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DOES KNOWLEDGE OF ETHICS AND END‐OF‐LIFE ISSUES INFORM CHOICES IN ADVANCE CARE PLANNING SCENARIOS?

although it is thought to result from lymphatic obstruction caused by local inflammation and the sclerosing action of injected drugs. Repeated lymphatic injury and destruction from long-standing intravenous injections eventually lead to protein extravasation and fibrotic replacement of subcutaneous tissue, resulting in the puffy hand. Patients typically present with bilateral swollen hands with loss of the surface anatomy of the dorsal veins and extensor tendons. The edema, which becomes permanent after a year of repeated injections, is primarily localized to the proximal segments of the fingers up to the wrist. This edema does not impair the function of the hand, is nonpitting, and is unaffected by elevation. The differential diagnosis of the puffy hand syndrome includes infection, venous or lymphatic obstruction, vessel harvesting for vascular or coronary artery bypass graft surgery, congestive heart failure, nephrotic syndrome, and cirrhosis. Except for lymphatic obstruction causing brawny edema, these conditions can be distinguished by their systemic manifestations and characteristic pitting edema. Most reports of puffy-hand syndrome in the literature concern a younger population, but as the generation from the 1960s and 1970s (the peak of the intravenous drug use epidemic in the United States) ages, the puffy hand is becoming increasingly identified in geriatric patients. As demonstrated by this case, the puffy hand may be the only telltale sign of prior drug use. Unfortunately, physicians may neglect to address prior drug use with elderly patients, and these patients may also be reluctant to share such information with their physicians. This may result in missing the diagnosis of hepatitis C in an at-risk population. (As many as 75% of intravenous drug users may be seropositive for hepatitis C, with the majority presenting with chronic infection.) Because of the ascendancy of hepatitis C as the most common cause of end-stage liver disease requiring transplant in the United States, we suggest that a new physical finding be added to the lexicon of the stigmata of chronic liver disease. This updated version of the ‘‘puffy-hand sign’’ should be called ‘‘hepatitis-C hands’’ to underscore linkage of the diagnostic sign with the etiologic agent. Thus the remote history of injection drug use could be more closely associated with the present day diagnosis of chronic hepatitis C.