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Objectives: To describe the substantive and procedural criteria used for placing patients on the waiting list for liver transplantation and for allocating available livers to patients on the waiting list; to identify principal decision-makers and the main factors limiting liver transplantation in Canada; and to examine how closely cadaveric liver allocation resembles theoretic models of source allocation., Design: Mailed survey., Participants: Medical directors of all seven Canadian adult liver transplantation centres, or their designates. Six of the questionnaires were completed., Outcome Measures: Relative importance of substantive and procedural criteria used to place patients in the waiting list for liver transplantation and to allocate available livers. Identification of principal decision-makers and main limiting factors to adult liver transplantation., Results: Alcoholism, drug addiction, HIV positivity, primary liver cancer, noncompliance and hepatitis B were the most important criteria that had a negative influence on decisions to place patients on the waiting list for liver transplantation. Severity of disease and urgency were the most important criteria used for selecting patients on the waiting list for transplantation. Criteria that were inconsistent across the centres included social support (for deciding who is placed on the waiting list) and length of time on the waiting list (for deciding who is selected from the list). Although a variety of people were reported as being involved in these decisions, virtually all were reported to be health to be health care professionals. Thirty-seven patients died while waiting for liver transplantation in 1991; the scarcity of cadaveric livers was the main limiting factor., Conclusions: Criteria for resource allocation decisions regarding liver transplantation are generally consistent among the centres across Canada, although some important inconsistencies remain. Because patients die while on the waiting list and because the primary limiting factor is organ supply, increased organ acquisition efforts are needed.

Background: Because the incidence rates of treated end-stage renal disease are much lower in Canada than in the United States, we hypothesized that decisions, made by family physicians and community internists, not to refer certain patients to nephrologists might explain this difference., Objective: To elicit patterns of practice and attitudes from nonnephrologist physicians who care for, and possibly refer, patients with renal disease., Methods: A mailed survey was sent to a random sample of 1924 members of the Ontario Medical Association, Sections on General and Family Practice and Internal Medicine. Of 1778 eligible respondents, responses were received from 728 physicians (40.9%)., Results: Patients with microscopic hematuria (79.2%), proteinuria (69.5%), and serum creatinine levels in the 120 to 150 mumol/L (1.4 to 1.7 mg/dL) range (84.3%) were generally not referred by family physicians. A hypothetical question about patient age and comorbid features revealed that physicians were less likely to refer patients as their age and comorbidity increased. In response to the question, "In the past 3 years, did you care for a patient who, after due consideration, died of renal failure without referral for dialysis," 14.2% of family physicians and 44.6% of internists said yes. Overall, 67.4% of respondents strongly or somewhat agree that rationing of dialysis is occurring now. Opinions about possible criteria for rationing of dialysis were that the majority strongly or somewhat agreed to basing a decision on the wishes of a competent patient (94.1%), short life expectancy (87.9), poor quality of life (87.0%), and age (63.6%)., Conclusions: These results suggest that nonreferral for dialysis occurs in Ontario and that the act of referral, or nonreferral as the case may be, is influenced by both age and coexisting disease. The patterns of nonreferral reported raise a concern that patients who might benefit are not being referred to dialysis centers.

The purpose of this study was to examine the effect of changing key factors in survey questions on public opinion regarding end-of-life decisions. These factors were: (a) patient prognosis (likely vs unlikely to recover from the illness); (b) end-of-life practice (foregoing treatment vs assisted suicide vs euthanasia); and (c) and decision making process (competent patient vs incompetent patient based on living will vs incompetent patient based on family wishes). A representative quota sample of 2019 Canadians 18 years of age or older were surveyed using a 13-item questionnaire with 12 items eliciting attitudes towards end-of-life decisions. The questions were systematically varied according to three key factors; patient prognosis, end-of-life practice and decision making process. One item assessed whether respondents had completed a living will. In the case of a decision to forgo life-sustaining treatment in a competent patient, public approval was 85% if the person was unlikely to recover and 35% if the person was likely to recover. In the case of a competent patient unlikely to recover, public approval was 85% for forgoing life-sustaining treatment, 58% for assisted suicide, and 66% for euthanasia. In the case of forgoing life-sustaining treatment for a patient unlikely to recover, public approval was 85% for a competent patient, 88% for an incompetent patient who had expressed his/her wishes in advance through a living will, and 76% for an incompetent patient based on a family's request. The influence of these key factors was similar in other cases examined. Ten percent of Canadians said they had completed a living will. It was concluded that patient prognosis has a major effect, end-of-life practice a moderate effect, and decision making process a minor effect on public opinion regarding end-of-life decisions.

