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Timothy E Quill

Publications and source records attributed to Timothy E Quill.

18 recordsLinked to original sources
PubMed2006

Ethical issues in palliative care.

Ethical concerns are common in palliative care settings. Rather than provide an exhaustive list of possible ethical problems one may come upon, this article describes areas of concern that are frequently encountered by perioperative health care providers, especially anesthesiologists, in the palliative care arena.

Advance Directives↗
PubMed2005

Eliminating analgesic meperidine use with a supported formulary restriction.

PURPOSE: Meperidine is a commonly used analgesic despite unique disadvantages compared with other opioid analgesics. The objective of this study was to measure the effects of a meperidine formulary restriction on the prescribing of parenteral opioid analgesics. MATERIALS AND METHODS: The study was performed at a single 750-bed tertiary care teaching hospital in Rochester, NY. The formulary restriction limited meperidine to use exclusively for rigors or procedural sedation and was supported by an educational initiative and a computerized order entry system. Independent computerized pharmacy records were used to capture all doses of parenteral morphine, meperidine, and hydromorphone administered to patients in the emergency department or on a medical or surgical inpatient floor during data-collection periods. Baseline data were collected during two 3-day periods before the formulary restriction; then comparison data were collected during three 3-day periods over 15 months after the formulary restriction. RESULTS: The number of administered doses of meperidine per day decreased from 37.5 (20.8% of parenteral opioid doses before the restriction) to 0.22 (0.1% of parenteral opioid doses, P = .001). The total number of opioid doses and morphine doses given did not change, whereas the number of hydromorphone doses increased significantly postrestriction, from 16.0 doses per day (8.9% of total) to 59.7 doses per day (29.5%) (P = .009). CONCLUSION: Meperidine formulary restriction, supported by an educational program and computerized order entry, effectively eliminated analgesic meperidine use. Hydromorphone use increased proportionately to offset the decreased use of meperidine.

Analgesics, Opioid↗
PubMed2004

Communicating evidence for participatory decision making.

CONTEXT: Informed patients are more likely to actively participate in their care, make wiser decisions, come to a common understanding with their physicians, and adhere more fully to treatment; however, currently there are no evidence-based guidelines for discussing clinical evidence with patients in the process of making medical decisions. OBJECTIVE: To identify ways to communicate evidence that improve patient understanding, involvement in decisions, and outcomes. DATA SOURCES AND STUDY SELECTION: Systematic review of MEDLINE for the period 1966-2003 and review of reference lists of retrieved articles to identify original research dealing with communication between clinicians and patients and directly addressing methods of presenting clinical evidence to patients. DATA EXTRACTION: Two investigators and a research assistant screened 367 abstracts and 2 investigators reviewed 51 full-text articles, yielding 8 potentially relevant articles. DATA SYNTHESIS: Methods for communicating clinical evidence to patients include nonquantitative general terms, numerical translation of clinical evidence, graphical representations, and decision aids. Focus-group data suggest presenting options and/or equipoise before asking patients about preferred decision-making roles or formats for presenting details. Relative risk reductions may be misleading; absolute risk is preferred. Order of information presented and time-frame of outcomes can bias patient understanding. Limited evidence supports use of human stick figure graphics or faces for single probabilities and vertical bar graphs for comparative information. Less-educated and older patients preferred proportions to percentages and did not appreciate confidence intervals. Studies of decision aids rarely addressed patient-physician communication directly. No studies addressed clinical outcomes of discussions of clinical evidence. CONCLUSIONS: There is a paucity of evidence to guide how physicians can most effectively share clinical evidence with patients facing decisions; however, basing our recommendations largely on related studies and expert opinion, we describe means of accomplishing 5 communication tasks to address in framing and communicating clinical evidence: understanding the patient's (and family members') experience and expectations; building partnership; providing evidence, including a balanced discussion of uncertainties; presenting recommendations informed by clinical judgment and patient preferences; and checking for understanding and agreement.

