When patients refuse beneficial treatment, whether they have decision-making capacity plays a key role in determining the best course of action. However, when patients refuse to explain their reasons, assessment of decision-making capacity can be impossible. How should clinicians respond to such situations? Declining to give reasons for refusing beneficial treatment does not signal the absence of decision-making capacity. However, following the wishes of patients who could be incompetent carries risks. This article argues that, although it cannot be concluded that such patients are incompetent, there are reasons to treat them as if they were. The basis of this possibility, however, points to a number of obligations for clinicians before such a situation can be said to exist.
Despite successful treatment, deep vein thrombosis may not fully resolve in some patients. Consequently, in patients with new symptoms in a previously affected leg, the presence of noncompressibility on ultrasound cannot be assumed to be due to recurrent thrombosis. In this article, Linkins and colleagues performed a cross-sectional study of 60 patients with stable, residual thrombosis to determine interobserver agreement on standardized ultrasound measurements of thrombus length using 4 surface landmarks. Study findings suggest that when 2 ultrasound examinations are compared, an apparent increase in thrombus length of 9 cm or more is likely to be supportive of a diagnosis of recurrent deep vein thrombosis.
Predictors for in-hospital mortality and attributable risks of death were investigated in a large cohort of 13 440 patients with ischemic stroke from 104 community hospitals in Germany. Different effects of comorbid conditions on in-hospital death were observed in men and women. Death rates attributed to serious medical and neurological complications were calculated for patients exposed to complications as well as for the entire stroke population.
The number of major noncardiac surgical procedures has dramatically increased over the last decade. Previous studies emphasized coronary artery disease while heart failure carries as significant a risk. In the future, patients who undergo these procedures are likely to be older and have more complex cardiovascular disease due to advances in care of chronic diseases, especially heart failure. This review summarizes preoperative risk evaluation and the importance of heart failure. The authors also discuss current strategies and future directions for perioperative care in patients with heart failure undergoing major noncardiac surgery.
Irritable bowel syndrome (IBS) significantly diminishes health-related quality of life (HRQOL). Current management guidelines suggest routine HRQOL screening in patients with IBS. However, data reveal that many providers do a poor job of performing an adequate biopsychosocial history review and that surprisingly few accurately assess HRQOL in IBS. A practical limitation in the busy outpatient setting is that many clinicians have neither the training nor time to accurately assess HRQOL with the appropriate methodological rigor and instead substitute clinical gestalt for objective measures of HRQOL. In this article, Spiegel et al therefore sought to identify a concise list of highly significant determinants of HRQOL in IBS. In a retrospective analysis of over 700 patients with IBS, the authors found that HRQOL was associated with abnormalities in sexuality, mood, anxiety, and chronic stress and was not determined by any of the traditionally elicited gastrointestinal symptoms, any demographic characteristics, or any health resource utilization characteristics. These findings suggest that rather than focusing on physiological epiphenomena (eg, stool characteristics and subtype of IBS) and potentially misleading clinical factors (eg, age and disease duration), physicians might be better served to gauge global symptom severity, address anxiety, and eliminate factors contributing to chronic stress in IBS.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2004;164(16):1717. doi:10.1001/archinte.164.16.1717