The purpose of this study was to describe the life-sustaining treatment preferences of dialysis patients and to compare the acceptability of two generic and a disease-specific advance directive (AD). Of 532 potentially eligible hemodialysis patients, 95 (17.9%) participated in the study. These patients completed two generic (the Centre for Bioethics Living Will and the Medical Directive) and one disease-specific (the Dialysis Living Will) AD in a randomized cross-over trial. Treatment preferences were measured by using the Centre for Bioethics Living Will. Acceptability of the AD was measured by using a 13-item advance directive acceptability questionnaire (ADAQ) for each AD, and the advance directive choice questionnaire (ADCQ) to elicit participants' preferred AD. Twenty-five percent of the participants wanted to continue dialysis in case of severe stroke, 19% in severe dementia, and 14% in permanent coma. Averaged across treatments, proportions of participants wanting treatment in various health states were: current health (86%), mild stroke (84%), moderate stroke (60%), severe stroke (21%), mild dementia (78%), moderate dementia (51%), severe dementia (14%), terminal illness (41%), and permanent coma (10%). Averaged across health states, proportions of participants wanting various types of treatment were: dialysis (58%), antibiotics (53%), transfusion (53%), surgery (48%), cardiopulmonary resuscitation (48%), respirator (47%), and tube feeding (41%). Mean ADAQ scores were: Dialysis Living Will, 71%; Centre for Bioethics Living Will, 70%; and Medical Directive, 60% (F = 8.27, P < 0.001 (repeat measures analysis of variance); the Dialysis Living Will and Centre for Bioethics Living Will scored significantly higher than the Medical Directive). The proportion of participants who said they would choose to complete each AD was: Dialysis Living Will, 28%; Centre for Bioethics Living Will, 38%; Medical Directive, 31%; and unsure, 3% (chi 2 = 1.465, df = 2, P = 0.48). In conclusion, twenty-five percent or less of hemodialysis patients want to continue dialysis in three specific health states: severe stroke, severe dementia, and permanent coma. Health states and illness severity, far more than treatment descriptions, influence preferences. Dialysis patients should be offered a generic AD, and some generic AD are more acceptable than others. Only a minority of dialysis patients will complete any AD, but the completion of written AD forms is only one element in the process of advance care planning.

Objective: To develop a set of minimum clinical guidelines for use by primary care physicians in the evaluation and management of patients with hyperthyroidism and hypothyroidism., Participants: Guidelines were developed by a nine-member ad hoc Standards of Care Committee of the American Thyroid Association (the authors of this article). The participants were selected by the committee chair and the president of the American Thyroid Association on the basis of their clinical experience. The committee members represented different geographic areas within the United States, in order to take into account different practice styles., Evidence: Guidelines were developed on the basis of expert opinion of the participants, as well as on available published information., Consensus Process: Input was obtained from all of the participants, each of whom wrote an initial section of the document. A complete draft document was then written by three participants (P.A.S., D.S.C., and E.G.L.) and resubmitted to the entire committee for revision. The revised document was then submitted to the entire membership of the American Thyroid Association for written comments, which were then reviewed (mainly by P.A.S., D.S.C., and E.G.L.). Many of the suggestions of the American Thyroid Association members were incorporated into the final draft, which was then approved by the Executive Council of the American Thyroid Association. The entire process, from initial drafts to final approval, took approximately 18 months., Conclusions: A set of minimum clinical guidelines for the diagnosis and treatment of hyperthyroidism and hypothyroidism were developed by consensus of a group of experienced thyroidologists. The guidelines are intended to be used by physicians in their care of patients with thyroid disorders, with the expectation that more effective care can be provided, and at a cost savings.

