s) and any suspected carcinoma diagnosis

2. Any health problem requiring diagnostic contrast medium radiography

3. Health problem that may require imminent surgical intervention

4. Health problem that becomes unstable requiring further consultation (i.e. hospitalization required)

5. Perform an internal biopsy

Included within the RN(NP) scope of practice is the provision for a collaborative based practice. This collaborative practice is outside the independent RN(NP) scope of practice, therefore the RN(NP) also has the ability to collaborate with health care team members to manage the health care of patients experiencing other medical disorders that are not included within the common medical disorders interpretation.

RN(NP)s are encouraged to follow evidence based peer reviewed clinical practice guidelines. When clinical practice guidelines are approved by the RN(NP) collaborative care team, the RN(NP) is able to independently manage patient care according to those same approved clinical practice guidelines.

SRNA has developed a Q and A document related to SRNA’s common medical disorders interpretation. You can access the original interpretation of common medical disorders and the Q and A document on the SRNA website www.srna.org. You will find this document under the Nurse Practitioner heading. If you have any further questions or comments related to this document or any RN(NP) issue please contact:

Maureen Klenk RN(NP). Nurse Practitioner Coordinator * Ph: Toll Free: 1-800-667-9945. ext 237 * 359-4225 (Regina) * E-mail: mklenk@snra.org

Important Points to Remember:

* If you are seeking RN(NP) licensure via the Competency Assessment Process your completed portfolio should be submitted to SRNA by February. 28. 2006 to meet the April 11. 2006 deadline

* It is mandatory for all RN(NP)s to complete the continuing competence workbook yearly. If you need copies of the Continuing Competence Workbook working pages you can download these pages from our website- www.srna.org. Follow the links - Nurse Practitioner > RN(NP) Continuing Competence Workbook > Extract Pages

* All RN(NPJs should have received the July 2005 June 2006 Saskatchewan Health Formulary and its regular updates. If you have not received this book please contact Lorna Billang, Saskatchewan Drug Plan-1-306-787-1511

Police are to hold a murder inquiry into the case of a doctor MP who mentioned during a parliamentary debate that he had withdrawn treatment from a 2 year old boy with leukaemia at the parents’ request to save him any more distress.

Peter Brand, Liberal Democrat MP for the Isle of Wight and a GP, said that if the Medical Treatment (Prevention of Euthanasia) Bill had been law when he qualified as a doctor in 1971, he would by now be a “multimurderer”. He made his comments during the second reading debate on the bill, sponsored by the right-wing Conservative MP Ann Winterton, who came top in the ballot for private members’ bills.

Under the bill it would be unlawful for doctors to withhold or stop treatment or sustenance if one of the purposes was to hasten or cause the death of the patient. It would make it unlawful for artificial nutrition and hydration to be withdrawn in the case of patients in a persistent vegetative state, as happened to Tony Bland, a victim of the Hillsborough disaster in 1989.

Hampshire police said that they would investigate after receiving a complaint from a woman in Weybridge, Surrey, who heard Dr Brand interviewed on the radio about the issue. The incident he referred to during the debate happened in 1973 when he was a house officer specialising in paediatrics. The police admitted, however, that they had not read the record of the debate in Hansard.

There is substantial parliamentary support for the principle behind Mrs Winterton’s bill. Twelve of the 16 members of the committee considering the bill are in favour, said Dr Brand

The bill would not allow people to refuse treatment through advance directives. The only circumstance in which treatment could be withheld or withdrawn was if a patient who was in a position to refuse actively did so.

It also dashes with government plans for legislation to allow people to appoint a friend or family member to take treatment decisions for them should they become incapacitated.

Under the current law, parents may refuse treatment for their children if the treatment would not be in the child’s best interests–for example, if it would cause suffering–even if death results.

Dr Brand, who had not been questioned by police as the BMJ went to press, said, “I didn’t do anything other than describe past and current accepted practice.”

Dr Brand said that he planned to raise a series of amendments to the bill at the report stage on 14 April. The bill will fall at that stage if it is either forced to a vote and defeated, or talked out by MPs. Dr Brand said: “I have a suspicion the government will make sure all the private members’ bill time will be taken up with discussion.”

