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Skolarus LE, Lin CC, Kelley AS, Burke JF. National End-of-Life-Treatment Preferences are Stable Over Time: National Health and Aging Trends Study. J Pain Symptom Manage 2022; 64:e189-e194. [PMID: 35764201 DOI: 10.1016/j.jpainsymman.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/21/2022]
Abstract
CONTEXT Advance Care Planning is a process of understanding and sharing preferences regarding future medical care. OBJECTIVE To explore individual and national stability of end-of-life treatment preferences among a sample of older adults. METHODS National Health and Aging Trends Study is a nationally representative sample of older adults. In 2012, a random sample, and in 2018, the entire sample were queried on end-of-life treatment preferences defined as acceptance or rejection of life prolonging treatment (LPT) if they had a serious illness and were at the end of their life and in severe pain or had severe disability. Using a cohort design, we explored individual trends in preferences for LPT among those with responses in both waves (pain scenario: N = 606, disability scenario: N = 628) and, using a serial cross-sectional design, national trends in LPT among the entire sample (1702 older adults in wave 2 and 4342 in wave 8). RESULTS In the cohort study, individual preferences were stable over time (overall percent agreement = 86% for disability and 76% for pain scenarios), particularly for older adults who would reject LPT in wave 2 (overall agreement 92% for disability and 86% for pain). In the serial cross-sectional study, national trends in preferences for receipt of LPT were stable over time in the pain (27.4% vs. 27.0%, P = 0.80) and disability (15.8% vs. 15.7%, P = 0.99) scenarios. CONCLUSIONS We found that national trends in preferences for end-of-life treatment did not substantially change over time and may be stable within individual older adults.
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Affiliation(s)
- Lesli E Skolarus
- Department of Neurology (L.E.S., C.C.L.), Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan, USA.
| | - Chun Chieh Lin
- Department of Neurology (L.E.S., C.C.L.), Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine (A.S.K.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J Peters VA Medical Center (A.S.K.), Bronx, New York, USA
| | - James F Burke
- Department of Neurology (J.F.B.), Health Services Research Program, Ohio State University, Columbus, Ohio, USA
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Dowson L, Friedman ND, Marshall C, Stuart RL, Buising K, Rajkhowa A, Gotterson F, Kong DC. Antimicrobial stewardship near the end of life in aged care homes. Am J Infect Control 2020; 48:688-694. [PMID: 31806238 DOI: 10.1016/j.ajic.2019.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The objective of this study was to understand how aged care home health professionals perceive antimicrobial use near the end of life and how they perceive potential antimicrobial stewardship activities near the end of life in aged care homes. METHODS Qualitative semi-structured interviews were undertaken with general practitioners, nurses, and pharmacists who provide routine care in aged care homes in Victoria, Australia. Interviews were coded using frameworks for understanding behavior change. RESULTS Themes were established within 14 interviews, and an additional 6 interviews were undertaken to ensure thematic saturation. Two major themes emerged: (i) Antimicrobial stewardship activities near the end of life in aged care homes need to enable aged care home nurses to make decisions substantiated by evidence-based clinical knowledge. Antimicrobial stewardship should clearly be part of an aged care home nurse's role, and accreditation standards provide powerful motivation for behavior change. (ii) Antimicrobial stewardship activities near the end of life in aged care homes must address family confidence in resident wellbeing. Antimicrobial stewardship activities should be inclusive of family involvement, and messages should highlight the point that antimicrobial stewardship improves care. CONCLUSIONS Antimicrobial stewardship activities that reinforce evidence-based clinical decision-making by aged care home nurses and address family confidence in resident wellbeing are required near the end of life in aged care homes. Accreditation standards are important motivators for behavior change in aged care homes.
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Dowson L, Friedman ND, Marshall C, Stuart RL, Buising K, Rajkhowa A, Gotterson F, Kong DCM. The role of nurses in antimicrobial stewardship near the end of life in aged-care homes: A qualitative study. Int J Nurs Stud 2019; 104:103502. [PMID: 32086026 DOI: 10.1016/j.ijnurstu.2019.103502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 11/29/2019] [Accepted: 12/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The excessive use of antimicrobials in aged-care homes is a widely recognised phenomenon. This is problematic because it can harm residents, and is detrimental to public health. Residents in the final month of life are increasingly likely to be prescribed an antimicrobial, commonly without having signs and symptoms of infection that support antimicrobial use. OBJECTIVES We aimed to describe the perspectives of health professionals on antimicrobial use near the end of life in aged-care homes and investigate the potential opportunities for nurses to undertake antimicrobial stewardship activities near the end of life in aged-care homes. DESIGN One-on-one, semi-structured, qualitative interviews. SETTINGS AND PARTICIPANTS Twelve nurses, six general practitioners and two pharmacists providing routine care to residents of aged-care homes in Victoria, Australia were interviewed. Diversity in terms of years of experience, aged-care funding type (government, private-for-profits and not-for-profits) and location (metropolitan and regional) were sought. METHODS Interviews were transcribed and open coded in a descriptive manner using validated frameworks for understanding behaviour change. The descriptive code was then used to build an interpretive code structure based on questions founded in grounded theory. RESULTS Thematic saturation was reached after fourteen interviews, and an additional six interviews were conducted to ensure emergent themes were consistent and definitive. There are opportunities for aged-care home nurses to undertake antimicrobial stewardship activities near the end of life in the provision of routine care. Aged-care home nurses are influential in antimicrobial decisions near the end of life in routine care because of their leadership in advance care planning, care co-ordination and care provision in an environment with stopgap and visiting medical resources. Nurses also have social influence among residents, families and medical professionals during critical conversations near the end of life. Past negative social interactions within the aged-care home environment between nurses and families can result in 'fear-based' social influences on antimicrobial prescribing. CONCLUSIONS The work of facilitating advance care planning, care coordination, care delivery, and communicating with families and medical professionals provide important opportunities for aged-care home nurses to lead appropriate antimicrobial stewardship activities near the end of life.
