The development of an individual differences end-of-life treatment preferences scale

The purpose of this study was to create an individual differences measure of end-of-life treatment preferences (EOLTPs). Young adults (n = 427) and older adults (n = 333) completed a survey. Results found that hope of recovery was an important factor in whether individuals preferred a given medical intervention. A single factor explained the majority of the variance in EOLTPs, and EOLTPs were distinct from more general attitudes about medical care. Older adults preferred less end-of-life medical intervention compared to younger adults. Overall, the results of the study support the use of an individual differences approach to measuring EOLTPs.

Advance Directives, Medical Conditions, and Preferences for End-of-Life Care Among Physicians: 12-year Follow-Up of the Johns Hopkins Precursors Study

CONTEXT

Stability of preferences for life-sustaining treatment may vary depending on personal characteristics.

OBJECTIVE

We estimated the stability of preferences for end-of-life treatment over 12 years and whether advance directives and medical conditions were associated with change in preferences for end-of-life treatment.

DESIGN

Mailed survey of older physicians.

METHODS

Longitudinal cohort study of medical students in the graduating classes from 1948 to 1964 at Johns Hopkins University. Eight hundred ninety eight physicians who completed the life-sustaining treatment questionnaire anytime in 1999, 2002, 2005, and 2011 (mean age 68.2 years at baseline). Preferences for life-sustaining treatment were assessed using a checklist questionnaire in response to a standard "brain injury" scenario and considered as a package using the latent class transition model.

RESULTS

End-of-life preferences grouped into three classes: most aggressive (wanting most interventions; 14% of physicians), least aggressive (declining most interventions; 61%), and an intermediate class (declining most interventions except intravenous fluids and antibiotics; 25%). Physicians without an advance directive were more likely to desire more treatment and were less likely to transition out the most aggressive class. Transition probabilities from class to class did not vary over time. Persons with cancer expressed preference for the least aggressive treatment, whereas persons with cardiovascular disease and depression had preferences for more aggressive treatment.

CONCLUSION

Transitions in end-of-life preferences and the factors influencing change and stability suggest that periodic reassessment for planning end-of-life care is needed.

Terminally Ill Elderly Patient's Experiences, Attitudes, and Needs: A Qualitative Study

The aim of this qualitative study was to clarify how terminally ill elderly patients in acute wards perceive the end of life and what are their needs and wishes regarding care. The patients, despite their advanced illness, wished to be treated actively and hoped for more conversations with doctors about active care. They were content with their daily care but evaluated the care in light of the great workload of the nurses, forgiving them for not having time to talk to individual patients. They had specific modest wishes, but were reluctant to express even these because of concern about troubling their caregivers. We conclude that death remained a distant abstraction for these patients with a terminal prognosis. The challenge is to create an intimate caring atmosphere, where the issues related to dying may be elaborated in interaction and the last wishes expressed in a safe atmosphere.

Attitude of elderly patients towards cardiopulmonary resuscitation in Greece

AIM

Although researchers in several countries have investigated patients' points of view regarding cardiopulmonary resuscitation, there has been no research investigating this issue in Greece. The present study aimed at identifying the attitude of older Greek patients regarding cardiopulmonary resuscitation.

METHODS

One basic questionnaire consisting of 34 questions was used in order to identify patients' opinions regarding cardiopulmonary resuscitation in five different hospitals from June to November 2011.

RESULTS

In total, 300 questionnaires were collected. Although patients' knowledge regarding cardiopulmonary resuscitation was poor, most of them would like to be resuscitated in case they suffered an in-hospital cardiac arrest. Also, they believe that they should have the right to accept or refuse treatment. However, the legal and sociocultural norms in Greece do not support patients' choice for the decision to refuse resuscitation. The influence of several factors, such as their general health status or the underlying pathology, could lead patients to give a "do not attempt resuscitation" order.

