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Although many observers believe that cancer chemotherapy is overused at the end of life, there are no published data on this. To determine the frequency and duration of chemotherapy use in the last 6 months of life stratified by type of cancer, age, and sex. Retrospective cohort analysis. Administrative databases from Massachusetts and California. All Medicare patients who died of cancer in Massachusetts and 5% of Medicare cancer decedents in California in 1996. Use of intravenous chemotherapy agents, chemotherapy administration, or medical evaluation for chemotherapy from Medicare billing data for each patient in 30-day periods from the date of death backward. In Massachusetts, 33% of cancer decedents older than 65 years of age received chemotherapy in the last 6 months of life, 23% in the last 3 months, and 9% in the last month. In California, the percentages were 26%, 20%, and 9%, respectively. Chemotherapy use greatly declined with age. Chemotherapy use was similar for patients with breast, colon, and ovarian cancer and those with cancer generally considered unresponsive to chemotherapy, such as pancreatic, hepatocellular, or renal-cell cancer or melanoma. Patients with types of cancer that are unresponsive to chemotherapy had shorter duration of chemotherapy use. Among patients who died of cancer, chemotherapy was used frequently in the last 3 months of life. The cancer's responsiveness to chemotherapy does not seem to influence whether dying patients receive chemotherapy at the end of life.

The dramatic growth in associations between investigators and industry has raised appropriate concern about financial conflicts of interest. Investigators are also faced with potent nonfinancial conflicts of interest. Because career advancement in academic medicine depends on grant awards and research publications, investigators have strong personal interests in the successful completion of their research studies, which often involve human subjects. In this essay, the author explores how nonfinancial interests of investigators can be at odds with the interests of research subjects and outlines an approach to better management of nonfinancial conflicts of interest. In 1963, before the advent of institutional review boards (IRBs), I was a young academic physician studying the regulation of sodium excretion by the kidneys. I paid medical students approximately $50 to serve as subjects for experiments involving only saline infusions and the collection of blood and spontaneously voided urine samples. I do not remember exactly what I told the students about the risks of the experiments but am quite certain that I characterized them as nominal. In one subject, severe phlebitis developed at the site of an intravenous infusion and required extensive therapy. The research project was funded by . . .

Although the maintenance of patients with end-stage renal disease on long-term dialysis is a triumph, the lifespan of dialysis patients remains abnormally short. Levinsky discusses the ways in which late evaluation of patients by nephrologists contribute to this high early mortality rate.

Since 1972, many victims of endstage renal disease (ESRD) have received treatment under a unique Medicare entitlement. This book presents a comprehensive analysis of the federal ESRD program: who uses it, how well it functions, and what improvements are needed.The book includes recommendations on patient eligibility, reimbursement, quality assessment, medical ethics, and research needs.Kidney Failure and the Federal Government offers a wealth of information on these and other topics:The ESRD patient population.Dialysis and transplantation providers.Issues of patient access and availability of treatment.Ethical issues related to treatment initiation and termination.Payment policies and their relationship to quality of care.This book will have a major impact on the future of the ESRD program and will be of interest to health policymakers, nephrologists and other individual providers, treatment site administrators, and researchers.

The transplantation of organs is a triumph of modern medicine. Life expectancy and the quality of life are greater with kidney transplantation than with maintenance dialysis. Successful liver and heart transplantations are lifesaving. However, the gap between the need for organs and their supply has widened progressively over the past decade. In 1999, 6448 people in the United States died while waiting for an organ transplant; 3088 of them were waiting for a kidney, and 1767 for a liver (United Network for Organ Sharing: unpublished data, May 6, 2000). These grim facts have led to growing pressure to increase the . . .

OBJECTIVE: To examine utilization and outcomes of intensive care unit (ICU) use for the elderly in the United States. DESIGN: We used 1992 data from the Health Care Financing Administration to examine ICU utilization and mortality by age and admission reason for hospitalizations of elderly Medicare beneficiaries. MAIN RESULTS: Use of the ICU was least likely for the oldest elderly overall (85+ years, 21.1% of admissions involved ICU; 75–84 years, 27.9%; 65–74 years, 29.7%), but more likely during surgical admissions. Eighty‐three percent of the Medicare patients who received intensive care survived at least 90 days. Of the oldest elderly, 74% survived. Even among the 10% most expensive ICU hospitalizations, 77% of all patients and 62% of those 85 years and older survived at least 90 days. CONCLUSIONS: The likelihood of ICU use among these elderly decreased with age, especially among those 85 years or older. Diagnostic mix importantly influenced ICU use by age. The great majority of the elderly, including those 85 years and older and those receiving the most expensive ICU care, survived at least 90 days.

Methods for advance medical planning were originally developed to ensure that patients' preferences would guide the nature and intensity of their future medical care. Increasingly, however, advance planning is viewed as a tool to limit care. For example, a study of the effects of advance directives on medical treatments and costs was performed, the authors said, with the “hope that executing the California Durable Power of Attorney for Health Care might provide a more ethical approach to reducing health care costs.” 1 Even when the purpose is not cost containment, there may be a philosophical emphasis on limiting, rather than maintaining, . . .

The Medicare End Stage Renal Disease (ESRD) Program began in 1973. Over the past 26 years, it has illustrated both the benefits of modern, high-technology medicine and the problems associated with it. Life of good quality has been extended for hundreds of thousands of people. However, the cost of the program has increased far beyond original estimates. In 1997, Medicare spent approximately $11.76 billion on the ESRD program, and total spending by all insurers was estimated to be about $15.64 billion. 1 The increase in cost came about mostly because long-term dialysis, originally intended for relatively young patients without systemic illnesses, . . .

We have examined the effects of 25 min of ischemia in the isolated erythrocyte-perfused rat kidney (IEPK). We have previously shown that, in this model, perfusate flow rate is close to blood flow rates in vivo and morphology is normal. The functional and morphological consequences of both warm ischemia (at 37°C) and ischemia induced during mild hypothermia (27°C) were compared. (1) Warm ischemia resulted in a 51% increase in renal vascular resistance (RVR) during the reflow period, while glomerular filtration rate (GFR) was reduced to 24% of control levels. (2) Kidneys subjected to warm ischemia showed marked morphological damage localized to the proximal tubule. There was dilatation of the proximal segments and widespread loss of the proximal brush border due both to shedding into the lumen and interiorization into the cell. In contrast to the proximal tubular damage, the cells of the medullary thick ascending limb segments were intact. However, the lumena of many of these segements were filled with cytoplasmic blebs and necrotic cell debris. There was also pronounced vascular congestion of the capillary plexus in the inner stripe of the outer medulla. (3) Hypothermia to 27°C resulted in almost complete protection against ischemic injury: RVR and GFR were not different from control values. Also, kidneys subjected to cold ischemia showed only isolated areas of mild brush border damage; no evidence of tubular obstruction or vascular congestion was present. (4) Thus, warm ischemia in the IEPK results in functional and morphological effects comparable to those found in vivo. Post-ischemic vasoconstriction as well as medullary congestion occur in the absence of systemic hormones and renal nerves. These consequences of ischemia are prevented by modest hypothermia.

National attention is currently focused on the organization of medical care in the United States. Competing groups with different ideas about reorganizing health care advance views based on socioeconomic hypotheses and evaluations of health care systems in other countries. The participants in the debate about the reorganization of U.S. health care have taken little notice of the experience with existing health care systems organized by our government. The Medicare program that provides treatment for patients with end-stage renal disease (ESRD) is 20 years old; recently, it has been the subject of extensive review and analysis 1 . Over the past 20 . . .