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Affiliation(s)
- Leslie Dowson
- National Centre for Antimicrobial Stewardship at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia; Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia
| | - N Deborah Friedman
- National Centre for Antimicrobial Stewardship at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia; School of Medicine, Deakin University, 75 Pigdons Rd, Geelong, Victoria 3216, Australia; Department of General Medicine and Department of Infectious Diseases, Barwon Health, Ryrie St and Bellerine St, Geelong, Victoria 3220, Australia
| | - Caroline Marshall
- National Centre for Antimicrobial Stewardship at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia; Department of Medicine, Building 181, University of Melbourne, Grattan St, Melbourne, Victoria 3010, Australia; Victorian Infectious Diseases Service at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia; Infection Prevention and Surveillance Service, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria 3052, Australia
| | - Rhonda L Stuart
- National Centre for Antimicrobial Stewardship at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia; Department of Medicine, School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria 3800, Australia; Monash Infectious Diseases and Infection Control and Epidemiology, Monash Health, 246 Clayton Rd, Clayton, Victoria 3168, Australia
| | - Kirsty Buising
- National Centre for Antimicrobial Stewardship at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia; Department of Medicine, Building 181, University of Melbourne, Grattan St, Melbourne, Victoria 3010, Australia; Victorian Infectious Diseases Service at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia
| | - Arjun Rajkhowa
- National Centre for Antimicrobial Stewardship at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia
| | - Fiona Gotterson
- National Centre for Antimicrobial Stewardship at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia; Department of Medicine, Building 181, University of Melbourne, Grattan St, Melbourne, Victoria 3010, Australia
| | - David C M Kong
- National Centre for Antimicrobial Stewardship at The Peter Doherty Institute for Infections and Immunity, 792 Elizabeth St, Melbourne, Victoria 3000, Australia; Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, 381 Royal Parade, Parkville, Victoria 3052, Australia; Pharmacy Department, Ballarat Health Services, 1 Drummond St N, Ballarat, Victoria 3350, Australia.
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Impact of brief education on healthy seniors' attitudes and healthcare choices about Alzheimer's disease and associated symptoms. Int Psychogeriatr 2018; 30:1889-1897. [PMID: 29720286 DOI: 10.1017/s1041610218000479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED ABSTRACTObjective:The primary objective of this study was to determine whether a brief education session about Alzheimer's disease (AD) stages and associated behavioral and psychological symptoms of dementia (BPSD) changes healthy seniors' treatment choices. A secondary objective was to determine whether pharmacotherapy to reduce BPSD would be preferred over other potentially more restrictive interventions. METHODS Participants (n = 32; 8 men; aged > 64years; no self-reported dementia diagnosis) were assigned to one of ten group sessions during which they received information about AD and BPSD. Our a-priori hypotheses were: (1) education about AD stages significantly changes care preferences in moderate and severe stages, i.e. less active treatment options (no CPR/hospitalization) are chosen as the disease progresses; and (2) most participants prefer pharmacotherapy over restraints and seclusion to manage BPSD. The main outcome measure was a change in the interventions chosen including CPR and hospitalization. Participants completed three questionnaires and two decisional grids before and after the information session. Qualitative data were derived from discussions during the session. RESULTS Participants expressed a wide range of attitudes about AD, BPSD, and their management. Those who are born in Canada, had a proxy, and a university education, each have around half of the odds of receiving treatment compared to those in the complementary group. (OR 0.47, 0.40, 0.43) Finally, not knowing someone with AD increases the odds of wanting a treatment by around six times (OR 6.4). Pharmacological measures were preferred over restraints. CONCLUSIONS Education about dementia and advance directives should consider the person's educational background and experience with dementia. Discussing BPSD may impact a person's advance directives and preferences.
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Gil E, Agmon M, Hirsch A, Ziv M, Zisberg A. Dilemmas for guardians of advanced dementia patients regarding tube feeding. Age Ageing 2018; 47:138-143. [PMID: 29040344 DOI: 10.1093/ageing/afx161] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 09/23/2017] [Indexed: 02/03/2023] Open
Abstract
Background advanced dementia is an incurable illness, its last stage marked by inability to eat. Tube feeding was deemed a helpful solution at this stage, but in recent years its inefficiency has been proved, and it is no longer practiced in many countries around the world. In Israel, however, the procedure is still accepted. In the gastroenterology department at the Bnai Zion Medical Center, a serious interaction is ongoing with patients' legal guardians, where detailed information is given about the inefficiency of the tube procedure. Nevertheless, the great majority of guardians choose to have it performed. Purpose to probe the considerations underlying the decision for gastrostomy, despite the data and the recommendations. Method qualitative research, including participant observation at the clinic and in-depth interviews with guardians. Findings the families of most patients did not discuss end-of-life issues with them. The overwhelming preference for using the technology was interpreted as life-saving, in contrast to comfort feeding, which was deemed euthanasia. The reasons given for the decision to tube feed were drawn from a range of outlooks: religion, the patient's earlier survival capacity, and pragmatic considerations involving relations with nursing home staff. Conclusion study of the decision-making process of advanced dementia patients' guardians sheds light on the layers of meaning of the Israeli discourse regarding end-of-life issues.
