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Palliative care is generally agreed to be the standard of care for the dying, but there remain some patients for whom intolerable suffering persists. In the face of ethical and legal controversy about the acceptability of physician-assisted suicide and voluntary active euthanasia, voluntarily stopping eating and drinking and terminal sedation have been proposed as ethically superior responses of last resort that do not require changes in professional standards or the law. The clinical and ethical differences and similarities between these 4 practices are critically compared in light of the doctrine of double effect, the active/passive distinction, patient voluntariness, proportionality between risks and benefits, and the physician's potential conflict of duties. Terminal sedation and voluntarily stopping eating and drinking would allow clinicians to remain responsive to a wide range of patient suffering, but they are ethically and clinically more complex and closer to physician-assisted suicide and voluntary active euthanasia than is ordinarily acknowledged. Safeguards are presented for any medical action that may hasten death, including determining that palliative care is ineffective, obtaining informed consent, ensuring diagnostic and prognostic clarity, obtaining an independent second opinion, and implementing reporting and monitoring processes. Explicit public policy about which of these practices are permissible would reassure the many patients who fear a bad death in their future and allow for a predictable response for the few whose suffering becomes intolerable in spite of optimal palliative care.

Objective: To determine how physicians respond to a request for an expensive, unindicated test., Design: Cross-sectional observational study., Setting: Four sites of a group-model HMO., Participants: Thirty-nine internist volunteers., Intervention: A standardized patient requesting magnetic resonance imaging (MRI) of the head to rule out multiple sclerosis (MS) was inserted unannounced into physicians' regular schedules. The patient's only complaint was fatigue with no neurologic symptoms., Measurements and Main Results: Physicians and standardized patients completed assessments after each visit. Thirty-five (90%) of 39 physicians "had no idea" that the patient they saw was the standardized patient, and the remaining four participants (10%) were only "somewhat suspicious." Three (8%) of the physicians agreed to the MRI at the initial visit, and eight (22%) said they might order an MRI in the future. All doctors who refused the MRI told the patient this was based on lack of a medical indication for the test; seven (19%) also cited the test's expense. Twenty physicians (53%) of 38 agreed to a neurology referral. In response to the standardized patient's concerns, nine physicians (23%) verbalized that MS is scary, and four (10%) asked the patient about their friend's experience with MS. A few physicians appeared to dismiss the patient's concerns, such as by telling the patient they were being "paranoid.", Conclusions: Few physicians agreed to a standardized patient's request for a medically unindicated MRI, but more than half agreed to refer this patient to a specialist. As physicians practice cost-conscious medicine, they may need to focus on good communication to maintain patient satisfaction.

Context: Patients with tuberculosis (TB) who are persistently nonadherent to treatment present a public health risk. In 1993, California created a new civil detention process and allowed detention of noninfectious but persistently nonadherent patients., Objectives: To determine (1) which patients TB controllers attempt to detain, (2) how often and where patients are detained, and (3) how many of these patients complete TB treatment., Design: Case series with cross-sectional comparison to other adult TB patients in the study counties., Setting: Twelve California counties with the largest number of new TB cases reported in 1994., Subjects: All patients whom TB controllers sought to detain during 1994 and 1995 because of persistent nonadherence to treatment., Data Sources: Public health records, interviews with county TB officials, and Reports of Verified Cases of Tuberculosis to the California Tuberculosis Control Branch., Results: Tuberculosis controllers sought the civil detention or arrest of 67 patients during the study period (1.3% of adult TB patients with the same disease sites). Forty-six percent of these patients were homeless, 81% had drug or alcohol abuse, and 28% had mental illness. Tuberculosis controllers sought civil detention of 15 patients. Fourteen patients were detained (median length of detention, 14.5 days). Tuberculosis controllers sought to arrest 62 patients during the study period. Fifty-three patients were arrested (median time in jail, 83 days). In 10 cases, both civil and criminal detention were attempted. We analyzed completion of therapy after excluding patients who were not detained or who died or moved. Overall, 41 (84%) of the remaining 49 detained patients completed therapy. Of the patients who completed therapy, only 17 were detained until treatment was completed. Compared with other TB patients in these counties, detained patients had 4 times the proportion lost to follow-up and half the proportion completing therapy within 12 months., Conclusion: Further improvements in the care of persistently nonadherent patients may require more psychosocial services, appropriate facilities for civil detention, and detaining patients long enough to assure completion of treatment.