The purpose of this study was to evaluate a six-station ethics objective structured clinical examination (OSCE) on a volunteer sample of 66 medical students and 33 residents from three Ontario medical schools. The internal consistency reliability was 0.46 and the median interrater reliability was 0.675 (range 0.30 to 0.89). The residents' scores were higher than those of the medical students (F = 2.24, 0.046). Also, the scores differed among the three schools (F = 3.19, p = 0.0004). The ethics OSCE has adequate interrater reliability and construct validity, but low internal consistency reliability. There are differences among the schools that may assist in ethics curriculum evaluation and development.

Objective: To describe the prevalence and content of long-term care facility policies regarding the use of life-sustaining treatments (cardiopulmonary resuscitation (CPR), artificial hydration and nutrition, dialysis, antibiotics for life-threatening infections, transfer to acute care hospital) and advance directives in Canada., Design: Cross-sectional mailed survey., Setting: Canadian long-term care facilities with 25 beds or more listed in the 1991-92 Directory of Long Term Care Centres in Canada. Institutions listed as, "general hospitals," "psychiatric hospitals," "children's treatment centres," "group homes," or as purely residential facilities were excluded., Participants: Chief Executive Officers or their designates., Main Outcome Measures: Respondents' self-reports regarding the existence of life-sustaining treatment or advance directive policies and content analysis of the policies themselves., Results: Of 1472 long-term care facilities, 1021 (69%) responded. Of these, 344 (34%) institutions had 397 policies regarding the use of life-sustaining treatments or advance directives. Three hundred twenty facilities (31%) had 349 do-not-resuscitate (DNR) policies (40% on CPR alone and 60% on CPR plus other life-sustaining treatments). Seventeen institutions (2%) each had one policy addressing life-sustaining treatments other than CPR, and 31 institutions (3%) each had one policy addressing advance directives. Of the 397 policies, 171 (43%) required routine discussion with all patients, 156 (39%) mentioned futility, 331 (83%) indicated that the competent patient had the right to make a decision about life-sustaining treatment, 265 (67%) indicated that the family of the incompetent patient had this right, 27 policies (7%) mentioned conflict resolution, 378 (95%) had an explicit requirement for recording the decision, 10 (3%) required explicit communication of the decision to the competent patient, 10 (3%) required such communication to the family of the incompetent patient, 260 (66%) required updating of the decision, and 213 (54%) mentioned rescinding or changing the decision., Conclusions: Only one-third of Canadian long-term care facilities have do-not-resuscitate policies, and even fewer have policies on advance directives or life-sustaining treatments other than CPR. The policies themselves could be improved by encouraging routine advance discussions, scrutinizing the use of the futility standard, stipulating procedures for conflict resolution, and explicitly requiring communication of the decision to competent patients or substitute decision makers of incompetent patients.

A written advance directive (AD) is a document intended to indicate a person's preferences with respect to treatment decisions that may be necessary if and when that person becomes incompetent. Both in research and in practice, there are features of the dialysis population that make ADs potentially quite relevant and useful. An evolving body of empiric literature supports the use of these documents in this unique population. This article reviews this literature, discusses the philosophic foundations and legal status of ADs, provides some pilot data on a dialysis-specific living will being developed at the University of Toronto Centre for Bioethics, examines clinical considerations related to ADs, and finally suggests future research directions.