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Affiliation(s)
- Efrat Gil
- Geriatric Unit, Bnai Zion MC, Haifa, Israel
- Technion Israel Institute of Technology Ruth and Bruce Rappaport Faculty of Medicine, Haifa, Israel
| | - Maayan Agmon
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Ayal Hirsch
- Gastroenterology Institute, Bnai Zion MC, Haifa, Israel
| | - Miriam Ziv
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Anna Zisberg
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
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Bravo G, Rodrigue C, Thériault V, Arcand M, Downie J, Dubois MF, Kaasalainen S, Hertogh CM, Pautex S, Van den Block L. Should Medical Assistance in Dying Be Extended to Incompetent Patients With Dementia? Research Protocol of a Survey Among Four Groups of Stakeholders From Quebec, Canada. JMIR Res Protoc 2017; 6:e208. [PMID: 29133281 PMCID: PMC5703982 DOI: 10.2196/resprot.8118] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/01/2017] [Accepted: 09/06/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Alzheimer's disease and related disorders affect a growing number of people worldwide. Quality of life is generally good in the early stages of these diseases. However, many individuals fear living through the advanced stages. Such fears are triggering requests for medical assistance in dying (MAiD) by patients with dementia. Legislation was recently passed in Canada and the province of Quebec allowing MAiD at the explicit request of a patient who meets a set of eligibility criteria, including competence. Some commentators have argued that MAiD should be accessible to incompetent patients as well, provided appropriate safeguards are in place. Governments of both Quebec and Canada are currently considering whether MAiD should be accessible through written requests made in advance of loss of capacity. OBJECTIVE Aimed at informing the societal debate on this sensitive issue, this study will compare stakeholders' attitudes towards expanding MAiD to incompetent patients with dementia, the beliefs underlying stakeholders' attitudes on this issue, and the value they attach to proposed safeguards. This paper describes the study protocol. METHODS Data will be collected via a questionnaire mailed to random samples of community-dwelling seniors, relatives of persons with dementia, physicians, and nurses, all residing in Quebec (targeted sample size of 385 per group). Participants will be recruited through the provincial health insurance database, Alzheimer Societies, and professional associations. Attitudes towards MAiD for incompetent patients with dementia will be elicited through clinical vignettes featuring a patient with Alzheimer's disease for whom MAiD is considered towards the end of the disease trajectory. Vignettes specify the source of the request (from the patient through an advance request or from the patient's substitute decision-maker), manifestations of suffering, and how close the patient is to death. Arguments for or against MAiD are used to elicit the beliefs underlying respondents' attitudes. RESULTS The survey was launched in September 2016 and is still ongoing. At the time of submission, over 850 respondents have returned the questionnaire, mostly via mail. CONCLUSIONS This study will be the first in Canada to directly compare views on MAiD for incompetent patients with dementia across key stakeholder groups. Our findings will contribute valuable data upon which to base further debate about whether MAiD should be accessible to incompetent patients with dementia, and if so, under what conditions.
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Affiliation(s)
- Gina Bravo
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
- Faculty of Medicine and Health Sciences, Community Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Claudie Rodrigue
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
| | - Vincent Thériault
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
| | - Marcel Arcand
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
- Faculty of Medicine and Health Sciences, Family Medicine, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Jocelyn Downie
- Schulich School of Law, Dalhousie University, Halifax, NS, Canada
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Marie-France Dubois
- Research Centre on Aging, University Institute of Geriatrics of Sherbrooke, Sherbrooke, QC, Canada
- Faculty of Medicine and Health Sciences, Community Health Sciences, University of Sherbrooke, Sherbrooke, QC, Canada
| | | | - Cees M Hertogh
- EMGO+ Institute for Health and Care Research, General Practice & Elderly Care Medicine, Vrije Universiteit Medical Center, Amsterdam, Netherlands
| | - Sophie Pautex
- Geneva University Hospital, Community Medicine and Primary Care, Geneva, Switzerland
| | - Lieve Van den Block
- Vrije Universiteit Brussel, UGhent End-of-Life Care Research Group, Brussels, Belgium
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Harrison Dening K, King M, Jones L, Vickestaff V, Sampson EL. Advance Care Planning in Dementia: Do Family Carers Know the Treatment Preferences of People with Early Dementia? PLoS One 2016; 11:e0159056. [PMID: 27410259 PMCID: PMC4943594 DOI: 10.1371/journal.pone.0159056] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/27/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND AIMS When a person with dementia (PWD) has lost the ability to make treatment decisions, clinicians often rely on family carers to know and articulate these preferences with assumed accuracy. This study used the Life Support Preferences Questionnaire (LSPQ) to explore whether family carers' choices show agreement with the end of life care preferences of the person with dementia for whom they care and what factors influence this. METHODS A cross-sectional study interviewing 60 dyads (a person with early dementia and preserved capacity and their family carer) each completing a modified LSPQ. We assessed how closely carers' choices resembled the PWD's preferences for treatment in three proposed health states: the here and now; severe stroke with coma; terminal cancer. Agreement between the PWD and their family carer responses was assessed using Kappa and Prevalence-Adjusted Bias-Adjusted Kappa (PABAK) statistics. We examined whether carer burden and distress, and relationship quality, influenced agreement. RESULTS In interviews PWD were able to indicate their treatment preferences across all three scenarios. In the here-and-now most wanted antibiotics (98%), fewer cardio-pulmonary resuscitation (CPR) (50%) and tube feeding (47%). In severe stroke and coma antibiotics remained the more preferred treatment (88%), followed by CPR (57%) and tube feeding (30%). In advanced cancer PWD expressed lower preferences for all treatments (antibiotics 68%; CPR 50%; tube feeding 37%). Carers' choices were similar to the PWDs' preferences in the here-and-now (71% (k = 0.03; PABAK = 0.4) with less agreement for future hypothetical health states. In severe stroke and coma carers tended wrongly to suggest that the PWD preferred more intervention (antibiotic, 67%; k = -0.022; PABAK = -0.60; CPR, 73%; k = 0.20; PABAK = -0.20, tube feeding, 66%; k = 0.25; PABAK = -0.12). In advanced cancer the agreement between PWD and carers was low (antibiotics; k = -0.03; PABAK = -0.52; CPR, k = -0.07; PABAK = -0.45; tube feeding; k = 0.20; PABAK = -0.22). However, both PWD and carers showed marked uncertainty about their preferences for end of life treatment choices. Relationship quality, carer distress and burden had no influence on agreement. CONCLUSIONS This study is the first to have used the LSPQ with PWD in the UK to consider treatment options in hypothetical illness scenarios. Key finding are that family carers had a low to moderate agreement with PWD on preferences for end of life treatment. This underscores how planning for care at the end of life is beset with uncertainty, even when the carer and PWD perceive the care-giving/receiving relationship is good. Families affected by dementia may benefit from early and ongoing practical and emotional support to prepare for potential changes and aid decision making in the context of the realities of care towards the end of life.