Two US courts of appeals have ruled that competent, terminally ill patients have a constitutional right to physician-assisted suicide. The cases are now before the US Supreme Court, which is expected to issue a ruling later this year. This article analyzes the keystone of the courts' ruling: their assertion that competent, terminally ill patients who are being kept alive on life support are equivalent to competent, terminally ill patients who do not require such support. Because the former are permitted to end their lives by refusing treatment, the courts found that the latter also have a right to determine the time and manner of their death, through prescriptions for lethal doses of medication. This article analyzes whether the courts' thinking is premised on a clinically plausible view of the care of terminally ill patients. Based on a discussion of common situations involving terminal illness, we argue that the courts' reasoning is deeply flawed. The article also analyzes how the implications of the courts' reasoning might undermine the care of terminally ill patients.

This paper describes the development and evaluation of a computer-aided learning (CAL) program. The program was tested in a trial that involved 36 people with diabetes; 20 received CAL lessons in diabetes management and 16 attended conventional diabetes classes conducted by diabetes educators. When measurements taken before and three months after the education were compared, both groups showed significant improvement in their knowledge; the blood glucose levels of the CAL group were significantly lower but those of the conventional education group were higher. This means that the CAL program was as effective as conventional education in imparting knowledge but it was more likely to motivate people to control their glucose levels. The CAL program allows diabetes educators to spend less time on education in basic knowledge and to concentrate more on motivational and social factors that are important determinants of patient compliance. It can also benefit people with diabetes whose access to health professionals and/or conventional diabetes education is restricted.

We described a profoundly intellectually disabled 24-year-old man with Wolf-Hirschhorn syndrome, left hemiplegia, epilepsy, atrophy of the right cerebral hemisphere, and dilatation of the right ventricle. The patient had a small ventricular septal defect, was wheelchair bound, and totally dependent. He had no speech, but vocalised to show his feelings. In this patient, the del(4)(p15) was subtle and arose due to the inheritance of a recombinant chromosome (4) from a maternal pericentric inversion-46,XX,inv(4) (p15.32q35). Fluorescence in situ hybridisation with probe D4S96 confirmed the deletion. This is the second case of Wolf-Hirschhorn syndrome resulting from a large pericentric inversion of chromosome 4.

Background: Blunt trauma patients without vital signs on admission are potential non-heart-beating donors., Objective: To review the feasibility of postmortem visceral perfusion and organ donation in blunt trauma patients without vital signs., Design: A retrospective case series of blunt trauma victims who were declared dead in the emergency department., Setting: A level I trauma center., Main Outcome Measures: Factors potentially precluding donation and potential donor yield., Results: The mean trauma-to-death interval was 71 minutes (< 60 minutes in 57% of the cases). Injuries likely to interfere with in situ perfusion were present in 41% of the cases. The tissue donation consent rate was 45%. Assuming a similar organ donation consent rate, the potential donor yield was 9% after excluding victims who were younger than 60 years of age, warm ischemia times that were less than 60 minutes, and patients who had injuries precluding perfusion., Conclusions: The potential organ yield from non-heart-beating, blunt trauma victims is low, which highlights the ethical and legal problems of this approach.

Objective: To report a new case of de novo 7q deletion distal to q35., Methodology: Developmental, cytogenetic and audiological investigations were carried out in the assessment of this rare chromosomal condition., Results: Moderate developmental delay, mild congenital microcephaly, growth retardation and conductive hearing impairment were found for this case of 46,XX,del(7)(q35)., Conclusions: The phenotype of 7q terminal deletion is highly variable.