Clinical Quiz questions are based on selected articles in this issue. Answers appear in this issue.

American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit hours. Term of approval covers issues published within one year from the beginning distribution date of January 2003. This issue has been approved for up to 3.5 Prescribed credit hours. Fifteen minutes of these credit hours conform to AAFP criteria for evidence-based CME clinical content. When reporting CME credit hours, AAFP members should report total Prescribed credit hours earned for this activity. It is not necessary for members to label credit hours as evidence-based CME Prescribed for CME reporting purposes.

AAFP members who satisfy the Academy’s continuing medical education requirements are automatically eligible for the AMA/PRA.

Physicians who are not members of the AAFP are eligible to receive the designated number of credit hours in Category 1 of the AMA/PRA on completion and return of the Clinical Quiz answer card. AFP keeps a record of AMA/PRA Category 1 credit hours for nonmember physicians. This record will be provided on request; however, nonmembers are responsible for reporting their own Category 1 CME credits when applying for the AMA/PRA or other certificates or credentials.

For health care professionals who are not physicians and are AFP subscribers, a record of CME credit is kept by AAFP and will be provided to you on written request. You are responsible for reporting CME hours to your professional organization.

Note: The full text of AFP is available online (www.aafp.org/afp), including each issue’s Clinical Quiz. The table of contents for each online issue will link you to the Clinical Quiz. Just follow the online directions to take the quiz and, if you’re an AAFP member, you can submit your answers for CME credit.

Instructions

Read each article, answer all questions on the quiz pages, and transfer your answers to the Clinical Quiz answer card (bound into your copy of AFP). This will help you avoid errors and permit you to check your answers against the correct answers.

A Mail the Clinical Quiz answer card within one year (by August 31, 2004). The bar code on the answer card contains your identification for CME credit hours.

Before beginning the test, please note: Each Clinical Quiz includes two types of questions: Type A and Type X.

News of a recent study by a Connecticut newspaper suggesting that graduates of Howard and Meharry medical schools were among the nation’s most reprimanded physicians left officials at both institutions and their alumni steaming with rage.

The study, conducted by The Hartford Courant and published the last week in June, called into question the academic quality of the two historically Black medical schools, the competence of their graduates and the future of the medical students who currently attend them.

“Classmates that I have spoken with are outraged,” says Dr. David Travillion, a 2002 graduate of Meharry Medical College in Nashville, and a resident at the University of Texas Health Science Center in San Antonio. Travillion heard about the newspaper’s findings while listening to an interview with one of the study’s authors on National Public Radio.

“The report made me feel self-conscious at first,” he says. “I expected to be confronted by colleagues…. I think it will bring unwarranted scrutiny on Meharry graduates.”

Both Howard, Meharry and a number of other organizations in the medical profession questioned the newspaper’s methodology and, therefore, its findings. Among them were Dr. Jordan Cohen of the Association of American Medical Colleges; Dr. L. Natalie Carroll, president of the National Medical Association; and Dr. Roxane Spitzer, CEO of Meharry’s teaching hospital, Nashville General.

“We are reviewing the methodology employed by The Hartford Courant,” a statement on Howard University’s Web site, posted July 7, said. “We also question the failure of The Hartford Courant to appropriately distinguish the type and manner of discipline involved in these cases and the reasons for the discipline. There is no way to determine, based upon the article, whether the discipline was in the form of an admonition, censure, suspension or revocation of license.”

Carroll of the National Medical Association, the leading organization of African American physicians, said in a July 1 letter to the newspaper’s editor:

“We at the National Medical Association are extremely disturbed by the article’s unsubstantiated findings and the sweepingly negative implications upon the medical community at large, and specifically upon two premier medical colleges that have educated a large number of the nation’s physicians of color.”

Prior to the newspaper’s publication of the articles, Meharry President John Maupin said he asked one of the reporters of the study if the school could have access to the data in order to properly review them. The reporter said he would share some of it but not all, according to Maupin.