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Affiliation(s)
| | - Michael King
- Division of Psychiatry, Faculty of Brain Sciences, UCL, Maple House, London, United Kingdom
| | - Louise Jones
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, 6th Floor, Maple House, London, United Kingdom
| | - Victoria Vickestaff
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, 6th Floor, Maple House, London, United Kingdom
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, 6th Floor, Maple House, London, United Kingdom
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Abstract
BACKGROUND Infections frequently occur in patients with dementia and antibiotics are often prescribed, but may also be withheld. OBJECTIVES The aim of this systematic review is to provide a systematic overview of the prevalence of antibiotic use, and factors associated with prescribing antibiotics in patients with dementia. DATA SOURCES A systematic search of MEDLINE, EMBASE, PSYCINFO, CINAHL, and the Cochrane library databases until February 13, 2014 was performed, using both controlled terms and free-text terms. RESULTS Thirty-seven articles were included. The point prevalence of antibiotic use in patients with dementia ranged from 3.3 to 16.6%. The period prevalence ranged from 4.4 to 88% overall, and from 23.5 to 94% in variable time frames before death; the median use was 52% (median period 14 days) and 48% (median period 22 days), respectively. Most patients with lower respiratory tract infections or urinary tract infections (77-91%) received antibiotic treatment. Factors associated with antibiotic use related to patients, families, physicians, and the healthcare context. More severe dementia and a poor prognosis were associated with less antibiotic use in various countries. Associations with aspiration and illness severity differed by country. CONCLUSIONS AND IMPLICATIONS Antibiotic use in patients with dementia is substantial, and probably highly associated with the particular healthcare context. Future studies may report antibiotic use by infection type and stage of dementia, and compare cross-nationally.
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Abstract
Dementia raises many ethical issues. The present review, taking note of the fact that the stages of dementia raise distinct ethical issues, focuses on three issues associated with stages of dementia's progression: (1) how the emergence of preclinical and asymptomatic but at-risk categories for dementia creates complex questions about preventive measures, risk disclosure, and protection from stigma and discrimination; (2) how despite efforts at dementia prevention, important research continues to investigate ways to alleviate clinical dementia's symptoms, and requires additional human subjects protections to ethically enroll persons with dementia; and (3) how in spite of research and prevention efforts, persons continue to need to live with dementia. This review highlights two major themes. First is how expanding the boundaries of dementias such as Alzheimer's to include asymptomatic but at-risk persons generate new ethical questions. One promising way to address these questions is to take an integrated approach to dementia ethics, which can include incorporating ethics-related data collection into the design of a dementia research study itself. Second is the interdisciplinary nature of ethical questions related to dementia, from health policy questions about insurance coverage for long-term care to political questions about voting, driving, and other civic rights and privileges to economic questions about balancing an employer's right to a safe and productive workforce with an employee's rights to avoid discrimination on the basis of their dementia risk. The review highlights these themes and emerging ethical issues in dementia.
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Limitation of care orders in patients with a diagnosis of dementia. Resuscitation 2015; 98:118-24. [PMID: 25818706 DOI: 10.1016/j.resuscitation.2015.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/11/2015] [Accepted: 03/16/2015] [Indexed: 11/22/2022]
Abstract
The prevalence of dementia is growing with an ageing population. Most persons with dementia die of acute illness and many are hospitalised at the end of life. In the acute hospital setting, limitation of care orders (LCOs) such as Do Not Attempt CPR and Physician Orders For Life Sustaining Treatment (POLST), appear to be underused in patients with dementia. These patients receive the same aggressive life-prolonging therapies as any other patient, despite drastically higher mortality. However, limitation of care orders in patients with dementia is not addressed by current guidelines or policies. Systems and processes for obtaining and documenting LCO need improvement at the individual, organisational and societal level. The issue is controversial amongst the public and poorly understood by clinicians. Balanced and empathetic decision-making requires an individualised approach and recognition of the complexities (legal, ethical and clinical) of this issue. We examine the domains of: (a) treatment effectiveness, (b) burden of care and quality of life and (c) patient autonomy and capacity.
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Affiliation(s)
- Antoine Leuzy
- McGill Centre for Studies in Aging, Douglas Mental Health University Institute, Montreal, QC, Canada.