Background: Health care providers and providers of emergency services are sometimes called to help with people who are found alone in their homes either helpless or dead. It is not known who is at risk for being found helpless or dead, what the mortality rates are among those found alive, or how frequently this situation occurs., Methods: We conducted a population-based study of patients who were found in their homes either helpless or dead. Over 12 weeks, paramedics employed by the city of San Francisco identified 387 such events involving 367 persons. We obtained information on these patients from the emergency-medical-services department or the hospitals to which they were taken and determined their outcomes., Results: The median age of the persons found helpless or dead was 73 years; 51 percent were women. The frequency of such incidents increased sharply with age, from a rate of 3 per 1000 per year among those 60 to 64 years of age to 27 per 1000 per year among those 85 years of age or older. The highest rate was among men 85 years and older who were living alone (123 per 1000 per year). In 23 percent of the cases, the person was found dead; an additional 5 percent died in the hospital. Thus, total mortality was 28 percent. Of the patients found alive, 62 percent were admitted to the hospital. The average hospital stay was eight days, and 52 percent of those admitted required intensive care. Of the survivors, 62 percent were unable to return to living independently. The total mortality was 67 percent for patients who were estimated to have been helpless for more than 72 hours, as compared with 12 percent for those who had been helpless for less than 1 hour., Conclusions: For elderly people who live alone, becoming incapacitated and unable to get help is a common event, which usually marks the end of their ability to live independently.

Background: Medical residents commonly discuss resuscitation decisions with hospitalized patients. Previous studies suggest that the quality of these discussions is poor., Objective: To learn about residents' experience with do-not-resuscitate (DNR) discussions and their attitudes toward them., Methods: Medical house officers on the wards of three teaching hospitals were eligible to participate. A subset had previously audiotaped actual DNR discussions as part of a study that described the quality of discussions. In a self-administered questionnaire, house officers rated their performance conducting a recent DNR discussion, stated their attitudes, and described their experience learning to talk to patients about these issues., Results: One hundred one (88%) of 115 residents responded to the survey. Eighty-six (90%) of 96 stated they had done a good job with the discussion and 78 (77%) of 101 reported feeling comfortable discussing the topic with patients. Ninety-four (94%) of 100 residents said they discuss code status with all seriously ill patients and while on the medical wards they conduct a median of one DNR discussion per week. On average, they had observed four discussions conducted by more senior clinicians. One third of the residents had never been observed talking to patients about DNR decisions and 71% had been observed two or fewer times., Conclusions: These findings help explain the observations about the quality of DNR discussions. House staff "see" and "do" these discussions, but are not taught through observation and feedback. We recommend that communication about end-of-life treatment decisions be treated as a medical skill to be taught with the same rigor as other clinical procedures.

Doctors in different countries have different approaches to bioethical problems. We studied how attitudes to life-sustaining treatment for terminally ill patients differ in Japan and the USA by administering a questionnaire to Japanese (136) and Japanese-American (77) physicians. In a series of clinical scenarios the questionnaire asked what life-sustaining interventions the doctors would recommend to a patient with metastatic gastric cancer. Most Japanese physicians would recommend blood transfusions for gastrointestinal bleeding (74%), total parenteral nutrition for malnutrition (67%), and vasopressors for life-threatening hypotension (61%) when the patient did not know of his diagnosis and outlook. Significantly fewer Japanese physicians would want these interventions for themselves: 29% would want transfusion, 36% would want total parenteral nutrition, and 25% would want vasopressors. 36% of Japanese physicians would override the explicit request of a competent moribund cancer patient to withdraw all life-support. By contrast, among Japanese-American physicians only 42% would recommend blood transfusions, 33% total parenteral nutrition, and 34% vasopressors to a terminally ill cancer patient who did not know of his diagnosis or outlook. Cross-cultural studies in medical ethics can help physicians and the public in different countries to take a fresh look at accepted practices and the ethical reasons behind them.

