Center, Denver, CO PURPOSE: Among patients with hypoxemic chronic obstructive pulmonary disease (COPD), supplemental oxygen provides significant physical and cognitive benefits. Despite these benefits to therapy, no trial has demonstrated an improvement in subjective quality of life and patient adherence to therapy is low. The purpose of this study was to describe the experience of using supplemental oxygen therapy to identify barriers to its use and aid in improving adherence to therapy and quality of life among oxygen users. METHODS: 27 participants with hypoxemic COPD underwent semi-structured interviews to explore their experiences with supplemental oxygen therapy. Interviews were taped, transcribed, and analyzed for thematic content in a manner informed by grounded theory. RESULTS: The most commonly described barrier to oxygen use among participants was a fear of dependency. Two metaphors were used to describe this fear: crutches and addiction. As described by participants, a crutch was an external device or a behavior used to compensate for some weakness. Achievements and activities accomplished while using a crutch were considered tainted and illegitimate. Subjects feared that using a crutch made them more dependent on the crutch and less able to function without it. They feared that accepting dependency on a crutch was accepting a lesser state of being and a sign of moral weakness. Respondents described addiction as dependency on some substance used to illegitimately induce a sense of well-being or to reduce physical or psychic discomfort. Oxygen was likened to alcohol, psychotropic prescription medications, and illicit drugs. Participants equated using oxygen to relieve breathlessness with using alcohol or other drugs to alleviate psychic or physical discomfort. They feared that their need for oxygen would increase if they allowed themselves to become dependent on it and they considered using a substance to relieve their symptoms a sign of moral weakness. CONCLUSION: Fear of dependency is a significant barrier to oxygen use among patients who will benefit from supplemental oxygen therapy. In many patients, improving adherence to oxygen therapy may require exploring the metaphors of crutches and addiction with patients to help them see the flaws in these analogies. PURPOSE: The current procedures for procuring tissues and organs for donation have resulted in both organ and tissue shortages and general dissatisfaction with the current system. A new system for allowing individuals to delineate the treatment of their organs and tissues after death could improve donation and assure patient autonomy. METHODS: We reviewed and analyzed current research and opinions on upholding the wishes of patients regarding the treatment of the body after death. This included a review of literature regarding advance directives, organ and tissue donation, and burial preferences. RESULTS: It has been shown that for psychological health, individuals need to believe that they can decide what will happen to their bodies after their deaths. Many proposed systems for the procurement of organs and tissues for donation, including both presumed consent and the requirement of familial consent, directly or indirectly deprive the individual of control over the fate of his or her body after death. In addition, the fear caused by misconceptions regarding organ donation leads otherwise willing people to refuse to donate their own or their relatives' organs. CONCLUSION: In order to improve the current system of organ and tissue procurement, we propose the concept of the``Dying Will,'' a legal document in which an individual may delineate his or her wishes regarding organ and tissue donation, funeral procedures, and the like. In order to alleviate the fears of the individual, physicians could be responsible for helping their patients to write their dying wills. This might increase the number of individuals willing to donate their organs or tissues. In addition, with such a system, the permission of family members would be unnecessary for organ donation. This could further increase the number of available donors and prevent family members from overriding the wishes of the deceased. To expedite the transferal of dying will information to medical personnel, computerized databases such as the one recently initiated by Medic Alert could be used. PURPOSE: Since the beginning of the practice of medicine, family members have played a role in the treatment of a patient. Although this role has traditionally been limited to providing emotional support, loved ones can also become directly involved in doctor-patient communication or in the medical treatment of a patient. But there may be detriment to patient care due to the involvement of friends or family. METHODS: We reviewed and analyzed both literary and scholarly opinion on the role of the family in the practice of medicine. RESULTS: Family members have been described as both helping and hurting the quality of care received by patients. They can provide health care in the home, especially for chronically or terminally ill patients, often facing emotionally or technically trying situations. When a patient is mentally or emotionally compromised, a loved one can speak on the patient's behalf. But this kind of involvement can easily be detrimental to the patient if a friend or relative tries to control the patient or makes decisions based on his or her own values rather than on those of the patient. CONCLUSION: Friends and relatives can help a patient receive the best care possible; but when these individuals have selfish motivations or feel the need to control their loved one, they can do more harm than good. Physicians should take steps to encourage positive family participation while preventing this involvement from interfering in the patient's care. The physician must be able to tell whether a friend or relative is truly helping the patient or merely acting in his or her own interests. In addition, efforts should be made to contact supportive friends or family members for patients. When no loved one is available, a nurse, social worker, or appointed guardian could play the part of a third party in the doctor ± patient relationship. As indicated by the literature, the doctor ± patient relationship can greatly benefit from the involvement of a patient advocate. University of Michigan, Ann Arbor, MI PURPOSE: Physicians may occasionally encounter an ethical dilemma about whether to protect the rights of an individual patient, versus acting in the interests of society. When physicians act on the behest of society, such as in cases of impaired airline pilots, it is usually on the basis of legal imperatives or clearly stated normative guidelines. However, there may be cases where no such guidelines exist, or those in which physicians act to help society despite professional values to the contrary. We examine these situations. METHODS: We have conducted several studies in which physicians were asked about hypothetical dilemmas involving the potential for harm to the society, but in which there are no clear guidelines; or in which guidelines state that physicians should not act in behest of the society due to harm to the individual. These cases involve the report of a past crime by the patient, the issue of patient-initiated health insurance fraud, and the issue of physician involvement in lethal injection for capital punishment. We also conducted a literature review on this subject. RESULTS: A number of physicians in each of these studies would be willing to act on behalf of society and against the individual patient despite no clear normative values or those actually contrary to the physicians' decisions. When analyzed for the factors being most likely to influence the respondents, duty to society and the values of the overall population were most associated with the decision to act on behalf of society rather than in the interest of the individual patient. CONCLUSION: In some settings, a number of physicians are willing to act on behalf of society rather than on behalf of the patient. In such circumstances, physicians rely on their personal and societal values, rather on those promulgated within the medical profession. Some of these decisions may actually be harmful to the patient, and therefore contrary to ethical guidelines established by the medical profession. The impact of societal values on physician decision making needs further exploration.