The Patient Self-Determination Act and the future of advance directives

Article Abstract:

The Patient Self-Determination Act is a new federal law designed to promote greater awareness by patients and physicians of the individual's right to provide advance directives in the case of serious illness. Advance directives are instructions given by an individual while healthy outlining what treatments he or she is willing to undergo in the event of serious illness. Some of the treatments addressed in advance directives include cardiopulmonary resuscitation or CPR, artificial respiration and artificial nutrition. The law was passed in the wake of a number of controversial ''right to die'' court cases, in which relatives of comatose or incapacitated persons asked for court orders to remove artificial life supports and permit those incapacitated persons to die. The law requires health care providers such as hospitals and nursing homes to establish written policies on the use of advance directives, to ask all new patients if they have prepared advance directives, such as living wills, to educate the patients about their institutional policy and provide staff and community education about advance directives. Some perceived drawbacks of the new law include the fact that these discussions are taking place in an inpatient setting, when they might be more effective and less stressful in an outpatient setting, and when the patient is not seriously ill. Physicians should encourage discussions of advance directives in their offices. Health insurers might require that all new enrollees state whether they have prepared such directives. In the absence of explicit advance directives by patients on what their treatment preferences would be in the event of catastrophic illness, some courts have opted for a strong presumption in favor of life at any cost. Polls indicate, however, that a substantial majority of the population would not choose existence in an unconscious state, and would decline extraordinary interventions in those circumstances, pointing to the need for advance directives to clarify individual preferences in extreme circumstances. The Patient Self-Determination Act provides a much needed means for patients to make their preferences known in advance of medical crises. (Consumer Summary produced by Reliance Medical Information, Inc.)

Laws, regulations and rules, Ethical aspects, Advance directives (Medicine), Right to die, Living wills

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Cost effectiveness of low-dose zidovudine therapy for asymptomatic patients with human immunodeficiency virus (HIV) infection

Article Abstract:

Cost-benefit analyses are used to weigh the cost of a new treatment against its benefits, in terms of years of life saved or decreased need for other expensive treatments. Zidovudine is one of few drugs shown to retard the progress of infection in people who have the human immunodeficiency virus (HIV), the cause of AIDS. The annual cost of zidovudine therapy was calculated to be $2,653 per person in 1989. Use of the drug can decrease a patient's risk of disease progression by 53 percent. Because of broad statistical assumptions in the way these numbers are calculated, determining the range of the costs (from the least amount the drug could cost to the most per year of life saved) yields cost-benefit ratios from around $6,500 to more than $70,000 per year of life saved per patient. What is known about zidovudine and its effects suggest that its cost per year of life saved per patient is in the lower end of that broad range, and that it is indeed a strategy with adequate benefit for its cost, which is largely borne by the government. (Consumer Summary produced by Reliance Medical Information, Inc.)

Economic aspects, Finance, Drug therapy, AIDS (Disease), Zidovudine

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The effect of pharmaceutical benefits managers: is it being evaluated?

Article Abstract:

There needs to be more accountability from pharmaceutical benefits managers. Employers and health maintenance organizations hire pharmaceutical benefits managers to reimburse and track drug costs as well as oversee approved drug lists. Researchers surveyed the literature and interviewed a series of pharmaceutical benefits managers, employers, and drug companies to evaluate their current practices of prescription drug management and suggested areas for improvement. Pharmaceutical benefits managers reimburse drug costs to participants either from a defined list of drugs or at a discount if the defined list is used. These managers update participating doctors on current drug recommendations and report on costs generated by these doctors. It may be advisable for pharmaceutical benefits managers to maintain open drug lists due to the recent purchases of many benefits managers by drug companies. These managers could more effectively track cost and drug benefits.

Evaluation, Drugs, Prescription drug plans, Prescriptions (Drugs)

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