CONCLUSIONS

The attitudes of older Greek patients regarding resuscitation are not different from others', whereas the legal and sociocultural norms in Greece do not support patient choice in end-of-life decisions, namely the decision to refuse resuscitation. We advocate the introduction of advanced directives, as well as the establishment and implementation of specific legislation regarding the ethics of resuscitation in Greece.

[Living will declarations: Qualitative study of the elderly and primary care general practitioners]

OBJECTIVES

First, to assess knowledge and attitudes of people aged 65 and over to the Advance Directives Document (ADD) and know the role that, in their opinion, a family doctor should play in the early planning of death. Second, to assess the level of knowledge and attitude of primary care physicians to that document, as well as to know the role played by these professionals.

DESIGN

Qualitative, using discussion groups. Between March and May 2009 4 groups, 2 of physicians and 2 of older people, were formed.

SETTING

Castile-La Mancha Primary Care Setting, Albacete and Guadalajara health areas.

SUBJECTS

15 people in the groups formed by older people and 13 in the groups of doctors.

METHOD

The Krueger recommendations (1991) were followed both for the selection of subjects, conducting of the discussion groups and analysis of data.

RESULTS

Doctors and patients have a positive attitude towards the ADD, but lack sufficient information to make more widespread use of it. Ignorance makes it impossible for patients to get information about the document and the lack of time makes it difficult for physicians to raise the issue in the consultation.

CONCLUSIONS

Neither physicians nor the elderly have enough information regarding ADD, allowing us to recommend carrying out information campaigns and/or specific educational activities. According to physicians, alternatives to primary care consultations should be sought for patients to be informed.

Resuscitation of the Elderly

The changing demographics of America's population over the past couple of decades have propelled geriatric medicine into the fore-front. Due to this, emergency medicine physicians will face numerous challenges managing an increasing number of critically ill elderly patients. This article will focus on success of resuscitation in this population, important pathophysiologic changes that occur with aging, as well as ethical considerations in end-of-life care.

Patient desires: A model for assessment of patient preferences for care of severe or terminal illness

Objective:Patient-centered care is better achieved through a comprehensive understanding of patients' preferences for how they want to live their life and how they want to influence their own death. Though much has been written on identifying goals of care, it is often difficult for clinicians to articulate patient goals to guide care planning. We explored the literature on patient's preferences for their care in chronic or life-limiting illness to develop a model for assessment of patient perspectives. We then illustrated our model with composite patients from our clinics and we provide questions to guide patient discussion.

Methods:We searched MEDLINE from 1986 to 2004 for primary research articles that relate primarily to a patient's preferences for his or her care. We reviewed over 3500 titles, abstracts, and research papers. Hundreds of articles described patients' quality of life, health status, or satisfaction. We excluded consensus guidelines, non-English papers, reviews, and articles focused on medical professional perspectives. Forty-eight studies focused primarily on patient preferences. Using an iterative process, we identified unique issues and broader themes in patients' desires for their care.

Results:Studies focused on patients with cancer, those in hospice or those with terminal disease. Three domains emerged: patient feelings about disease, feelings about suffering, and feelings about the circumstances of death. Attention was given to the differences between patients in terms of the strength and persistence of feelings in each domain.

Significance of results:Based on existing data, there are three fundamental domains of patient perspective that influence preferences for care. These domains can be assessed by the care team to guide the development of a plan of care and to identify areas of conflict. Our review identifies gaps in the end-of-life literature and areas for future work in patient preferences.

End-of-life treatment preferences among older adults

With the advancement of medical technology, various life-sustaining treatments are available at the end of life. Older adults should be encouraged to establish their end-of-life treatment preferences (ELTP) while they are physically and mentally able to do so. The purpose of this study was to explore ELTP among older adults and to compare those preferences in a subset of individuals who had reported their ELTP in a survey completed the previous year. This was a descriptive study of 191 older adults living in a continuing care retirement community. Approximately half of the participants did not want cardiopulmonary resuscitation, to be put on a respirator, or to receive dialysis. The findings in this study suggest that many older adults do not want aggressive interventions at the end of life, but choose rather those measures that will keep them comfortable. Moreover, treatment choices may change over time. Health care providers should initiate discussions about ELTP at regular intervals (yearly) to assist older adults in dictating their end-of-life care.