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Cardin F. Special considerations for endoscopists on PEG indications in older patients. ISRN GASTROENTEROLOGY 2012; 2012:607149. [PMID: 23227352 PMCID: PMC3512294 DOI: 10.5402/2012/607149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 10/31/2012] [Indexed: 01/29/2023]
Abstract
Undernutrition in frail elderly people is a pathological condition that needs to be recognized and addressed early. Neurological dysphagia is among the most frequent causes of this condition in the elderly but should be considered a terminal event in Alzheimer-type dementias. Tube feeding is an important resource for facilitating metabolic recovery in cachectic patients and is particularly successful in "bridging" and stabilizing therapies prior to major treatment able to cure the patient. Clinical management of tube feeding in "incurable" conditions is complex and becomes part of the palliative care and comfort provided in the terminal stages of illness. Non-specialized physicians are often unfamiliar with the theory and practice of end-of-life interventions, and the resulting decisions are in many cases actually contrary to patient comfort. These problems deserve to be more carefully addressed when the patient is unable to cooperate or express his/her preferences and needs. The success of percutaneous endoscopic gastrostomy has led to increasingly frequent referrals for placement in critically ill elderly patients. Endoscopists therefore become a key figure in stimulating rational, correct treatment of these patients.
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Affiliation(s)
- Fabrizio Cardin
- Geriatric Surgery Unit, Geriatric Department, Padova University and General Hospital, Via Giustiniani 1, 35100 Padova, Italy
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Preferences for end-of-life treatment: concordance between older adults with dementia or mild cognitive impairment and their spouses. Int Psychogeriatr 2012; 24:1798-804. [PMID: 22613082 DOI: 10.1017/s1041610212000877] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is considerable debate about the ability of proxies to adequately reflect patients' preferences regarding end-of-life care, when patients are no longer capable of stating their preferences. This study evaluated concordance in end-of-life preferences between patients with mild cognitive impairment (MCI) or dementia and their spouses. METHODS A cross-sectional sample of 106 respondents (53 couples) was recruited in two psychogeriatric clinics. Bivariate analyses were conducted to evaluate the degree of agreement between the patients' preferences and those of their spouses. RESULTS Patients were more likely to opt for more treatment than their spouses. Moderate agreement between patients and spouses was evident for preferences regarding end-of-life decisions for the patients. There was little concordance between the wishes of spouses regarding their own preferences and what they wanted for the patient or what the patient wanted. When incorrectly predicting patients' preferences, spouses were more likely to ask for treatment. CONCLUSIONS Our results show that regarding end-of-life preferences for patients, there is moderate agreement between patients and their spouses, but limited evidence for projection of spouses' preferences on patients (i.e. spouse making a prediction based on own wishes). Potential differences in end-of-life preferences between older adults with MCI or mild dementia and their caregivers should be taken into consideration in the preparation of advance care planning.
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Sommer S, Marckmann G, Pentzek M, Wegscheider K, Abholz HH, in der Schmitten J. Advance directives in nursing homes: prevalence, validity, significance, and nursing staff adherence. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:577-83. [PMID: 23093987 DOI: 10.3238/arztebl.2012.0577] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/22/2012] [Indexed: 11/27/2022]
Abstract
BACKGROUND The German Advance Directives Act of 2009 confirms that advance directives (ADs) are binding. Little is known, however, about their prevalence in nursing homes, their quality, and whether they are honored. METHODS In 2007, we carried out a cross-sectional survey in all 11 nursing homes of a German city in the state of North Rhine-Westphalia (total nursing home population, 1089 residents). The ADs were formally analyzed and assessed by 3 raters with respect to 5 clinical decision-making scenarios. The specifications of the ADs were compared with what the nurses reported that they would do in each scenario. RESULTS 11% of the nursing home residents had a personal AD, and a further 1.4% an AD by proxy. 52% of the 119 ADs that we analyzed contained no documentation of the patient's decision-making capacity and/or voluntariness, and only 3% contained documentation of a medical consultation. Most ADs failed to state what should be done in case the patient acutely became incapable of consenting to treatment (inter-rater agreement [IRA] >83%). For the case of permanent decisional incapacity, many ADs contained ambiguous information (IRA<43%). 23 directives stated that the patient should not have cardiopulmonary resuscitation in case an arrest occurred in the patient's current clinical condition, but the nurses reported a corresponding do-not-resuscitate agreement for only 9 of these 23 patients. CONCLUSION In 2007, ADs were rare in these German nursing homes, and most of the existing ones were invalid, of little meaning, and/or disregarded by the nursing staff. There is little reason to believe that the Advance Directives Act of 2009 will bring about any major change in this miserable status quo. Advance care planning, a system-oriented concept still uncommon in Germany, could give new impulses to promote a cultural change in this respect.
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Affiliation(s)
- Sarah Sommer
- Institute of General Practice, Düsseldorf University Hospital, Germany
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15
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Belmin J, Min L, Roth C, Reuben D, Wenger N. Assessment and management of patients with cognitive impairment and dementia in primary care. J Nutr Health Aging 2012; 16:462-7. [PMID: 22555792 DOI: 10.1007/s12603-012-0026-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To evaluate care provided by primary care physicians in community practice to older patients presenting with cognitive impairment and dementia. DESIGN Secondary analysis of an intervention study. SETTING Primary care clinics. PARTICIPANTS 101 patients 75 years and older enrolled in the ACOVE-2 study who presented with a new cognitive problem, new dementia, or prevalent dementia. MEASUREMENTS Patients assessment and management were evaluated from medical record review and caregiver interviews. RESULTS Among 34 patients presenting with a new cognitive problem, half received a cognitive assessment comprising of a test of memory and one other cognitive task, 41% were screened for depression and 29% were referred to a consultant. Of the 27 patients with newly diagnosed dementia, 15% received the components of a basic neurological examination, one-fifth received basic laboratory testing and for one third the medical record reflected an attempt to classify the type of dementia. Counseling was under-reported in the medical record compared to the caregiver interview for the 101 patients with dementia, but even the interview revealed that about half or fewer patients received counseling about safety and accident prevention, caregiver support or managing conflicts. Less than 10% were referred to a social worker. CONCLUSION This small but detailed evaluation suggests patients presenting with cognitive problems to primary care physicians do not consistently receive basic diagnosis and management.