Communication↗
PubMed2003

Professional organizations' position statements on physician-assisted suicide: a case for studied neutrality.

Position statements opposing legalization of physician-assisted suicide by organizations such as the American College of Physicians-American Society of Internal Medicine rightly emphasize that palliative care should be the standard of care for the dying, and that the inadequacies that exist in its delivery should be remedied. But such position statements generally understate the limitations of palliative care to alleviate some end-of-life suffering, and they do not provide adequate guidance about how physicians should approach patients with intractable suffering who are prepared to die. In this manuscript, we briefly present data about severe suffering before death for terminally ill patients, including those enrolled in hospice programs. We also review some of what is known about requests and responses for physician-assisted suicide in Oregon and in the rest of the United States. Preliminary data from Oregon suggest that legally sanctioned access to physician-assisted suicide is used by a very small number of patients and seems to be associated with improved delivery of hospice and palliative care. Physicians of good will, deep religious convictions, and considerable palliative care experience exist on both sides of the debate about legalization of physician-assisted suicide. In an effort to respect this diversity, and to encourage our profession to continue to struggle with the genuine dilemmas faced by some patients toward the end of their lives and by their families, we argue in favor of medical organizations' taking a position of studied neutrality on this contentious issue.

Depression↗
PubMed2003

An integrated biopsychosocial approach to palliative care training of medical students.

In 1996 the University of Rochester School of Medicine, Rochester, New York, began a major curricular reform called the Double Helix Curriculum, integrating basic science and clinical training over 4 years of medical school. This transition provided a unique opportunity to develop and implement a fully integrated, comprehensive palliative care curriculum. In this three-part paper, we will describe: (1) our process of finding curricular time, setting priorities, and deciding on pedagogical strategies; (2) an overview of how palliative care teaching was integrated into the general curriculum, including examples of different teaching opportunities; and (3) our evaluation process, and some ongoing challenges. Because palliative care is a core element in the care of all seriously ill patients, we chose to integrate our teaching into multiple courses over 4 years of undergraduate medical education, and not isolate it in a particular course. We view this report not as an ideal curriculum to be emulated in its entirety but as a work in progress that may be somewhat unique to our institution. We intend to illustrate a process of incremental curriculum building, and to generate some fresh teaching ideas from which palliative care educators can select depending on their own curricular needs and objectives.

Curriculum↗
PubMedDate not supplied

Underdosing of morphine in comparison with other parenteral opioids in an acute hospital: a quality of care challenge.

OBJECTIVE: We observed that parenteral morphine is routinely prescribed in doses that are quite low in relation to doses of alternative parenteral opioids and in comparison with published effective doses and guidelines. The present study was undertaken to determine: 1) whether different parenteral opioids are dosed equivalently; 2) which patient factors affect equianalgesic dose; and 3) which patient factors affect opioid choice. DESIGN: At a 750-bed tertiary care, teaching hospital in Rochester, NY, patients on the medical and surgical floors and in the emergency department who received one or more doses of parenteral morphine, hydromorphone, or meperidine were identified using computerized pharmacy records. A detailed chart review was performed for each patient, recording a variety of patient variables, which were then correlated separately with opioid dose and choice. RESULTS: Of the 293 patients treated with boluses of a parenteral opioid, 75% received morphine at a median dose of only 2 mg. Patients prescribed hydromorphone or meperidine received median equianalgesic doses that were 6.7 and 3.4 times higher, respectively. A prescriber's choice of opioid affected the equianalgesic dose more significantly than any of the patient variables studied, including active home opioid use. CONCLUSIONS: At our institution, parenteral morphine boluses are routinely given at relatively low doses compared with: 1) other opioids; 2) patient-controlled analgesic dosing; 3) usual doses required for analgesia from previous studies; and 4) a historical control in the same hospital. The reasons for this pattern are largely unexplained by patient variables. Inadequate bolus dosing of morphine may be a barrier to appropriate patient analgesia.

Analgesics, Opioid↗