“Without being provided with the data in full, in the same format as it was obtained by the newspaper, we felt denied the opportunity to make an informed response,” Maupin said in a July 18 interview.

Regarding the methodology, Maupin said:

“First, we still don’t know what methodology the paper used…. The paper did not provide the complete analysis of the data, explaining their precise methodology. In fact, the most basic question concerning this group of physicians, ‘When did they graduate from medical school’? was never addressed in the article.

“Second, the paper looked at all disciplinary actions taken as a result of any infraction. … Without knowing the specifics of the infractions, it is impossible to judge how a physician’s medical school experience may have ultimately contributed to it…. Finally … there are any number of factors one must thoroughly review if trying to determine the causal relationship associated with disciplinary action against a physician. It is erroneous and just simply faulty to make a direct relationship between disciplinary actions and the quality of medical school education alone.”

The implications of the study’s findings were not lost on The Hartford Courant’s editorial staff. The newspaper ran the lead article with the stark title, “Med Schools: Four That Flunk.” After analyzing three separate databases, the study author’s concluded that Meharry and Howard, along with the Autonomous University of Guadalajara in Mexico and Manila Central University in the Philippines, were the only “elite” medical schools in the United States that were in the bottom 5 percent of all three databases. The Courant defined “elite” as “larger, well-established schools.” Graduates of these well-established schools made up 90 percent of the doctors in the three databases that the newspaper analyzed, according to the Courant. The databases, which included the consumer advocacy organization Public Citizen’s “Questionable Doctors” and two “physician profiles” maintained by California and Ohio, listed doctors who had been disciplined by federal and state regulators.

Jack Dolan, one of the two reporters of the Courant study said the newspaper struck a balance in its coverage by writing “the stories with an eye toward the remarkable challenges Howard and Meharry have faced over the decades.” As part of the two-day series, the newspaper reported a separate story on the historically Black medical schools entitled, “Black Medical Schools Struggle to Compete,” which ran June 30. The article discussed some of the factors, besides academics, that could have landed the schools at the bottom of the study. Among the other factors discussed were racism, inadequate funding, increased competition for good African American students, serving underserved students, and graduates serving underserved communities.

The answer is as unique and varied as your specific needs, circumstances and preferences. Here are a few of the distinctions between the MMM offered by Tulane, Carnegie Mellon and USC and the Online MBA offered by UMass:

Content — The Master of Medical Management (MMM) was designed by senior physician executives and nationally recognized faculty. The MMM takes the best aspects of general MBA educational programming, then adds content unique to the issues and concerns of medical management. It integrates health care research with business, policy and systems research in order to teach relevant management and leadership competencies in a doctors-only classroom. By contrast, the UMass online MBA in Medical Management teaches management & leadership competencies from a broad, comprehensive business school approach using examples from all industries (with other non-physician professionals in the classroom).

Format — The MMM is a blended format–4 short on-campus sessions blended with independent study and distance learning coursework. The MBA is 100% distance learning (independent study & online learning). The distance learning assignments for both programs are asynchronous so that you can fit your studies into the time of day/week that works best for you.

Duration — After ACPE’s Section I is completed, then the MMM takes one year to 18 months to complete with tuition ranging from $21,600-$29,000. The MBA can be completed in two to four years with tuition averaging $18,100.

Credential — The MMM credential is quickly gaining recognition in health care circles with nearly 500 graduates working in leadership positions across the country. While the degree is relatively new (first graduates were in 1997), physician executive recruiters are seeing it included in the list of expected credentials more and more. The MBA is a widely recognized credential and can be especially effective if you need to gain quick respect with business leaders who have little health care background.

As we move forward in the 21st century, healthcare issues dominate. We are seeing medical advances that were unheard of in the early 1900s. Organ transplants, for one, have become almost commonplace. Meanwhile, Financing health care has become a political hot potato. Federal and state governments are struggling to provide health care in the face of budget shortfalls and rising costs. With dwindling resources, the question becomes how can those resources be best used to serve the greatest numbers of American people? Who is entitled to what?