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Affiliation(s)
- J Belmin
- Department of Geriatrics, Hôpital Charles Foix et Université UPMC-Paris 6, 7 avenue de la République. F-94200 Ivry-sur-Seine, France
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Gillick MR. Doing the right thing: a geriatrician's perspective on medical care for the person with advanced dementia. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2012; 40:51-56. [PMID: 22458462 DOI: 10.1111/j.1748-720x.2012.00645.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Developing a reasonable approach to the medical care of older people with dementia will be essential in the coming decades. Physicians are the locus of decision making for persons with dementia. It is the responsibility of the physician to assure that the surrogate understands the nature and trajectory of the disease and then to elicit the desired goal of care. Physicians need to ascertain whether any advance directives are available, and if so, whether they apply to the situation of advanced dementia. Finally, physicians should help surrogates understand how the goals of care are best translated into practice. When the goal is comfort, this is achieved by assuring dignity, minimizing suffering, and promoting caring. In general, comfort should be the default goal of care, best implemented through palliative care or hospice.
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Westenhaver TF, Krassa TJ, Bonner GJ, Wilkie DJ. Advance care plans for CPR or mechanical ventilation in patients with dementia. Nurse Pract 2010; 35:38-42. [PMID: 21088562 DOI: 10.1097/01.npr.0000390436.13252.81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Early development of advance care plans is an ethical and supportive intervention providers can offer patients and families facing a dementia diagnosis.
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20
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Goodman C, Evans C, Wilcock J, Froggatt K, Drennan V, Sampson E, Blanchard M, Bissett M, Iliffe S. End of life care for community dwelling older people with dementia: an integrated review. Int J Geriatr Psychiatry 2010; 25:329-37. [PMID: 19688739 DOI: 10.1002/gps.2343] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To review the evidence for end-of-life care for community dwelling older people with dementia (including those resident in care homes). DESIGN An integrated review synthesised the qualitative and quantitative evidence on end-of-life care for community dwelling older people with dementia. English language studies that focused on prognostic indicators for end-of-life care, assessment, support/relief, respite and educational interventions for community dwelling older people with dementia were included. A user representative group informed decisions on the breadth of literature used. Each study selected was screened independently by two reviewers using a standardised check list. RESULTS Sixty eight papers were included. Only 17% (12) exclusively concerned living and dying with dementia at home. Six studies included direct evidence from people with dementia. The studies grouped into four broad categories: Dementia care towards the end of life, palliative symptom management for people with dementia, predicting the approach of death for people with dementia and decision-making. The majority of studies were descriptive. The few studies that developed dementia specific tools to guide end of life care and outcome measures specific to improve comfort and communication, demonstrated what could be achieved, and how much more needs to be done. CONCLUSIONS Research on end-of-life care for people with dementia has yet to develop interventions that address the particular challenges that dying with dementia poses. There is a need for investigation of interventions and outcome measures for providing end-of-life care in the settings where the majority of this population live and die.
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Affiliation(s)
- Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK.
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21
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Lee M, Chodosh J. Dementia and Life Expectancy: What Do We Know? J Am Med Dir Assoc 2009; 10:466-71. [DOI: 10.1016/j.jamda.2009.03.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Revised: 03/11/2009] [Accepted: 03/27/2009] [Indexed: 11/25/2022]
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22
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Abbo ED, Sobotka S, Meltzer DO. Patient preferences in instructional advance directives. J Palliat Med 2008; 11:555-62. [PMID: 18454606 DOI: 10.1089/jpm.2007.0255] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Instructional advance directives (ADs) are traditionally written to apply in terminal illness. As such, they do not readily capture patient preferences for care in acute and chronic illness. OBJECTIVE To test whether patients prefer a modified AD that includes preferences to limit life-sustaining therapy (LST) for critical illness and advanced dementia over a traditional AD. METHODS A convenience sample of medically stable, hospitalized general medical patients were presented a traditional AD (the recommended Illinois statutory living will that limits LST in terminal illness) and a modified AD. The modified AD presents four conditional options: (1) to limit LST in terminal illness, (2) to limit LST in critical illness to a reasonable trial, (3) to refuse LST in advanced dementia (described in lay language), and (4) to refuse artificial hydration and nutrition (AHN) in advanced dementia. The primary outcome was the preferred AD to present to patients. Secondary outcomes included the AD choice of those who executed an AD and the options chosen by those executing the modified AD. RESULTS Seventy-two patients completed the survey. Eighty-six percent (95% confidence interval [CI], 76%-93%), preferred that the modified AD be presented to patients over the traditional AD. Twenty-one patients chose to execute an AD. Eighteen (86%; 95% CI, 64%-97%), executed the modified AD. Twelve executed all four options. CONCLUSIONS Traditional instructional ADs fail to capture important patient preferences. Future research should further validate these preferences and explore whether including these specific options in ADs can improve their efficacy.
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Affiliation(s)
- Elmer D Abbo
- Section of General Internal Medicine, Department of Medicine, The University of Chicago, Chicago, Illinois 60637, USA.
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23
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Abbo ED, Volandes AE. A Forced Choice: The Value of Requiring Advance Directives. THE JOURNAL OF CLINICAL ETHICS 2008. [DOI: 10.1086/jce200819204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Bernat JL. Ethical issues in the care of the patient with dementia. HANDBOOK OF CLINICAL NEUROLOGY 2008; 89:121-136. [PMID: 18631738 DOI: 10.1016/s0072-9752(07)01212-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- James L Bernat
- Dartmouth-Hitchcock Medical Center, Dartmouth Medical School, Hanover, NH 03756, USA.