Objective: To determine the prevalence and content of hospital policies on life-sustaining treatments (cardiopulmonary resuscitation [CPR], mechanical ventilation, dialysis, artificial nutrition and hydration, and antibiotic therapy for life-threatening infections) and advance directives in Canada., Design: Cross-sectional mailed survey., Setting: Canada., Participants: Chief executive officers or their designates at public general hospitals., Main Outcome Measures: Information regarding the existence of policies on life-sustaining treatments or advance directives and the content of the policies., Results: Questionnaires were completed for 697 (79.2%) of the 880 hospitals surveyed. Of the 697 respondents 362 (51.9%) sent 388 policies; 355 (50.9%) sent do-not-resuscitate (DNR) policies (i.e., policies that addressed CPR alone or in combination with other life-sustaining treatments). Of the 388 policies 327 (84.3%) addressed CPR alone, 28 (7.2%) addressed CPR plus other life-sustaining treatments, 10 (2.6%) addressed advance directives, and the remaining 23 (5.9%) addressed other life-sustaining treatments. Of the 355 DNR policies 1 (0.3%) stated that routine discussion with patients is required, 315 (88.7%) restricted their scope to terminally or hopelessly ill patients, 187 (52.7%) mentioned futility, 29 (8.2%) mentioned conflict resolution, 9 (2.5%) and 13 (3.7%) required explicit communication of the decision to the competent patient or family of the incompetent patient respectively, 110 (31.0%) authorized the family of an incompetent patient to rescind the DNR order, 224 (63.1%) authorized the nursing staff to do so, and 217 (61.1%) authorized physicians to do so., Conclusions: Although about half of the public general hospitals surveyed had DNR policies few had policies regarding other life-sustaining treatments or advance directives. Existing policies could be improved if hospitals encouraged routine advance discussions, removed the restriction to terminally or hopelessly ill patients, scrutinized the use of the futility standard, stipulated procedures for conflict resolution, explicitly required communication of the decision to competent patients or substitute decision-makers of incompetent patients and scrutinized the provision allowing families and health care professionals to rescind the wishes of now incompetent patients.

This study examined patient acceptance of two different advance directives. Outpatients completed the two directives and a 12-item acceptability questionnaire for each, and then stated their directive preferences. Of 128 patients enrolled, 97 (76%) responded. Overall, 47% of the respondents were satisfied with the Let Me Decide directive and 53% with the Medical Directive (NS). Thirty-nine percent preferred the Let Me Decide directive, 37% preferred the Medical Directive, and 25% had no preference or were uncertain which they preferred. Although there was no difference in patient acceptance between the directives, 76% of the patients preferred one or the other. Therefore, different people like different directives, and a variety of directives should be available for patients to review before they complete one.

Cruzan v. Director, Missouri Department of Health, the first "right to do die" case to be decided by the United States Supreme Court, constitutionalizes the principle of patient self-determination. The case encourages competent patients to reflect thoughtfully about the possibility that one day they may be incapacitated just as Nancy Beth Cruzan was and to prepare for that possibility by completing an advance directive. Furthermore, the recently enacted Patient Self-Determination Act requires hospitals to ask adult patients upon admission whether they have advance directives. However, a number of practical concerns arise for physicians about operationalizing these patient self-determination principles within their states and their scopes of practice. Will physicians be prosecuted for "assisting suicides" if they withdraw feeding tubes or forgo other life-sustaining treatments? Will physicians be liable in medical malpractice for "undertreatment" or "overtreatment" in such cases? Will physicians be asked to violate their own moral codes in treating patients? Will others intrude into the traditional physician-patient relationship and decision-making process? Will physicians be caught in the middle of troublesome family, staff, and institutional disputes? How will physicians learn of patients' advance directives? Will physicians be asked to continue care in futile cases? Will Cruzan's self-determination doctrine be improperly extended? Successful implementation of patient self-determination principles will require consideration and discussion of these practical physician concerns.

Objective: To examine the knowledge of, previous experience with, attitudes toward and perceived barriers to completing advance directives among outpatients at two general medicine clinics., Design: Cross-sectional questionnaire administered in face-to-face structured interviews., Setting: General internal-medicine outpatient clinics at a university teaching hospital., Patients: One hundred and five adult outpatients who could communicate in spoken English and who consented to be interviewed., Results: Of 167 patients approached, 58 were excluded because they could not communicate in spoken English, and 4 refused to participate. Of the remaining 105 patients, 17 (16%) knew about living wills, 12 (11%) about durable powers of attorney for health care and 4 (4%) about advance directives. Twenty-three (22%) had thought about their preferences for life-sustaining treatment, 20 (19%) had discussed them, none had written them down, and 45 (43%) had thought about choosing a proxy. Sixty-one (58%) wanted to think about their preferences for treatment, 65 (62%) wanted to discuss them, 32 (30%) wanted to write them down, and 80 (76%) wanted to choose a proxy. The perceived barriers to completing an advance directive were inability to write, the belief that an advance directive was unnecessary, a fatalistic attitude, previous discussion of preferences, a desire to leave the decision to doctors, uncertainty about preferences, a desire to discuss preferences rather than document them, a desire to wait until the situation arose, a desire to write down preferences in the future and a desire to avoid thinking about preferences or advance directives. Respondents with more knowledge of life-sustaining treatments were more likely to want to complete an advance directive., Conclusions: Outpatients have positive attitudes toward advance directives, but their knowledge and experience are limited. These data underscore the need for patient education and for policies to eliminate the barriers to completing advance directives that patients face.

