Overriding Psychiatric Advance Directives: Factors Associated with Psychiatrists' Decisions to Preempt Patients' Advance Refusal of Hospitalization and Medication

Psychiatric advance directives (PADs) are intended to support patients' treatment decisions during a crisis. However, PAD statutes give clinicians broad discretion over whether to carry out patients' advance instructions. This study uses data from a survey of psychiatrists (N=164) to examine reasons for overriding PADs. In response to a hypothetical vignette, 47% of psychiatrists indicated that they would override a valid, competently-executed PAD that refused hospitalization and medication. PAD override was more likely among psychiatrists who worked in hospital emergency departments; those who were concerned about patients' violence risk and lack of insight; and those who were legally defensive. PAD override was less likely among participants who believed that involuntary treatment is largely unnecessary in a high-quality mental health system.     

Cardiac rupture in acute myocardial infarction: a reassessment

Cardiac rupture as a complication of acute myocardial infarction (AMI) has been described as occurring infrequently. Because of the recent dramatic decrease in autopsy rates, the authors believe that current studies do not accurately represent the frequency of this catastrophic complication. Autopsy protocols and archived histologic slides of patients with AMI were retrospectively reviewed to determine whether the frequency of cardiac rupture, as a complication of AMI, is altered when a non-hospital-based patient cohort after autopsy is evaluated. This review yielded 153 cases of 41 women and 112 men, whose postmortem examinations revealed gross and histologic evidence of AMI. Cardiac rupture was present in 30.7% of these cases. Of the 47 patients with rupture, 35 had no relevant medical history. The remaining 12 patients had various medical conditions. None of the patients in the rupture group had previously treated symptoms related to coronary artery conditions. Whereas women constituted 26.8% of the total AMI group, they had a cardiac rupture rate of 61%. By contrast, men with AMI had a cardiac rupture rate of 19.6%. All patients in the cardiac rupture group had heart weights over the predicted expected weight as a function of body weight. Age, gender, and heart weight were significant factors associated with cardiac rupture, whereas body mass index was not significantly related. When these factors were evaluated jointly, age was a significant explanatory factor for rupture among both men and women, whereas body mass index and heart weight were significant for men but not for women. When the rupture sites occurred on the left ventricular myocardium, the anterior wall was affected in 21 cases (45%), the posterior wall in 18 (38%), the lateral wall in 4 (9%), and the apex in 3 (6%). The right ventricular myocardium ruptured in 1 case (2%). Most of the patients had severe multivessel coronary artery disease. Histologic study of the specimens showed that the majority of ruptures occurred between 24 and 72 hours after myocardial infarction. This study showed a frequency of cardiac rupture of 30.7% in patients with AMI and sudden death according to medical examiner's records. These findings confirm and reinforce the importance of postmortem examination and autopsy as an adjunct to clinical medical practice.     

Developmental patterns of sex differences in delinquency among African American adolescents: A test of the sex-invariance hypothesis

This paper addresses a developmental issue concerning longitudinal patterns of sex differences in delinquency. Hirschi and Gottfredson argue that the age-delinquency relation is invariant across sex and that sex differences in delinquency are invariant over time as well. A combination of these two propositions generates a hypothesis, called here the sex-invariance hypothesis, that sex differences in delinquency are invariant over developmental stages of adolescents. To test the sex-invariance hypothesis, nine waves of panel data collected from a representative urban sample of African American adolescents are analyzed. The overall findings show that sex differences in delinquency tend to vary as the subjects grow older, rather than remain constant as the invariance thesis posits. Specifically, sex differences in delinquency peak at the age of 15 and thereafter declines with age. We also find that parental supervision significantly explains sex differences in delinquency for younger adolescence, but not for older adolescence.     

The President's Commission to Study Capital Budgeting: An Interim Review

The President's Commission to Study Capital Budgeting is slated to complete its report by year-end 1998. Even though it would be premature to try to anticipate the Commission's recommendations, it is already clear that the Commission will contribute significantly to the capital budgeting debate by casting the concept of capital budgeting broadly, as a systematic decision process, rather than merely a budget accounting or scoring convention or a government financing alternative to the balanced budget rule. This article summarizes some of the analytical accomplishments of the Commission at the mid-point of its expected life.     

Research utilization in policymaking: A tale of two series (of social experiments)

This paper is an exploratory attempt to view the role that social experiments in general, and the income maintenance experiments and work/welfare demonstrations in particular, have played in the policy process through the lens provided by the knowledge utilization literature. In addition to suggesting that the decision to conduct a social experiment is rarely, if ever, made according to an essentially rational paradigm, this framework helps highlight the range of uses to which findings from social experiments can be put and the circumstances under which various types of uses are more or less likely. Specifically, the knowledge utilization literature suggests that rather than having the dramatic, decisive effects on policy choices that their promoters have often envisioned, social experiments are more likely to affect policy in a variety of subtle ways.     

USING LINEAR TREND MODELS TO ANALYZE POLICY IMPACT

Policy researchers have become increasingly familiar with a number of improved techniques for analyzing data obtained from interrupted time-series designs for evaluating public programs and policies. In this paper we contribute to this trend by presenting two groups of data analysis techniques which are not currently widely used by policy researchers, but are likely to be valuable adjuncts to traditional regression techniques for analyzing data obtained from interrupted time-series designs. First, aids for model specification are presented that enable the analyst to define an appropriate linear trend model—often one which will reduce the degree of multicollinearity and, therefore, produce more precise estimates of the impacts of a public program or policy. Next we consider approaches for point estimation and joint (simultaneous) interval estimation of a policy intervention's total effect at various points in time.     

Calcium and Phosphorus Detection Using Benchtop Versus Handheld X‐ray Fluorescence Spectrometers

Elemental analysis of calcium (Ca) and phosphorus (P) has been shown to be useful in differentiating skeletal and nonskeletal material. X‐ray fluorescence spectrometry (XRF) is an attractive, nondestructive technique for forensic anthropologists, and the development of portable XRF instrumentation is promising for field applications. This study examines the performance of handheld XRF instrumentation operated in air compared to a traditional benchtop XRF device that has the ability to control the analysis atmosphere. Both instruments can be used to effectively distinguish skeletal from nonskeletal remains. However, as the measurement atmosphere affects detection levels for calcium and phosphorus, Ca/P ratios obtained from the instruments and analysis conditions were found to differ significantly, with analyses conducted in air showing significantly lower phosphorus detection. Consequently, comparison of Ca/P ratios to conclude skeletal versus nonskeletal origin must be based on data collected under similar analysis conditions.