One of the greatest opportunities for American public policy to improve the nation’s health is to differentiate between the macroallocation and the microallocation of resources. Those who distribute commonly collected resources, such as tax monies and health premiums, among a group of people macroallocate. Healthcare providers microallocate when their decisions focus on specific patients. We must better think through these two roles.

The individual focus of biomedical ethics is too Narrow to be useful in the macroallocation by payers. Macroallocation involves trade-offs and setting priorities. Distributing commonly collected resources among a group of patients involves very different dynamics than a provider caring for individual patients. Those distributing commonly collected funds do not have the luxury of individualized care. Government must provide multiple services to its citizens, and health insurers must provide service to multiple beneficiaries. Both have comprehensive duties to a wide group of beneficiaries. The scope of the differences between macroallocation and microallocation is considerable.

No nation, state, or health plan in the macroallocation of its funds can assume that its healthcare distributions can meet the cumulative medical need of all its individual members. This is clearer in other nations where the government more directly funds health care.

We must better reconcile individual need with the common resources that fund most of that individual need. Providers theoretically can meet all the medical needs of their patients; states can never meet all the health needs of their citizens. Providers can focus on an individual, but a government must meet many needs of all its citizens in a world of trade-offs and priorities. Providers ration when they fail to provide a medical service to a patient. A state or nation, however, rations both when it denies a needed medical benefit and when it fails to provide universal coverage. All governments ration medicine.

Once we slop avoiding the responsibility of rationing health care, we will recognize the occasional conflict between the goals and ethics of paying for (macroallocating) health care with commonly collected funds and the goals and ethics of delivering (microallocating) health care. To recognize and admit this conflict exists will be politically difficult but socially inevitable. Doing so will require a change in the cultural values of citizens and healthcare providers, but the rewards are gargantuan. America can deliver more health to its citizens for less money once it adopts a broader moral vision of health care.

Medical practice and ethics have been developed without consideration of trade-offs with other public goods, even though taxpayers pay almost half of the healthcare dollar. Government now funds about 45 percent of U.S. health care, and employers fund another 33 percent, bringing the total government and employer share of healthcare funding to almost 80 percent. (a) We lack a means of setting priorities in the macroallocation of health care and the tools for comparing health needs with other needed social goods. We have just begun to analyze the moral framework applicable to the macroallocation of resources.

Public policy has allowed providers to be the definers of the nation’s health and the chief architects of the nation’s healthcare system. We have been assuming, inappropriately, that a nation’s best route to health was to fund medical care one patient at a time, thereby allowing healthcare providers to impose their doctor-patient relationship on taxpayer monies without accountability or oversight. The total need of the group was the sum total of individual need. Public policy has not adequately asked the larger question, “How do you keep a society healthy?” How do we reconcile macroallocation with microallocation? Those who fund health care from collective funds must look beyond the individual to the entire group. When pooling money, we have to ask, “What maximizes the health of those who make up the pool?”

Private Need: Common Resources

The problem of allocating resources reaches beyond public policy in health care. Allowing a physician to focus on the patient and a hospital to focus on who comes through the hospital door lets them ignore what is going on down the street or across town. That is not a criticism, but simply a recognition of reality. Our strengths are often our weaknesses. The single-minded devotion of health providers to their patients makes them inadequate judges of the total system. Lacking the luxury of individual focus, public policy must consider the total moral landscape of public needs. That landscape has shifted in the past 10 years as we have increasingly recognized that we cannot provide everything to everybody. We must recognize that the macroallocation of healthcare resources is not the cumulative total of all individual care.

TORONTO — Ontario Superior Court Justice John Ferrier ordered the Ontario government to continue paying for treatment for two children diagnosed with Autism Spectrum Disorder. He said the delay in treatment between now and an expected court decision next fall “could result in irreversible losses” for the two boys.

Judge Ferrier ordered the payment of treatment for the two boys despite a Supreme Court landmark decision issued last fall and known as Auton. In that decision, the Court refused to order the British Columbia government to provide treatment for a child with autism, saying the province has the right to determine which health care programs it will provide.