Family physicians can play an important role in helping patients and their families to discuss life-sustaining treatments and to complete advance directives. This article reviews the legal status of, and empirical studies on, advance directives and addresses some important clinical questions about their use relevant to family practice.

Categorical data are usually displayed in medical publications with pie graphs and bar graphs. We here consider some of the problems that occur in displaying the rank, magnitude, width, and spacing of categorical data. A solution to some of these problems is offered by the dot chart, which has been used in other scientific literature, but not in medical publications. The dot chart can be a preferred alternative to pie graphs and offers a useful alternative to bar graphs. Dot charts can also be helpful in displaying categorical data for two groups.

This survey concerns the variation in attitudes among European gastroenterologists to truth telling in cases of cancer. Gastroenterologists in all parts of Europe were asked to consider a case of colonic cancer and to state what they would tell the patient and the patient's spouse. 260 replied. Gastroenterologists in northern Europe would usually reveal the diagnosis to both the patient and the patient's spouse, but some would inform only the spouse with the patient's permission. They would sometimes embellish the truth if the cancer had metastasised. Gastroenterologists in southern and eastern Europe would usually conceal the diagnosis from the patient, in many cases even when the patient asked to be told the truth. Most, however, would tell the spouse the full truth about both diagnosis and prognosis. The variation probably reflects differences in both doctors' attitudes and patients' expectations.

Pneumocystis carinii infection of the thyroid gland has previously been described in only four living patients with acquired immunodeficiency syndrome, three of whom had been receiving inhaled pentamidine prophylaxis against P carinii pneumonia. We treated three additional patients with P carinii thyroid involvement, all of whom were receiving aerosolized pentamidine. Two of our patients presented with clinical features suggestive of subacute granulomatous thyroiditis. The diagnosis of P carinii in our patients, as well as in the previously described patients, was established by thyroid fine-needle aspiration and Gomori's silver methenamine stains. The recent emergence of P carinii infection of the thyroid gland is likely related to the use of inhaled pentamidine prophylaxis, which appears to predispose to the development of extrapulmonary pneumocystosis. Clinicians need to be aware of the possibility of P carinii thyroiditis and should use aspiration and Gomori's methenamine silver staining in studying patients with the acquired immunodeficiency syndrome who have a painful (or other unexplained) thyroid mass so as to be able to initiate prompt and appropriate therapy.

Objective: To examine public opinion regarding certain elements of consent: disclosure, advance directives, substitute decisions, emergency treatment, and advocacy., Design: Cross-sectional random-digit-dialing telephonic survey., Setting: General public., Participants: One thousand randomly-selected adults living in Ontario., Interventions: None., Main Outcome Measures: Self-reported attitudes and behaviors., Results: Of 5,708 telephone numbers drawn, 641 were non-valid or non-residential, 1,283 were not in service, 1,068 had no answer, a busy line, or an unavailable respondent, 147 subjects had a language barrier, 1,497 subjects refused, 72 interviews were incomplete, and 1,000 interviews were completed. With regard to disclosure, 33% of respondents said that a doctor should withhold information from a patient if asked to do so by the patient's family. With regard to advance directives, 36% of respondents had had advance discussions with their families, and 12% had completed a living will. With regard to substitute decisions, 77% of respondents said that they would went their wishes followed if they were unable to make medical decisions for themselves; 58% wanted their spouse or partner to make such decisions for them. With regard to emergency treatment, 48% of respondents stated that a doctor should give a life-saving blood transfusion to an unconscious adult carrying a card stating that blood transfusion was against his or her religious beliefs. With regard to advocacy, 78% of respondents supported mandatory advocacy services for serious health decisions such as whether to have heart surgery; 33% supported advocacy services for less serious decisions such as whether to have a dental filling., Conclusions: These data highlight the need to reconsider legislative provisions regarding and/or target public education programs toward specific consent-related issues including disclosure, advance directives, substitute decisions, emergency treatment, and advocacy.