Objective: To describe how medical residents discuss do-not-resuscitate (DNR) orders with patients., Design: Prospective observational study., Setting: Inpatient medical wards of one university tertiary care center, one urban city public hospital, and one Veterans Affairs medical center., Participants: Thirty-one medical residents self-selected 31 of their English-speaking, competent patients, with whom they had DNR discussions., Measurements: Three independent observers rated audiotaped discussions about DNR orders between the medical residents and their patients. Ratings assessed whether the physicians met standard criteria for requesting informed consent (e.g., disclosed the nature, benefits, risks, and outcomes), addressed the patients' values, and attended to the patients' emotional concerns., Main Results: The physicians often did not provide essential information about cardiopulmonary resuscitation (CPR). While all the physicians mentioned mechanical ventilation, only 55% mentioned chest compressions and 32% mentioned intensive care. Only 13% of the physicians mentioned the patient's likelihood of survival after CPR, and no physician used a numerical estimate. The discussions lasted a median of 10 minutes and were dominated in speaking time by the physicians. The physicians initiated discussions about the patients' personal values and goals of care in 10% of the cases, and missed opportunities to do so., Conclusions: Medical ethicists, professional societies, and the public recommend more frequent discussions about DNR orders. Even when housestaff discuss resuscitation with patients, they may not be accomplishing the goal of increasing patient autonomy. Research and education must focus on improving the quality, as well as the quantity, of these discussions.

Objectives: To describe how parents actually use federally mandated vaccine information pamphlets and to evaluate the pamphlets' effects on parents' opinions about vaccination., Design: A controlled trial of vaccine information pamphlets based on a survey mailed to parents who either received (n = 140) or did not receive (n = 167) the pamphlets., Study Population: Parents of infants aged 2 to 8 months in a suburban, mainly upper-middle class private group practice in northern California., Results: More than 90% of parents believed that they had enough information to decide whether their child should be vaccinated, even among those who did not receive the pamphlets. Among parents who received the pamphlets, fewer than half (38%) read them thoroughly, and most (63%) said that they should be distributed only on the first visit for vaccinations. Parents who received the pamphlets did not differ from those who did not in terms of the proportions who would have liked more time to be spent discussing vaccines (34% vs 34%) or who were anxious about how the diphtheria and tetanus toxoids and pertussis vaccine would affect their child (60% vs 52%)., Conclusions: Vaccine information pamphlets, when used as an adjunct to discussions with physicians and nurses, have little effect on the opinions of well-educated parents. Future research and policy changes might focus on how to make the contents of the pamphlets less frightening and on allowing greater flexibility in how they are distributed.

In this study, cimetidine uptake and its regulation by LLCPK1 monolayers were investigated. Uptake was temperature dependent with kinetic and specificity characteristics typical of a carrier-mediated mechanism. With cimetidine uptake in the presence of an excess concentration of the potent inhibitor quinidine as a measure of nonspecific transport, the estimated kinetic parameters for cimetidine uptake at 37 degrees C under steady-state conditions are Km = 32.3 +/- 6.4 microM and Vmax = 20.2 +/- 2.1 pmol/mg per minute. Amiloride, quinidine, and quinine inhibited cimetidine uptake, whereas N1-methylnicotinamide, tetraethylammonium, and guanidine did not. The uptake of cimetidine was increased in the presence of a cell-->lumen H+ gradient, consistent with the behavior of a cimetidine-H+ antiport system. Furthermore, the activity of both the Na(+)-H+ exchanger and H(+)-ATPase acted to dissipate the cell-->lumen H+ gradient, thereby decreasing net cimetidine transport. These results suggest that there is a cimetidine-H+ exchange system in LLCPK1 cells and that the net secretion of organic base in vivo may be regulated by luminal acidification mechanisms.

Objective: Wider use of written advance directives may prevent many ethical dilemmas about life-sustaining interventions for patients who have lost decision-making capacity. We investigated whether a simple educational intervention increased patient completion of the durable power of attorney for health care., Design: A randomized, controlled trial., Setting: A health maintenance organization., Subjects: All patients aged 65 years and older and discharged from a hospital between January 1991 and May 1991 (n = 1101) were randomized to either an intervention group or a control group., Intervention: An educational pamphlet on the durable power of attorney for health care and a durable power of attorney for health care form were mailed to all patients in the intervention group. The control group received conventional care only., Main Outcome Measure: Completion of the durable power of attorney for health care form., Results: There were no significant baseline differences between the intervention group and the control group. Following our intervention, 18.5% of the subjects in the experimental group completed a durable power of attorney for health care form, compared with 0.4% of the control group (P < .0001)., Conclusions: A simple educational intervention significantly increased the completion of the durable power of attorney for health care. Our findings should stimulate further efforts to empower patients to make informed decisions about their health care.

