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The importance of delivering goal-concordant care to seriously ill patients is widely recognized. Yet there are no methods that can reliably and accurately be used to measure whether care that was provided to patients was concordant with their goals.

Why Diverse Clinical Trial Participation MattersFor efforts focused on increasing diversity in clinical trials, the promise of knowledge generation shouldn’t overshadow the goals of improving the trustworthiness and fairness of U.S. health care.

No current policy or practice designed to improve care for dying Americans is backed by a fraction of the evidence that the FDA would require to approve even a relatively innocuous drug. Achieving evidence-based end-of-life care will require several key developments. The disquieting patterns of end-of-life care in the United States have been well documented. In the last month of life, one in two Medicare beneficiaries visits an emergency department, one in three is admitted to an intensive care unit, and one in five has inpatient surgery. But one of the most sobering facts is that no current policy or practice designed to improve care for millions of dying Americans is backed by a fraction of the evidence that the Food and Drug Administration would require to approve even a relatively innocuous drug. For example, more than two thirds of U.S. . . .

Efforts to promote the completion of advance directives implicitly assume that completion rates of these documents, which help ensure care consistent with people's preferences in the event of incapacity, are undesirably low. However, data regarding completion of advance directives in the United States are inconsistent and of variable quality. We systematically reviewed studies published in the period 2011-16 to determine the proportion of US adults with a completed living will, health care power of attorney, or both. Among the 795,909 people in the 150 studies we analyzed, 36.7 percent had completed an advance directive, including 29.3 percent with living wills. These proportions were similar across the years reviewed. Similar proportions of patients with chronic illnesses (38.2 percent) and healthy adults (32.7 percent) had completed advance directives. The findings provide benchmarks for gauging future policies and practices designed to motivate completion of advance directives, particularly among those people most likely to benefit from having these documents on record.

ChatGPT is a large language model trained on text corpora and reinforced with human supervision. Because ChatGPT can provide human-like responses to complex questions, it could become an easily accessible source of medical advice for patients. However, its ability to answer medical questions appropriately and equitably remains unknown. We presented ChatGPT with 96 advice-seeking vignettes that varied across clinical contexts, medical histories, and social characteristics. We analyzed responses for clinical appropriateness by concordance with guidelines, recommendation type, and consideration of social factors. Ninety-three (97%) responses were appropriate and did not explicitly violate clinical guidelines. Recommendations in response to advice-seeking questions were completely absent (N = 34, 35%), general (N = 18, 18%), or specific (N = 44, 46%). 53 (55%) explicitly considered social factors like race or insurance status, which in some cases changed clinical recommendations. ChatGPT consistently provided background information in response to medical questions but did not reliably offer appropriate and personalized medical advice.

Experience with his 103-year-old grandfather teaches a physician-bioethicist that for people without terminal or mental illness who desire to end their life, the alternative to physician-assisted dying — to stop eating and drinking — is just too challenging.

In this randomized trial of financial incentives in smokers, both reward-based and deposit-based incentive programs were more effective than usual care in achieving smoking cessation. Reward programs were much more commonly accepted than deposit-based programs. Financial incentives have been shown to promote a variety of health behaviors. 1 – 8 For example, in a randomized, clinical trial involving 878 General Electric employees, a bundle of incentives worth $750 for smoking cessation nearly tripled quit rates, from 5.0% to 14.7%, 8 and led to a program adapted by General Electric for its U.S. employees. 9 Although incentive programs are increasingly used by governments, employers, and insurers to motivate changes in health behavior, 10 , 11 their design is usually based on the traditional economic assumption that the size of the incentive determines its effectiveness. In contrast, behavioral economic theory suggests that incentives . . .

In a pragmatic trial involving smokers, financial incentives were more effective than free cessation aids; free cessation aids or e-cigarettes were no more effective than usual care. Cessation rates among smokers assigned to financial incentives were less than 3%.

Purpose The effect of capacity strain in an ICU on the timing of end-of-life decision-making is unknown. We sought to determine how changes in strain impact timing of new do-not-resuscitate (DNR) orders and of death. Methods Retrospective cohort study of 9891 patients dying in the hospital following an ICU stay ≥72 h in Project IMPACT, 2001–2008. We examined the effect of ICU capacity strain (measured by standardized census, proportion of new admissions, and average patient acuity) on time to initiation of DNR orders and time to death for all ICU decedents using fixed-effects linear regression. Results Increases in strain were associated with shorter time to DNR for patients with limitations in therapy (predicted time to DNR 6.11 days for highest versus 7.70 days for lowest quintile of acuity, p  = 0.02; 6.50 days for highest versus 7.77 days for lowest quintile of admissions, p  < 0.001), and shorter time to death (predicted time to death 7.64 days for highest versus 9.05 days for lowest quintile of admissions, p  < 0.001; 8.28 days for highest versus 9.06 days for lowest quintile of census, only in closed ICUs, p  = 0.006). Time to DNR order significantly mediated relationships between acuity and admissions and time to death, explaining the entire effect of acuity, and 65 % of the effect of admissions. There was no association between strain and time to death for decedents without a limitation in therapy. Conclusions Strains in ICU capacity are associated with end-of-life decision-making, with shorter times to placement of DNR orders and death for patients admitted during high-strain days.

Background Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend the diagnosis of chronic obstructive pulmonary disease (COPD) only in patients with a post-bronchodilator forced expiratory volume in 1 s to forced vital capacity ratio (FEV 1 /FVC) less than 0.7. However the impact of this recommendation on clinical practice is unknown. Objective To estimate the effect of a documented post-bronchodilator FEV 1 /FVC < 0.7 on the diagnosis and treatment of COPD. Design We used a regression discontinuity design to measure the effect of a post-bronchodilator FEV 1 /FVC < 0.7 on COPD diagnosis and treatment. Participants Patients included in a national electronic health record database who were 18 years of age and older and had a clinical encounter between 2007 and 2022 in which a post-bronchodilator FEV 1 /FVC value was documented. Main measures An encounter was associated with a COPD diagnosis if an international classification of disease code for COPD was assigned, and was associated with COPD treatment if a prescription for a medication commonly used to treat COPD was filled within 90 days. Results Among 27,817 clinical encounters, involving 18,991 patients, a post-bronchodilator FEV 1 /FVC < 0.7 was present in 14,876 (53.4%). The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 increased the probability of a COPD diagnosis by 6.0% (95% confidence interval [CI] 1.1–10.9%) from 38.0% just above the 0.7 cutoff to 44.0% just below this cutoff. The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 had no effect on the probability of COPD treatment (−2.1%, 95% CI −7.2 to 3.0%). Conclusions The presence of a documented post-bronchodilator FEV 1 /FVC < 0.7 had only a small effect on the diagnosis of COPD and no effect on corresponding treatment decisions.