The problem with advance directives: maybe it is the medium, not the message

Some of today's most significant bioethical challenges center around decisions to initiate or withhold medical treatment for incapacitated patients. In order to ascertain what treatment the patient would have desired, physicians often rely on written advance directives and designated surrogate decision-makers. Unfortunately, both approaches suffer from numerous shortcomings that ultimately limit their usefulness. Although several strategies have been proposed to improve their value, problems nevertheless remain when relying upon written advance directives. We submit that the problem is the medium, not the message-that written advance directives and/or reliance on surrogate decision-makers are fundamentally inadequate. We hypothesize that videotaped advance directives (VADs) can better communicate the specifics, depth, strength and passion of a patient's wishes, more closely approximating the communication that occurs when a physician discusses these issues directly with a patient. VADs may thus enhance the physician's understanding of the patient's wishes. VADs may also ease family conflict and save physician's considerable time by helping family members reach a stronger consensus on the patient's wishes, and do so in a timelier manner. This article reviews the limitations of written advance directives and surrogate decision-makers and describes why VADs may be helpful in overcoming these limitations.

Ethical issues in geriatrics: a guide for clinicians

Because of demographic trends, it is reasonable to expect that clinicians will care for an increasing number of elderly persons with challenging medical and psychosocial problems. These problems and issues, in turn, may lead to daunting ethical dilemmas. Therefore, clinicians should be familiar with ethical dilemmas commonly encountered when caring for elderly patients. We review some of these dilemmas, including ensuring informed consent and confidentiality, determining decision-making capacity, promoting advance care planning and the use of advance directives, surrogate decision making, withdrawing and withholding interventions, using cardiopulmonary resuscitation and do-not-resuscitate orders, responding to requests for interventions, allocating health care resources, and recommending nursing home care. Ethical dilemmas may arise because of poor patient-clinician communication; therefore, we provide practical tips for effective communication. Nevertheless, even in the best circumstances, ethical dilemmas occur. We describe a case-based approach to ethical dilemmas used by the Mayo Clinic Ethics Consultation Service, which begins with a review of the medical indications, patient preferences, quality of life, and contextual features of a given case. This approach enables clinicians to identify and analyze the relevant facts of a case, define the ethical problem, and suggest a solution.

[Factors which influence cardiopulmonary resuscitation and medical information preferences in a geriatric population]

BACKGROUND

Whether or not performing cardiopulmonary resuscitation (CPR) is a complex decision that requires taking account of several factors. The aim of this study was to analyse the preferences of elderly people with regard to CPR.

SUBJECTS AND METHOD

Survey administered to 181 elderly subjects from nursing homes and ambulatory care centres.

RESULTS

66.9% of them would request information if hospitalised. 80.7% would wish to undergo CPR. However, this figure decreased to 40.9% in case of serious sequeles as a result of the procedure and to 32.5% in case of previous dementia.

CONCLUSIONS

Request information would be high. Age and functional status of the elderly person

Urinary incontinence treatment preferences in long-term care

OBJECTIVE

To elicit preferences for different urinary incontinence (UI) treatments in long-term care (LTC) from groups likely to serve as proxy decision makers for LTC residents.

DESIGN

A descriptive, comparative study of preference for UI treatments of frail older adults, family members of nursing home (NH) residents, and LTC nursing staff. Surveys were mailed to families and self-administered by staff. Older adults were interviewed.

SETTING

Four LTC facilities and two residential-care facilities in Los Angeles.