However, in his judgement, Justice Ferrier said despite the Supreme Court’s argument regarding the provision of health services and “notwithstanding Auton, serious issues remain which should be determined at a trial, whether the benefit claimed is medical in nature or a question of access to education,” as the lawyers for the two boys had argued.

His order also remains in effect until at least the fall, when it is expected that a ruling will be made in a major treatment for autism case known as Wynberg, which involves the question ot whether it is constitutional for the province to eliminate funding for treatment for children with autism once they turn six years of age.
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Unlike the Supreme Court, Justice Ferrier praised the treatment for autism, saying if the “ABA treatment is reduced or withdrawn, they will experience significant harm.”

The Bettencourt case, like the several other cases currently before the courts, was caused when funding for treatment for autism, called Intensive Behavioural Intervention or Applied Behavioural Analysis, was stopped because the twin boys had reached the age of six years.

When the treatment for the boys was cut off, the Bettencourts tried to continue the costly treatment by paying for it themselves, including mortgaging their home, but have since run into financial hardship. As well, there was an unsuccessful attempt to integrate the twins into the public school system, but both boys were unable to continue attending the school either wholly or partially because the school system was unprepared to deal with their special requirements and treatment needs.

The judge noted that both boys had made significant gains under the treatment, and stressed that the public school had neither the resources nor the training to allow the boys to learn in the school, but with treatment the boys are able to learn.

It’s bad enough to be a patient in a hospital. What’s worse, according to a team of British researchers, is that a substantial minority of medical patients is legally incompetent to make decisions about their treatment, yet their physicians often overlook this limitation.

Over an 18-month period, about one-third of a predominantly elderly group of people treated at a London hospital for at least 2 days exhibited an inability to understand the treatment decisions that they faced, say psychiatrist Matthew Hotopf of the Institute of Psychiatry in London and his colleagues. Yet physicians taking care of these patients rated only a small number of them as mentally incapacitated.

“More should be done to protect the interests of … the high proportion of medical patients who are treated without being able to give valid consent,” the investigators conclude.

In particular, physicians need to assess and document mental capacity in elderly patients facing critical health decisions, in Hotopf’s view. Such choices include a patient’s acceptance of placement in a nursing home and whether he or she wants physicians to withhold treatment under certain circumstances.
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The new study appears in the Oct. 16 Lancet.

Hotopf’s team considered 302 patients consecutively admitted mainly for acute heart, lung, or neurological disorders. None of them suffered from a progressive brain condition, such as Alzheimer’s disease.

Of the patients, 72 exhibited cognitive problems too severe to join the study. Another 71 refused to participate or were unable to speak English.

Researchers conducted standardized interviews with the remaining 159 patients to determine their medical-decision-making capacities. Interviews focused on the extent to which a person understood his or her disorder and its treatment, knowledge of how a treatment would affect his or her life, and the ability to compare alternative medical choices before picking an option.

Decision-making incapacity characterized 50 patients, or 31 percent of those interviewed. Only 12 patients, however, were rated by treating clinicians as unable to make informed decisions.

Of the 109 patients that the researchers characterized as mentally competent, none was tagged by doctors as mentally incapacitated.

Psychiatric disorders were rare in both groups.

The most troubling result, Hotopf contends, was the tendency of incapacitated persons to trust in physicians who failed to recognize or address those patients’ decision-making deficiencies.

The new findings don’t apply to all medical patients. For instance, an earlier study using the same standardized interviews with 82 people being treated for chronic ischemic heart disease in three U.S. hospitals found that nearly all of them possessed decision-making competence. That study, directed by Paul S. Appelbaum and Thomas Grisso, both of the University of Massachusetts Medical School in Worcester, included mainly middle-aged patients rather than elderly ones.

Further research needs to examine whether researchers, clinicians, and families, given the same interview information, agree on patients’ competency, remarks geriatric physician Jason H.T. Karlawish of the University of Pennsylvania in Philadelphia.

STATS

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Proportion of accurately ill patients at a British hospital rated as unable to make informed treatment decisions