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Williams N, Dunford C, Knowles A, Warner J. Public attitudes to life-sustaining treatments and euthanasia in dementia. Int J Geriatr Psychiatry 2007; 22:1229-34. [PMID: 17486679 DOI: 10.1002/gps.1819] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Issues surrounding end of life care, such as how aggressively to treat life threatening medical conditions in patients with dementia and when, if ever, to withhold or withdraw treatment require further scrutiny and debate. METHODS We conducted a cross-sectional survey to elicit the views of the general public on euthanasia and life-sustaining treatments in the face of dementia. RESULTS Seven hundred and twenty-five members of the general public completed this questionnaire throughout London and the South East. In the face of severe dementia, less than 40% of respondents would wish to be resuscitated after a heart attack, nearly three-quarters wanted to be allowed to die passively and almost 60% agreed with physician assisted suicide. Respondents were more likely to be in favour of life-sustaining treatments for their partner than for themselves and the opposite was true regarding euthanasia. White respondents were significantly more likely to refuse life-sustaining treatment and to agree to euthanasia compared with black and Asian respondents. CONCLUSION Our survey suggests that a large proportion of the UK general public do not wish for life-sustaining treatments if they were to become demented and the majority agreed with various forms of euthanasia.
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Affiliation(s)
- Nia Williams
- Department of Psychological Medicine, Imperial College London, UK
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Lorenz KA, Rosenfeld K, Wenger N. Quality Indicators for Palliative and End-of-Life Care in Vulnerable Elders. J Am Geriatr Soc 2007; 55 Suppl 2:S318-26. [PMID: 17910553 DOI: 10.1111/j.1532-5415.2007.01338.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Karl A Lorenz
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90064, USA.
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Richardson SS, Sullivan G, Hill A, Yu W. Use of aggressive medical treatments near the end of life: differences between patients with and without dementia. Health Serv Res 2007; 42:183-200. [PMID: 17355588 PMCID: PMC1955744 DOI: 10.1111/j.1475-6773.2006.00608.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To analyze whether acute care patients with dementia are more or less likely to receive each of five aggressive medical services near the end of life, compared with patients without dementia. DATA SOURCES Two years of Veterans Affairs (VA) and Medicare utilization data for all 169,036 VA users nationwide age 67 and older who died between October 1, 1999 and September 30, 2001. STUDY DESIGN We performed a retrospective analysis of acute care stays discharged in the final 30 days of life. The main outcome measure was the patient's likelihood of receiving each of five aggressive services (intensive care unit [ICU] admission, ventilator, cardiac catheterization, pulmonary artery monitor, and dialysis), controlling for demographic and clinical factors in probit regressions. PRINCIPAL FINDINGS There were 122,740 acute-stay discharges during the final 30 days of life, representing 94,100 unique patients (31,654 with dementia). In probit models comparing acute care patients with and without dementia, patients with dementia were 7.5 percentage points less likely to be admitted to the ICU (95 percent confidence interval [CI], 6.9-8.1; percent of stays with ICU admission=36.8 percent), 5.4 percentage points less likely to be placed on a ventilator (95 percent CI, 5.0-5.9; percent of stays with ventilator use=17.1 percent), 0.7 percentage points less likely to receive cardiac catheterization (95 percent CI, 0.6-0.8; percent of stays with cardiac catheterization=2.7 percent), 1.4 percentage points less likely to receive pulmonary artery monitoring (95 percent CI, 1.2-1.5; percent of stays with pulmonary artery monitoring=2.6 percent), and 0.6 percentage points less likely to receive dialysis (95 percent CI, 0.4-0.8; percent of stays with dialysis=4.6 percent). CONCLUSIONS During the final 30 days of life, acute care patients with dementia are treated substantially less aggressively than patients without dementia. Further research is warranted to determine the causes and appropriateness of these patterns of care.
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Affiliation(s)
- Samuel S Richardson
- VA Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA 94025, USA
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28
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Abstract
Despite the lack of clear benefits of feeding via gastrostomy tube in dementia patients, its use has been increasing. The views of health professionals, patients and their carers differ widely about the perceived benefits, which makes decision-making difficult and stressful. The palliative care approach of facilitating better communication and end-of life care planning can help avoid inappropriate gastrostomy tube placements. A case of an elderly male with dementia and two malignancies is described, and the place of the palliative care approach is explored.
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Affiliation(s)
- Sanjay H Shah
- Cransley Hospice and Kettering General Hospital, Kettering, UK.
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29
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Sanders C, Seymour J, Clarke A, Gott M, Welton M. Development of a peer education programme for advance end-of-life care planning. Int J Palliat Nurs 2006. [DOI: 10.12968/ijpn.2006.12.5.21174] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Caroline Sanders
- National Primary Care Research and Development Centre (NPCRDC), The University of Manchester, Oxford Road, Manchester
| | - Jane Seymour
- Sue Ryder Care Centre for Palliative and End-of-Life Studies, School of Nursing, University of Nottingham
| | | | - Merryn Gott
- Sheffield Institute for Studies on Ageing, University of Sheffield
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Conroy SP, Luxton T, Dingwall R, Harwood RH, Gladman JRF. Cardiopulmonary resuscitation in continuing care settings: time for a rethink? BMJ 2006; 332:479-82. [PMID: 16497767 PMCID: PMC1382552 DOI: 10.1136/bmj.332.7539.479] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Cardiopulmonary resuscitation is rarely successful in people who are old or frail, but current policy guidance fails to take this into account
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Affiliation(s)
- Simon P Conroy
- Division of Rehabilitation and Ageing, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, NG7 2UH.