PARTICIPANTS

Four hundred and three family members of incontinent NH residents were mailed surveys. Sixty-six nursing staff caring for these incontinent residents and 79 older adult residents of care facilities (nine cognitively intact NH respondents and 70 residential care residents) answered surveys.

MEASUREMENTS

Preference rankings between seven paired combinations of five different UI treatments were measured on an 11-point visual analog scale, with the verbal anchors "definitely prefer" this treatment, "probably prefer" this treatment, and "uncertain." Respondents gave open-ended comments as well.

RESULTS

Forty-two percent of family members (171/ 403) returned the mailed survey. Of all respondents, 85% "definitely" or "probably" preferred diapers, and 77% "definitely" or "probably" preferred prompted voiding (PV) to indwelling catheterization. Respondent groups occasionally differed significantly in their preferences. In choosing between treatment pairs using a visual analogue scale, nurses preferred PV to diapers significantly more than did older adults or families (both of whom preferred diapers) (F (2,295) = 13.11, P < .0001). Older adults, compared with family and nurse respondents, showed a significantly stronger preference for medications over diapers (F (2,296) = 41.54, P < .0001). In open-ended responses, older adults stated that they would choose a UI treatment based in part upon criteria of feeling dry, being natural, not causing embarrassment, being easy, and not resulting in dependence. Nurses said that they would base their choice of UI treatment upon increasing self-esteem and avoiding infection.

CONCLUSIONS

Although there was wide variation within and between groups about preferred UI treatment, most respondents preferred noninvasive strategies (diapers and PV) to invasive strategies (indwelling catheters and electrical stimulation). Older adults preferred to a greater degree medications and electrical stimulation, therapies directed at the underlying cause of UI. Despite data documenting that diapering is a less time intensive way to manage UI and that toileting programs are difficult to maintain in LTC, nurses viewed PV as "natural" and strongly preferred it to diapering. Several family members and older adults viewed PV as "embarrassing" and "fostering dependence." These data highlight the need to elicit preferences for UI treatment among LTC residents and their families.

Cardiopulmonary resuscitation preferences in Dutch community-dwelling and hospitalized elderly people: an interaction between gender and quality of life

OBJECTIVE

To study the effects of information, gender, quality of life, and hospitalization on cardiopulmonary resuscitation (CPR) preferences and on the wish for information and participation in CPR discussions.

METHODS

Seventy-five community-dwelling inhabitants of the city of Leiden and 45 consecutive patients in two hospitals in Leiden, The Netherlands, aged 75 years or older, were interviewed about their CPR preferences in their current states of health and in three hypothetical scenarios. Health-related quality of life (QOL) was assessed in separate items. The subjects were asked about their wishes for information and participation in CPR discussions.

RESULTS

The chances of surviving CPR were overestimated. After receiving accurate information, 65% of the subjects, more women than men, did not want CPR. Overall QOL did not differ between men and women. Concerning the separate QOL items, men's CPR preferences were more associated with pain, whereas women's were more associated with being impaired in physical functioning and daily and social activities. CPR preferences in the current state of health did not differ significantly between community-dwelling and hospitalized participants. Although only 6% of all participants had ever discussed CPR with their doctors, 70% indicated they wanted routine CPR discussions (either when in good health at home or upon hospital admission), and 61% preferred to make the final decision about CPR themselves.

CONCLUSIONS

CPR preferences are affected by different QOL items in men and women. CPR preferences in the current state of health do not differ between hospitalized and community-dwelling elderly people. As the majority of elderly people want CPR discussions, they should be involved in decision making concerning CPR.

Cardiopulmonary resuscitation of older, inhospital patients: immediate efficacy and long-term outcome

OBJECTIVE

To determine the independent effect of advancing age on prognosis after cardiopulmonary resuscitation (CPR).

DESIGN AND SETTING

Retrospective analysis of clinical records of patients who received CPR in a geriatric department equipped with an intensive care unit.