We examined how house officers coped with serious medical mistakes to gain insight into how medical educators should handle these situations. An anonymous questionnaire was mailed to 254 house officers in internal medicine asking them to describe their most important mistake and their response to it; 45% (N = 114) reported a mistake and completed the questionnaire. House officers experienced considerable emotional distress in response to their mistakes and used a variety of strategies to cope. In multivariate analysis, those who coped by accepting responsibility were more likely to make constructive changes in practice, but to experience more emotional distress. House officers who coped by escape-avoidance were more likely to report defensive changes in practice. For house officers who have made a mistake, we suggest that medical educators provide specific advice about preventing a recurrence of the mistake, provide emotional support, and help them understand that distress is an expected concomitant of learning from the experience.

The highly selective cardiac-M(2) muscarinic acetylcholine receptor (mAChR) antagonist methoctramine shows a number of concentration-dependent biochemical responses. At micromolar concentrations it interacts allosterically with the mAChR and has 'agonist-like' effects on the phosphoinositide and cyclic AMP second messenger systems. Direct stimulation or inhibition of second messenger systems has been reported to modulate cellular homoeostasis and differentiation. This study showed that methoctramine was toxic, in micromolar concentrations, to the human neuroblastoma cell lines SK-N-SH, LAN-5 and SH-EP1, the last being a clone that does not contain muscarinic receptors. The selective M2 mAChR antagonists 11-{2-[(diethylamino)methyl]-1-piperidinyl}-5,11-dihydro-6H-pyrido(2,3-6)(1-4)benzodiazepine-6-on (AF-DX 116) and gallamine, as well as the selective M1 and M3 antagonists pirenzepine and 4-diphenylacetoxy-n-methylpiperidine (4-DAMP), had no toxic effects. Lithium provided significant protection against methoctramine toxicity, whereas carbamylcholine, pertussis toxin and forskolin had no influence on its toxicity. At micromolar concentrations, the clinically used, non-selective mAChR antagonists ethopropazine, benztropine, trihexyphenidyl and orphenadrine displayed toxicity similar to that of methoctramine. Methoctramine, ethopropazine, benztropine and trihexyphenidyl enhanced significantly [(3)H]thymidine uptake at subtoxic concentrations. These results demonstrate that (a) the toxicity of methoctramine is by way of non-muscarinic mechanism, (b) some anticholinergic drugs commonly used in clinical medicine have toxic properties similar to those of methoctramine and (c) at subtoxic micromolar concentrations anti-muscarinic drugs have some trophic properties.

Background: Serious problems exist with respect to documentation of do not resuscitate (DNR) orders. We studied the impact of a procedure-specific DNR order form on documentation of these orders., Methods: We prospectively compared DNR chart documentation during a 3-month period before and after implementation of a procedure-specific DNR order form., Results: The order form was used in 41 (93%) of 43 charts after its implementation. Documentation of attending physician agreement with the DNR order form increased from 30 of 34 charts in which the order form was used). The number of orders where it was uncertain whether at least one component of acute cardiopulmonary life support-related procedures was to be performed decreased from 30 (88%) of 34 charts to three (7%) of 43 charts. The order form had no measurable impact on documentation of DNR discussion. Only 25% of the charts had any discussion of the risks and benefits of CPR., Conclusions: A procedure-specific DNR order form can improve documentation of DNR decisions. The reduction of uncertainty in these orders about the use of specific procedures can prevent errors in patient care.

Background: Longitudinal studies that collect sensitive data, such as test results for HIV antibodies, present difficult ethical problems for investigators. Personal identifiers are needed for longitudinal follow-up, but current regulations in the United States require that all subjects be informed of their HIV test results when identifiers are retained. Therefore, subjects who do not wish to learn their HIV status must be excluded from prospective research. Because these subjects may be at particularly high risk for HIV infection, this situation may lead to substantial bias., Methods: We describe a new application of a methodology for blinding such studies, based on the link-file system used for protecting subjects' sensitive research data. This design enables investigators to hold each subject's HIV test result and survey data for multiple ascertainments over time while effectively severing any link between this information and the subject's identity. This objective is achieved by a process of sequential coding, using at least two coders who are not associated with the study., Conclusions: The method described in this paper permits investigators in the United States to perform important prospective epidemiologic studies while adhering to current regulations for the conduct of such investigations.

