What does Cruzan mean to the practicing physician?

Article Abstract:

The implications for physicians of the US Supreme Court's 1990 decision in the legal case of Nancy Cruzan are evaluated. Nancy Cruzan entered a persistent vegetative state (characterized by a permanent loss of function and consciousness) as the result of an automobile accident in 1983, and her parents later sought to have her feeding tube removed, an act that would end her life. The Missouri Supreme Court ruled that ''clear and convincing evidence'' regarding Nancy's wishes about ending her life was necessary before the tube could be removed, and that such evidence had not been presented. Her parents appealed to the US Supreme Court, which upheld the Missouri Supreme Court's ruling when it decided that states may make their own rules in ''right to die'' cases. The points raised by the case with particular relevance for physicians include: (1) physicians should respect the preferences of their competent adult patients concerning treatment; (2) artificially delivered food and fluids constitute a medical treatment; (3) previously expressed wishes of now incompetent persons should be respected; (4) physicians and competent patients should discuss patients' wishes concerning life-sustaining treatment; and (5) appointment of a surrogate by the patient who will be responsible for treatment decisions should be encouraged. The Cruzan decision does not alter the ethical or clinical standards that govern the withdrawal of life-supporting care for incompetent patients, but it does call attention to the decision-making processes in determining when the right to die can be exercised. Many states may develop standards that are less strict than those in Missouri. The most important consequence of the Supreme Court decision is to place the responsibility for this aspect of health care with the physician and the patient, rather than with courts and families. (Consumer Summary produced by Reliance Medical Information, Inc.)

Laws, regulations and rules, Terminally ill persons, Terminally ill, Right to die, Cruzan, Nancy

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Effects of patient age and physician training on choice and dose of benzodiazepine hypnotic drugs

Article Abstract:

Aging is associated with changes in the metabolism or breakdown of the hypnotic (sleep-inducing) benzodiazepine drugs. Some types of benzodiazepines, such as flurazepam, are metabolized by the liver at a slower rate and distributed throughout the body more extensively in elderly patients as compared with younger patients, resulting in a slower elimination from the body in older persons. However, other types of these hypnotic agents, such as triazolam, have similar rates of elimination in elderly and young patients. Although benzodiazepines are safe and effective for short-term treatment of insomnia or inability to sleep, their long-term use may cause adverse effects including daytime sedation and ataxia, or lack of coordination. Thus, low doses of hypnotic agents that are rapidly eliminated from the body should be used in treating insomnia in the elderly. The prescriptions for flurazepam or triazolam written by physicians other than psychiatrists were reviewed to determine whether triazolam, which is more rapidly eliminated from the body than flurazepam, was prescribed more often than flurazepam for patients aged 70 years or older, and whether the dose of triazolam or flurazepam was lowered for elderly patients. The results show that the level of physician training, more than patient age, influenced the choice of hypnotic drug, although low doses of hypnotics were prescribed more often in the elderly. This suggests that physicians tend to prescribe a hypnotic agent based on habit, although they do appropriately reduce the dose given to elderly patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

Dosage and administration, Hypnotics and sedatives, Hypnotics

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Pharmacologic information and the doctor's dilemma

Article Abstract:

A recent study showed that the choice of a drug by a physician was not influenced by the age of a patient, although lower doses of a drug were used with elderly patients. In addition, the choice of drug therapy was related to the physician's age, which reflected the period of his or her medical training. It was suggested that more physician training was required in geriatric pharmacology, the study of drug effects in the elderly, for physicians to make appropriate therapeutic choices. Elderly patients are less able to clear or eliminate drugs from the body, because of the decreases in liver size and kidney function that occur with aging. In addition, physiologic mechanisms that compensate for drug excess may not be fully functioning in the elderly patient. Benzodiazepines are the most widely used hypnotic or sleep-inducing agents and generally have caused few serious adverse effects. Insomnia, the inability to sleep, is common in the elderly. The ideal hypnotic drug should act rapidly and last six to eight hours, and should not cause: tolerance or decreased sensitivity of the patient to the drug; addiction; rebound insomnia or increased sleeplessness after discontinuing the drug; or adverse reactions of the central nervous system. The benzodiazepines are relatively safe drugs, although they have been reported to cause amnesia or loss of memory, excitement, rage, and violent behavior. The characteristics of two hypnotic agents, flurazepam and triazolam, are discussed. (Consumer Summary produced by Reliance Medical Information, Inc.)

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