PATIENTS

A total of 245 patients (146 men, 99 women; mean age, 70+/-11 yrs) received CPR. Of these, 221 had a cardiocirculatory arrest (CA) in the intensive care unit and 24 had a CA in the general ward of the department. Acute myocardial infarction was the most frequent admission diagnosis.

INTERVENTIONS

CPR according to standard guidelines in all cases.

MEASUREMENTS AND MAIN RESULTS

Immediate, short-term (hospital discharge), and long-term (median follow-up, 31.5 months; range, <1-124 months) survival. Older patients had a lower immediate survival (<70 yrs [72/137] 52.6% vs. > or =70 yrs [43/108] 39.4%; p < .05) and, less frequently, ventricular tachycardia/ fibrillation (VT/VF) as a cause of CA. VT/VF bore the lowest immediate mortality rate (19/104; 18.3%) as compared with asystole/complete heart block (66/102; 64.7%) or pulseless electrical activity (40/49; 81.6%; p < .001). Acute myocardial infarction, acute heart failure, hypotension, and occurrence of CA in the intensive care unit were also univariate predictors of unfavorable, immediate prognosis. However, in a multiple logistic analysis model, the mechanism of CA (asystole/complete heart block or pulseless electrical activity vs. VT/VF), acute myocardial infarction, heart failure, and hypotension were independent predictors of unfavorable immediate prognosis, whereas advancing age was not. Similarly, after initially successful CPR, short-term survival was independently associated with acute myocardial infarction, hypotension before CA, initial rhythm at CA, and need for mechanical ventilatory support after CPR, but not with age. Longterm survival (42 patients; 17.2% of the original cohort; median survival, 32 months) was also independent of age, whereas it was negatively associated with heart failure.

CONCLUSION

Immediate, short- and long-term prognosis after in hospital CPR is independent of age, at least when possible confounders are simultaneously taken into account.

End-of-life care preferences of Canadian senior citizens with caregiving experience

A grounded theory study of senior citizens' preferences for end-of-life care was conducted in 1998 in Canada. Seniors who had experienced the deaths of others and who had considered their own death and dying were the target population. The sample was 49 seniors who met the study criteria. Participants provided end-of-life care in a variety of settings for 1-8 family members or friends. Two concepts identified were expected dependency while dying and appropriate end-of-life care. Almost all participants preferred to be cared for at home, yet family caregivers who could provide appropriate end-of-life care when dependent were needed for this to occur. The appropriateness of end-of-life care was contingent upon the place where end-of-life care occurred, as well as the type of care provided. Life prolongation was not desired, 53% even endorsed euthanasia as a way of bringing about the inevitable end to life.

Physician-older patient communication at the end of life

Communication with dying patients and their families requires special skills to assist them in this extremely stressful period. This article begins with a case that illustrates many of the challenges of communicating with the dying. It then reviews the literature about communication with older patients at the end of life, focusing on physician-patient discussions, decision-making, advance directives, and cultural factors. The article concludes with a practical discussion of problems that physicians may encounter when working with older patients at the end of life and their families and recommendations to improve communication.

[Advance directives in clinical practice]

DEFINITIONS

In the United States advance directives were developed since the late 60s in order to improve patients' medical decision making in case of incompetence in the future. In Germany 3 types of advance directives exist: 1. "Patientenverfügungen". 2. "Berreuungsverfügugen" and 3. "Vorsorgevollmachten".

EMPIRICAL STUDIES

In empirical studies, mostly from the US, the implementation of advance directives into clinical practice and the attitude of physicians, patients, relatives and the general population have been examined. This review article provides results of theses studies in text and tables.

CONCLUSION

Against the will of patients and of the general population advance directives are not often used in clinical practice. Physicians talk with patients about treatment procedures more often than they talk about end of life decisions. Informing patients about advance directives opens the chance to improve palliative care and respects their choices and values at the end of their lives.