A consensus has emerged in recent years that decisions about life-sustaining treatment made by informed, competent patients should be respected. Advance directives are expressions of a patient's preferences regarding life-sustaining treatments made while the patient is still competent, to be used if the patient loses competence. Patients infected with HIV have a high mortality rate and frequently lose competence as their disease progresses to AIDS. Therefore, the completion of advance directives in this patient group is vitally important.

The results of our study in four years, blood donors and tuberculosis patients HIV seroprevalence using ELISA for detection HIV1/HIV2 antibodies and Western-blot for confirmation, indicate that seroprevalence in blood donors is 0.28% without a significant increase tendency. Our data show that 88 HIV seropositive confirmed, 70% were HIV1, 25% HIV2 and 5% double reactivity HIV1/HIV2.

We do not like the idea of doctors and nurses being forced to provide care that offends their sense of themselves and their art. But we like even less the idea of physicians allocating resources without the force of society's judgment. Physicians must help craft the policies on futility or those policies will not reflect sound medical judgment. But how our country creates policies is as important as what the policies mandate. If our society requires physicians to create health care policies on their own, we will shirk our responsibility to ourselves.

To document the current prevalence of physician-patient sexual contact and to estimate its effect on involved patients, 10,000 family practitioners, internists, obstetrician-gynecologists, and surgeons were surveyed. Of the 1,891 respondents, 9% acknowledged sexual contact with 1 or more patients. Even in the unlikely case that none of the nonrespondents had sexual contact with patients, its prevalence among all 10,000 physicians surveyed would still be 2%. Of respondents, 23% had at least 1 patient who reported sexual contact with another physician; 63% thought this contact was "always harmful" to the patients. Almost all (94%) responding physicians opposed sexual contact with current patients; 37% also opposed sexual contact with former patients. More than half of respondents (56%) indicated that physician-patient sexual contact had never been addressed in their training; only 3% had participated in a continuing education course focusing on this issue. Clear and enforceable medical ethics codes concerning physician-patient sexual contact are needed, as well as preventive educational programs for medical schools and residency programs.

Georgetown University Hospital has been operating an image management and communications system (IMACS or PACS) for 3.5 years. This work was initially funded under the Army Medical Research and Development Command Digital Imaging Network Systems (DINS) project. The system was taken from a research system supporting only radiology tasks to one extended to clinical use, and has been used in clinical work for 3 years. This paper will summarize our PACS clinical experience and will describe the operational features implemented and those still necessary.

The tragedy of five patients who contracted human immunodeficiency virus (HIV) infection from a seropositive dentist has alarmed the public. The Centers for Disease Control (CDC) recently revised its recommendations for preventing the transmission of HIV infection to patients during invasive procedures. The CDC abandoned a previous plan to list exposure-prone invasive procedures that HIV-infected health care workers should not perform. The CDC said "expert review panels" should decide on a case-by-case basis whether seropositive health care workers may perform invasive procedures. As of February 1992, the revised recommendations were under review by the US Department of Health and Human Services. Many issues remain to be clarified, such as how these panels will operate and whether decisions will be consistent in similar cases. Disregarding the CDC guidelines or infection-control precautions may further erode public trust and lead to draconian restrictions on HIV-infected health care workers. Physicians and dentists should respond more effectively to public fears about HIV transmission. The challenge is to protect patients while respecting the privacy and livelihood of health care workers.