Objective: To develop objective structured clinical examination (OSCE) stations to assess the ability of physicians to address selected clinical-ethical situations, and to evaluate inter-rater agreement in these stations., Design: Two ten-minute OSCE stations were developed using video-taped encounters between attending physicians and standardized patients. One scenario involved a daughter requesting a do-not-resuscitate (DNR) order for her competent mother without the mother's knowledge; the other involved a competent elderly woman requesting not to be re-intubated if her congestive heart failure worsened. The scenarios were evaluated using foreign medical graduates taking an OSCE. Each candidate was scored on his or her interaction with a standardized patient in the two OSCE stations by two independent observers., Participants: Eight attending physicians from the Division of General Internal Medicine at the Toronto Hospital were used to develop the OSCE stations, and 69 foreign medical graduates taking the University of Toronto Pre-Internship Program OSCE were used to evaluate the stations., Results: The inter-rater reliability coefficients for the DNR and intubation scenarios were 0.79 (95% CI 0.69-0.87) and 0.75 (95% CI 0.62-0.84), respectively. For the DNR station, the scores of the two examiners, on a scale of 0 to 10, agreed exactly for 34 candidates (50%), within one mark for 59 candidates (87%), and within two marks for 65 candidates (96%). For the intubation station, the scores of the two examiners agreed exactly for 27 candidates (40%), within one mark for 56 candidates (84%), and within two marks for 63 candidates (94%)., Conclusions: The authors produced ethics OSCE stations with face and content validity and satisfactory inter-rater agreement. Ethics OSCE stations may be suitable for evaluating the ability of medical students and residents to address selected clinical-ethical situations.

Objective: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario., Design: Cross-sectional survey., Participants: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded., Results: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission., Conclusions: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.

Ethicists and lawyers agree that competent adult patients or their surrogate decision-makers have the right to forego life-sustaining treatment, but the views of practicing physicians have not been well-studied. To examine nephrologists' experience with and attitudes towards decisions to forego dialysis, a questionnaire was sent to all 161 nephrologists performing chronic dialysis in six New England states; 118 (73%) responded. The proportion of nephrologists who reported withholding (not starting) dialysis from the cited numbers of patients during the previous year was 11%, 0; 58%, 1 to 5; 20%, 6 to 10; 8%, 11 to 15; and 3%, greater than or equal to 16. For withdrawing (stopping), the proportions were 19%, 0; 73%, 1 to 5; 9%, 6 to 10; and 0%, greater than or equal to 11. The nephrologists withheld dialysis more times than they withdrew it (chi 2 = 26; P = 0.004). If requested to do so by a competent patient, 88% of nephrologists would stop dialysis. If requested by the family of an incompetent patient, 90% would stop if the patient had clear prior wishes, but only 63% would stop if prior wishes were unclear. With competent patients, the issue of withdrawal of dialysis was usually raised by the patient (56%). With incompetent patients, the issue was raised by the family (42%) or nephrologist (30%). It was concluded that decisions to withhold dialysis are more frequent than decisions to withdraw it. Moreover, nephrologists agree about the management of requests to withdraw dialysis in competent patients or incompetent patients with clear prior wishes; they disagree about the management of incompetent patients with unclear prior wishes.(ABSTRACT TRUNCATED AT 250 WORDS)

Background: Bone marrow transplantation has been shown to cure sickle cell disease, but it carries a 15 percent mortality risk. To determine whether parents would accept this risk to cure their children of sickle cell disease, we interviewed parents of children with sickle cell disease who were being followed in a university hospital clinic., Methods: We assessed parents' attitudes by using questions based on the standard reference-gamble paradigm. After we gave them descriptions of bone marrow transplantation and graft-versus-host disease (GVHD), the parents were presented with a series of hypothetical situations. In the first situation, bone marrow transplantation was described as offering certain (100 percent) survival with cure of sickle cell disease. In subsequent descriptions, the mortality rate associated with bone marrow transplantation was increased by 5 percent increments. The parents indicated the highest mortality risk at which they would consent to the procedure in order to cure their children., Results: In order to obtain a cure for their children, 36 of 67 parents (54 percent) were willing to accept some risk of short-term mortality, 25 of 67 (37 percent) were willing to accept at least the 15 percent short-term mortality risk we estimate to be the current figure for bone marrow transplantation, and 8 of 67 (12 percent) were willing to accept a short-term mortality risk of 50 percent or more. Nine parents (13 percent) said they would accept both a mortality risk of 15 percent or more and an additional 15 percent risk of GVHD. The parents' decisions were not related to the clinical severity of their children's illness., Conclusions: At current rates of mortality and morbidity with bone marrow transplantation, a substantial minority of the parents of children with sickle cell disease may consent to bone marrow transplantation for their children. Parental attitudes should be factored into decisions about whether to offer bone marrow transplantation to children with sickle cell disease.

