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Competing Interests: The authors declare no conflicts of interest. Author disclosures are available in the supporting information.

Patients living with advanced dementia (PLADs) face several challenges to attain the goal of avoiding prolonged dying with severe suffering. One is how to determine when PLADs' current suffering becomes severe enough to cease all life-sustaining treatments, including withdrawing assistance with oral feeding and hydrating, a controversial order. This article broadens the concept of suffering by including suffering that cannot be observed contemporaneously and the suffering of loved ones. Four paradigm shifts operationalize these concepts. During advance care planning, patients can judge which future clinical conditions would cause severe suffering. To decide when to allow patients to die, treating physicians/providers only need to assess if patients have reached patients' previously judged, qualifying conditions. Questions: Will this protocol prevent PLADs' prolonged dying with suffering? Deter early-stage dementia patients from committing preemptive suicide? Sway decision-making surrogates from withholding life-sustaining treatments from patients with middle-stage dementia? Provoke providers' resistance to relinquish their traditional, unilateral authority to determine patients' suffering?, Competing Interests: Dr. Terman owns the Institute for Strategic Change, a for‐profit California corporation that publishes books and forms related to end‐of‐life challenges and advance care planning. As a health‐care provider, he counsels patients about advance care planning in three settings: Institute for Strategic Change; Caring Advocates, a California not‐for‐profit corporation that he founded and for which serves as its CEO and Chief Medical Officer; and Psychiatric Alternatives and Wellness Center, as an independent contractor. He helps patients receive reimbursement for his services from health insurance companies, but his ability to accept new patients is limited so he trains other health‐care providers. He has not accepted fees as a consultant, provided expert testimony in this area, or received royalties. He infrequently receives modest honoraria for presentations. This article does not describe the advance directive or specific strategies that Dr. Terman and his colleagues developed since 2004, although it implies that advance directives should use “severe‐enough suffering” as a criterion to determine when to implement interventions that may allow patients to die. Those who read this article are not likely to be surprised to learn that Dr. Terman offers such a directive for dementia because who else but a directive drafter would analyze this area in such depth? Co‐author Karl E. Steinberg has no competing interests. Co‐author Nathanial Hinerman has no competing interests., (© 2024 The Authors. Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Many people dread prolonged dying with suffering in the terminal illness, advanced dementia. To successfully facilitate a timely dying, advance directives must be effective and acceptable. This article considers whether authorities, including treating physicians, can accept as moral, the effective intervention that ceases caregivers' assistance with oral feeding and hydrating. The article presents eight criticisms and "alternate views" regarding ceasing assisted feeding/hydrating. It draws on perspectives from clinical medicine, law, ethics, and religion. The conflict is between (A) people's core beliefs that reflect cultural norms and religious teachings regarding what is moral versus (B) patients' autonomous right of self-determination and claim right to avoid suffering. The article presents each side as strongly as possible. Accepting the intervention as moral could allow patients a peaceful and timely dying from patients' underlying disease. Confidence in future success can deter patients and their surrogates from considering a hastened dying in earlier stages of dementia., Competing Interests: Dr. Terman owns the Institute for Strategic Change, a for‐profit California corporation that publishes books and forms related to end‐of‐life challenges and advance care planning. As a health care provider, he counsels patients about advance care planning in three settings: Institute for Strategic Change; Caring Advocates, a California not‐for‐profit corporation that he founded and serves as its CEO and Chief Medical Officer; and Psychiatric Alternatives and Wellness Center, as an independent contractor. He helps patients receive reimbursement for his services from health insurance companies, but his ability to accept new patients is limited so he trains other health care providers. He has not accepted fees as a consultant, provided expert testimony in this area, or received royalties. He infrequently receives modest honoraria for presentations. This article does not specifically refer either to the advance directive or to specific strategies that Dr. Terman and his colleagues developed since 2004. Those who read this article are not likely to be surprised to learn that Dr. Terman offers a directive for dementia since who else but a drafter of a directive would analyze this area in such depth? Author disclosures are available in the supporting information., (© 2024 The Authors. Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring published by Wiley Periodicals LLC on behalf of Alzheimer's Association.)