Objective: The Cruzan case and the Patient Self-Determination Act will encourage patients to specify in advance which life-sustaining treatments they would want if they become mentally incompetent. However, strictly following such advance directives may not always be in a patient's best interests. We sought to determine whether patients differ in how strictly they want advance directives followed., Design: Interview study., Setting: Seven outpatient chronic dialysis centers., Participants: One hundred fifty mentally competent dialysis patients., Intervention: Using a structured questionnaire, we asked the subjects whether they would want dialysis continued or stopped if they developed advanced Alzheimer's disease. We then asked how much leeway their physician and surrogate should have to override that advance directive if overriding were in their best interests. Subjects granting leeway were also asked what factors should be considered in making decisions for them., Results: Subjects varied greatly in how much leeway they would give surrogates to override their advance directives: "no leeway" (39%), "a little leeway" (19%), "a lot of leeway" (11%), and "complete leeway" (31%). Subjects also varied in how much they wanted various factors considered in making decisions, such as pain or suffering, quality of life, possibility of a new treatment, indignity caused by continued treatment, financial impact of treatment on family members, and religious beliefs., Conclusions: Strictly following all advance directives may not truly reflect patients' preferences. To improve advance directives, we recommend that physicians explicitly ask patients how strictly they want their advance directives followed and what factors they want considered in making decisions.

In a landmark decision, the U.S. Supreme Court affirmed a Missouri ruling that sharply limited family decisions about life-sustaining treatment for incompetent patients. The Court held that the Constitution protects the refusal of life-sustaining treatment by competent patients. For incompetent patients, states may require "clear and convincing" evidence of refusal, specifically for the withdrawal of tube feedings, if such a person were in a persistent vegetative state. The ruling left many clinical questions unanswered, such as whether life-sustaining treatment must be given to terminally ill incompetent patients, whether patients may refuse artificial feedings, and what constitutes clear and convincing evidence of refusal. The decision also has potentially harmful consequences. It may undermine family decision making, encourage cynicism and disregard of the law, and promote defensive medicine. Physicians can minimize such consequences by encouraging patients to provide advance directives, such as the durable power of attorney for health care, by urging legislative action, and by setting national practice standards for decisions regarding incompetent patients.

Georgetown University Hospital has been operating an image management and communications system (IMACS or PACS) for three-and-a-half years. This work was initially funded under the Army Medical Research and Development Command Digital Imaging Network Systems (DINS) project. The system was taken from a research system supporting only radiology tasks to one extended to clinical use, and has been used in clinical work for two-and-a-half years. This paper will summarize our PACS clinical experience and will describe the operational features implemented and those still necessary.

Mistakes are inevitable in medicine. To learn how medical mistakes relate to subsequent changes in practice, we surveyed 254 internal medicine house officers. One hundred fourteen house officers (45%) completed an anonymous questionnaire describing their most significant mistake and their response to it. Mistakes included errors in diagnosis (33%), prescribing (29%), evaluation (21%), and communication (5%) and procedural complications (11%). Patients had serious adverse outcomes in 90% of the cases, including death in 31% of cases. Only 54% of house officers discussed the mistake with their attending physicians, and only 24% told the patients or families. House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice. Residents were less likely to make constructive changes if they attributed the mistake to job overload. They were more likely to report defensive changes if they felt the institution was judgmental. Decreasing the work load and closer supervision may help prevent mistakes. To promote learning, faculty should encourage house officers to accept responsibility and to discuss their mistakes.

Persons at risk for infection with the human immunodeficiency virus are being encouraged to learn their serostatus. While such knowledge can help patients seek appropriate medical care, it can also be distressing. We describe an approach, based on crisis counseling, for physicians to use in working with patients infected with HIV. It can help physicians in assisting patients with emotional reactions to the diagnosis as well as in directing patients to manage practical issues of concern. Methods for discussing safer sex or injection practices are also presented.

Decreases in high-risk behavior have been observed when people have sought anonymous or confidential HIV-antibody testing accompanied by counseling. HIV-antibody testing also benefits those who are tested, since people who find that they are seropositive can receive closer medical follow-up, and, in certain cases, medical treatment. However, debates continue about appropriate testing policy. This study concerns the conditions under which people who are currently seeking anonymous testing at an alternative test site would be willing to obtain testing. On self-administered questionnaires all sexual orientation/gender groups expressed reluctance to obtain testing if anonymity were not assured. Bisexual men were especially concerned about seeking testing if there was mandatory reporting. Believing that one was infected with HIV was slightly associated with a decreased inclination to obtain testing under non-anonymous circumstances.