Do-not-resuscitate order after 25 years.

Background: In 1976, the first hospital policies on orders not to resuscitate were published in the medical literature. Since that time, the concept has continued to evolve and evoke much debate. Indeed, few initials in medicine today evoke as much symbolism or controversy as the Do-Not-Resuscitate (DNR) order.

Recommendations for incorporating palliative care education into the acute care hospital setting.

This article presents recommendations for improving the education of physicians about end-of-life care in the acute care hospital setting. The authors, who have a variety of backgrounds and represent several types of institutions, formulated and reached consensus on these recommendations as members of the Acute Care Hospital Working Group, one of eight working groups convened at the National Consensus Conference on Medical Education for Care Near the End of Life in May 1997. A recently published literature review on the status of palliative care education, a summary of recent research on education about end-of-life care, and expert opinion were helpful in developing the recommendations.

A staff dialogue on aggressive palliative treatment demanded by a terminally ill patient: psychosocial issues faced by patients, their families, and caregivers.

Shortly before his death in 1995, Kenneth B. Schwartz, a cancer patient at Massachusetts General Hospital (MGH), founded The Kenneth B. Schwartz Center at MGH.

Treatment of anxiety associated with electrophysiologic studies.

Programmed electrical stimulation, also known as electrophysiologic studies (EPS), is a cardiologic technique used to help guide physicians in their management of selected patients with cardiac arrhythmias. Data are presented for 14 consecutive patients undergoing EPS seen in psychiatric consultation who had a diagnosis related to anxious mood. Successful management strategies, which evolved from work with these patients, included psychologic approaches (supportive psychotherapy and education) and psychopharmacologic agents (most commonly alprazolam).

Psychostimulant treatment of depressive disorders secondary to medical illness.

Hospital charts were reviewed for 66 medical and surgical patients who received dextroamphetamine or methylphenidate to treat a depressive disorder. Approximately three-fourths showed some improvement; in half of the sample, improvement was marked or moderate. Of those who improved, 93% reached their peak response within the first 2 days.

Use of high-dose intravenous haloperidol in the treatment of agitated cardiac patients.

Although previous reports have documented the safe and effective use of intravenous haloperidol in agitated cardiac patients, the dosages advocated have in general been relatively low: 1 to 2 mg every 2 to 4 hours. In this report, the authors demonstrate that such doses may be insufficient to control severe agitation in coronary care unit patients. Four cases are presented in which more than 100 mg/day of intravenous haloperidol were required for safe and effective control of confusion and agitation.

Propranolol and depression revisited: three cases and a review.

The occurrence of major depressive episodes as complications of treatment with propranolol has been a matter of controversy. Three cases are reported of depressions meeting DSM-III criteria following administration of propranolol for medical conditions. Possible relationships between beta blockade and affective illness are discussed.

Use of psychostimulants in medically ill patients with neurological disease and major depression.

The effective therapeutic response to dextroamphetamine and methylphenidate by five depressed patients with neurological disease is described. In four of these patients tricyclic antidepressants had to be discontinued due to the concomitant deterioration of their cognitive functions, and in one case they were not used due to cardiovascular complications. There was a rapid remission of depressive symptomatology with no adverse side effects, consistent with the findings of other investigators.

The use of methylphenidate in depressed patients after cardiac surgery.

A positive therapeutic response to methylphenidate is described in four depressed patients who developed cardiovascular complications after cardiac surgery that contraindicated the use of tricyclic antidepressants. There was a rapid remission of depressive symptomatology with no adverse side effects. This observation is consistent with the findings of other investigators.

Intravenous lorazepam in neuroleptic-induced catatonia.

Presented here are four cases of catatonic reactions which were felt to be neuroleptic induced. Intravenous lorazepam was rapidly effective in reversing the catatonia and attendant symptoms. Lorazepam's previous uses and pharmacological profile are discussed.

Monoamine oxidase inhibitors in obsessive-compulsive disorder.

The authors describe the use of monoamine oxidase inhibitors (MAOIs) in eight patients with severe obsessive-compulsive disorder. In four cases, the MAOIs produced rapid and sustained remission of symptoms; no response was seen in four other patients. All patients who responded to MAOIs, but none of the nonresponders, had phobic anxiety and/or panic attacks.

Cardiovascular effects of antidepressants.

It is not the purpose of this paper to dismiss the possibility that tricyclics may somehow cause cardiac function to deteriorate, with resulting congestive heart failure. Any patient with heart disease should receive intense clinical scrutiny for the development of cardiac symptoms--dyspnea on exertion, ankle edema, orthopnea, paroxysmal nocturnal dyspnea, rales, and the presence of an S3 are never taken lightly. These parameters should be monitored because the patient has cardiac disease, not because he or she is on a tricyclic antidepressant.