The United States Supreme Court's recent decision in the Cruzan case declared that the states have broad powers to formulate their own rules in "right to die" cases. The Court held that competent adults have a constitutionally protected "liberty interest" that allows them to accept or refuse medical treatments. Since liberty interests are subject to rational state regulation, the narrow holding in Cruzan affirmed Missouri's authority to require a "clear and convincing" evidence standard to determine a patient's wishes before life-sustaining treatment could be withdrawn from a formerly competent adult now in a persistent vegetative state. For practicing physicians, some of the implications of Cruzan are as follows: (1) For competent adult patients, physicians should respect patient wishes regarding life-sustaining treatment. (2) Physicians also should discuss with competent patients their wishes for life-sustaining treatment at a future time, when a patient may no longer be able to participate in such decisions. (3) Physicians should record these wishes in a legally acceptable instrument that addresses two aspects of care that may arise in the future if the patient becomes incompetent. What would the patient want done? Who would the patient wish to designate as a surrogate or proxy? (4) For patients who are now incompetent, but for whom decisions must be made about life-sustaining treatment, physicians should focus on the previously expressed wishes of the patient rather than on the patient's current quality of life or on the wishes of the patient's family.

Patients with localized prostate cancer may be treated with either surgery (radical prostatectomy) or radiotherapy. Although controversial, many physicians believe that surgery offers a higher survival rate. However, the surgical treatment may also produce a higher rate of sexual impotency. Our study assessed how men value survival and sexual potency when asked to trade off one for the other. Using the treatment-choice technique, we interviewed 50 men aged 45 to 70 years without known prostate cancer. At hypothetical rates of survival (90% at 5 years for surgery) and impotency (90% for surgery and 40% for radiotherapy) representing published estimates, 32% of respondents were unwilling to trade off any survival, but 68% were willing to trade off a 10% or greater advantage in 5-year survival (by choosing radiotherapy) to maintain sexual potency. The median 5-year survival traded off was 10% (range, 0% to 80%). Willingness to trade off survival for sexual potency was significantly related to level of education, but not to age, interest in sex, frequency of sexual intercourse, or ability to achieve erection. We conclude that some men may choose treatment with lower long-term survival to increase their chance of remaining sexually potent. Because these men may be difficult to identify in clinical practice, physicians should thoroughly discuss both surgery and radiotherapy options with patients who have localized prostate cancer.

Inflammatory diseases of the thyroid are collectively the commonest thyroid disorder. Individually, they range from the rare case of acute bacterial thyroiditis to the other end of the spectrum, the even rarer Riedel's thyroiditis. Relatively common thyroid inflammatory diseases include the subacute thyroiditis syndromes. Of particular interest to endocrinologists is that both subacute granulomatous (painful) thyroiditis and subacute lymphocytic (painless) thyroiditis are very similar in terms of clinical course, although most likely have different etiologies. Nevertheless, their similarities suggest the possibility that there may be etiologic heterogeneity for the syndromes. From a clinical standpoint, it is essential to differentiate subacute painless thyroiditis from Graves' disease, because these two disorders also may mimic each other, yet only Graves' disease requires specific therapy. Chronic lymphocytic (Hashimoto's) thyroiditis, the commonest of the thyroiditides, presents with goiter and either hyperthyroidism (uncommon), hypothyroidism (common), or euthyroidism (most common). When L-T4 therapy is used in the treatment of Hashimoto's thyroiditis, the physician must be alert to the possibility of excess thyroid hormone administration. Sensitive TSH measurements help to avoid this therapeutic pitfall.