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31
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32
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Fairrow AM, McCallum TJ, Messinger-Rapport BJ. Preferences of older African-Americans for long-term tube feeding at the end of life. Aging Ment Health 2004; 8:530-4. [PMID: 15724835 DOI: 10.1080/13607860412331303829] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The purpose of this study was to elicit preferences and reasons behind preferences for percutaneous endoscopic gastrostomy (PEG) tube placement in an older African-American sample. Five focus groups were conducted with subjects invited from the Geriatric Clinic of an urban tertiary care hospital. Thematic and latent content analyses were used. Five broad themes emerged as reasons behind the acceptance or rejection of a PEG tube, namely: the nature of the illness; the quality of life at the time of the decision; the concern about dependency; experiences; and religion (including issues of death). The issue of proxy also arose and contained three themes: fear of loss of decision-making ability; trust in family or caregivers as proxy even when the proxy choices differed from their own choices; and trust in the doctor and family to respect personal decisions. Use of a qualitative approach enabled potentially sensitive issues to be discussed. Preferences and the reasons behind these preferences may not always be anticipated by clinicians.
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Affiliation(s)
- A M Fairrow
- Madonna Hall Nursing Home, Cleveland, Ohio, USA
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33
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Detweiler MB, Kim KY, Bass J. Percutaneous endoscopic gastrostomy in cognitively impaired older adults: a geropsychiatric perspective. Am J Alzheimers Dis Other Demen 2004; 19:24-30. [PMID: 15002341 PMCID: PMC10833934 DOI: 10.1177/153331750401900105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The increasing use of percutaneous endoscopic gastrostomy (PEG) in cognitively compromised elderly presents complex treatment-related and ethical questions. Approximately half of all dementia patients will be unable to feed themselves within eight years of their diagnosis. Moreover, 85 percent of dementia patients have demonstrated refusal to eat. Geropsychiatry is often employed to evaluate these cognitively impaired patients either prior to or following PEG tube placement. This manuscript presents three cases to illustrate the most commonly encountered general dementia presentations: the ability to communicate with decisional capacity, the ability to communicate without decisional capacity, and severe verbal aphasia without decisional capacity. The study discusses ethical issues and treatment strategies for pre- and post-PEG tube placement consultations, including environmental interventions, in order to improve quality of life for this population.
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Affiliation(s)
- Mark B Detweiler
- Salem Veterans Affairs Medical Center, Edward Via Virginia College of Osteopathic Medicine, University of Virginia, Virginia, USA
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35
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Abstract
Many percutaneous endoscopic gastrostomy patients are very elderly and frail. Outcomes after percutaneous endoscopic gastrostomy have been disappointing in some instances: about a fifth of patients are dead within 30 days of the procedure and those that survive often have a severely impaired functional status. Many healthy elderly persons would not wish for tube feeding especially in the context of advanced dementia. Despite this the number of patients receiving percutaneous endoscopic gastrostomy continues to increase. The case mix, outcomes and ethical issues of percutaneous endoscopic gastrostomy feeding are reviewed. Guidance on selection of appropriate patients is given.
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Marcus EL, Clarfield AM, Moses AE. Ethical issues relating to the use of antimicrobial therapy in older adults. Clin Infect Dis 2001; 33:1697-705. [PMID: 11595981 DOI: 10.1086/323757] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2001] [Revised: 06/08/2001] [Indexed: 02/05/2023] Open
Abstract
This article aims to review the literature relating to the ethics of antibiotic prescription decisions in older adults and to offer some suggestions as to how one might approach these difficult problems. According to many studies, most patients and their family members wish to receive antibiotics even when they are terminally ill or suffering from advanced dementia. Health care professionals are also frequently reluctant to deny the use of antibiotics in such situations. We suggest that the difficult decisions regarding whether one should withhold treatment can be based on consideration of the ethical principles of autonomy, beneficence, nonmaleficence, and justice. From the public health point of view, one should also take into account the need to avoid the emergence of antimicrobial resistance, keeping in mind the balance between the benefit to the specific patient and the cost to future patients. Infectious diseases consultants should actively participate in these ethical dilemmas.
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Affiliation(s)
- E L Marcus
- Acute Geriatric Department, Sarah Herzog Hospital, Jerusalem, Israel.
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McNamara EP, Kennedy NP. Tube feeding patients with advanced dementia: an ethical dilemma. Proc Nutr Soc 2001; 60:179-85. [PMID: 11681633 DOI: 10.1079/pns200083] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Many patients with dementia lose the ability to feed themselves in the advanced stages of the disease. Tube feeding is sometimes initiated to overcome feeding difficulties. Recent studies have questioned the appropriateness of tube feeding in these patients. There is limited research to support the benefits of enteral nutrition in patients with advanced dementia. Deciding whether to tube feed or to withhold tube feeding from a patient with dementia poses a difficult challenge, and many carers may make decisions without adequate information and with an overly hopeful view of the future clinical course. Numerous studies have examined opinions about life-sustaining treatments; many individuals do not want to be tube fed if they were to develop dementia. Results from studies examining the opinions of physicians and other health professionals regarding the use of tube feeding in these patients are conflicting. A number of factors, such as race and cultural background may affect decisions. Healthcare professionals, relatives and patients must be aware of the realistic expectations of tube feeding in patients with dementia, as it can be difficult to withdraw once it has been initiated.
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Affiliation(s)
- E P McNamara
- Department of Clinical Medicine, Trinity Centre for Health Sciences, St James's Hospital, Dublin, Republic of Ireland.
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Abstract
This article discusses nine important medical ethical issues following the progression of irreversible dementia from diagnosis to dying. Issues include prevention, research, truth telling, advance planning, cognitive-enhancing drugs, driving restrictions, respectful caring, distribution, justice, and natural dying.
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Affiliation(s)
- S G Post
- Center for Biomedical Ethics, School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106-4976, USA
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