Background: The terminal illness of late-stage (advanced) Alzheimer's and related dementias is progressively cruel, burdensome, and can last years if caregivers assist oral feeding and hydrating. Options to avoid prolonged dying are limited since advanced dementia patients cannot qualify for Medical Aid in Dying. Physicians and judges can insist on clear and convincing evidence that the patient wants to die-which many advance directives cannot provide. Proxies/agents' substituted judgment may not be concordant with patients' requests. While advance directives can be patients' last resort to attain a peaceful and timely dying consistent with their lifelong values, success depends on their being effective and acceptable. A single flaw can provide opponents justification to refuse the directive's requests to cease assisted feeding., Aim: This article considers 24 common advance directive flaws in four categories. Process flaws focus on how patients express their end-of-life wishes. Content flaws reflect drafters' selection of conditions and interventions, and how they are described. Inherent flaws can make advance directives unacceptable to authorities concerned about premature dying. Strategies are needed to compel physicians to write needed orders and to prevent third parties from sabotaging these orders after they are  implemented. The article includes excerpts from "dementia-specific" directives or supplements that exemplify each flaw-mostly from the US and Europe. No directive critiqued here included an effective strategy to resolve this long-debated bioethical conflict: the past directive requests "Cease assisted feeding" but the incapacitated patient apparently expresses the desire to "Continue assisted feeding." Some opponents to the controversial request, cease assisted feeding, use this conflict as a conceptual wedge to practice hard paternalism. This article proposes a protocol to prevent this conflict from emerging. These strategies may prevent authorities from requiring patients to fulfill authorities' additional clinical criteria as a prerequisite to honor the requests in patients directives., Conclusion: This critique of flaws may serve as a guide to drafting and to selecting effective and acceptable advance directives for dementia. It also poses several bioethical and clinical questions to those in authority: Does your paternalistic refusal to honor patients' wishes respect their self-determination? Protect vulnerable patients from harm? Force patients to endure prolonged suffering? Violate the principles of bioethics? Violate the very foundation of patient-centered care?, (© 2022. The Author(s).)

Objective: The present study sought to assess the clarity of Physician Orders for Life-Sustaining Treatment (POLST) or Living Will (LW) documents alone or in combination with a video message/testimonial (VM)., Methods: Emergency medical services (EMS) personnel responded to survey questions about the meaning of stand-alone POLST and LW documents and those used in conjunction with emergent care scenarios. Personnel were randomized to receive documents only or documents with VM. Questions sought a code status for each scenario and a resuscitation decision. Code status responses were analyzed for consensus (95% response rate), resuscitation responses for correct treatment decisions., Results: The survey response rate was 85%. Approximately half of emergency medical technician (EMT) respondents were EMT basic, and half EMT respondents were paramedic, with an average age of 42 years. Less than half had previous POLST/LW training averaging 2 hours. Consensus failed to be reached for stand-alone documents. For clinical scenarios, responses to POLST documents specifying do not resuscitate/comfort measures only or cardiopulmonary resuscitation/full treatment exceeded 80% for code status designation and correct resuscitation decisions. Other POLST resuscitation/treatment combinations showed more disparate responses, and most benefited from VM with changes in responses of 20% or more (P ≤ 0.025). Code status responses to LW-based scenarios evidenced a nonconsensus majority (79%-83%) that was significantly affected with VMs (≥12%, P ≤ 0.004); half evidenced large changes in resuscitation decisions (49%, P < 0.001)., Conclusions: Document clarity, judged by consensus response, was rarely evidenced. video message/testimonial seems to be a helpful aid to both POLST and LWs. Standardized education and training reveal opportunities to improve patient safety to ensure patient wishes., Competing Interests: The authors disclose no conflict of interest., (Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus., Methods: We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes., Results: Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs., Conclusions: For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.

A terminal patient expressed the wish to hasten her death and refused nutrition. The psychiatrist asked to render an opinion relevant to her competence employed questions in a semi-structured interview derived from a new instrument originally designed to determine competence to create 'Advance Directives'. Although the patient ultimately demonstrated her resolve by totally ceasing fluid intake, the complexity of the case--including the question of the stability of her choice--illustrates the need for specific patient safeguards.

In an attempt to develop a quantitative method of evaluating rheumatoid arthritic activity, Tc-99m HEDP joint uptake values and joint-to-bone ratios were studied in ten adult rheumatoid arthritic patients and 17 nonarthritic patients. A joint-to-bone activity ratio of 1.8 at the fourth hour after injection (RA Index) discriminated clinically active rheumatoid arthritic joints from control joints with 95% accuracy. Serial studies on five patients during drug trial demonstrated a positive correlation between RA Index and the clinical manifestations of rheumatoid arthritic activity. The RA Index may be a useful quantitative parameter for evaluation of rheumatoid arthritic activity following therapy.

Newly synthesized proteins were pulse labeled with radioactive amino acids at several developmental stages of the sea urchin, Arbacia punctulata-in normal embryos and in embryos continuously exposed to the drug Dactinomycin. The soluble proteins were fractionated by electrophoresis through polyacrylamide gels. A simple procedure for complete solubilization of the proteins in slices of gels into a solution of toluene for liquid scintillation counting, and a computer program to display and to compare statistically the distributions of (14)C- and (3)H-labeled proteins fractionated on the same gel, allowed quantitative statements to be made on the relative changes in protein synthesis. The conclusion is that translation-level control provides most of the changes in protein synthesis that occur between fertilization and hatched blastula stage.