Dissociation between the wishes of terminally ill parents and decisions by their offspring

Patient and caregiver agreement on prognosis estimates for older adults with advanced cancer

BACKGROUND

Disagreements between patients and caregivers about treatment benefits, care decisions, and patients' health are associated with increased patient depression as well as increased caregiver anxiety, distress, depression, and burden. Understanding the factors associated with disagreement may inform interventions to improve the aforementioned outcomes.

METHODS

For this analysis, baseline data were obtained from a cluster-randomized geriatric assessment trial that recruited patients aged ≥70 years who had incurable cancer from community oncology practices (University of Rochester Cancer Center 13070; Supriya G. Mohile, principal investigator). Patient and caregiver dyads were asked to estimate the patient's prognosis. Response options were 0 to 6 months, 7 to 12 months, 1 to 2 years, 2 to 5 years, and >5 years. The dependent variable was categorized as exact agreement (reference), patient-reported longer estimate, or caregiver-reported longer estimate. The authors used generalized estimating equations with multinomial distribution to examine the factors associated with patient-caregiver prognostic estimates. Independent variables were selected using the purposeful selection method.

RESULTS

Among 354 dyads (89% of screened patients were enrolled), 26% and 22% of patients and caregivers, respectively, reported a longer estimate. Compared with dyads that were in agreement, patients were more likely to report a longer estimate when they screened positive for polypharmacy (β = 0.81; P = .001), and caregivers reported greater distress (β = 0.12; P = .03). Compared with dyads that were in agreement, caregivers were more likely to report a longer estimate when patients screened positive for polypharmacy (β = 0.82; P = .005) and had lower perceived self-efficacy in interacting with physicians (β = -0.10; P = .008).

CONCLUSIONS

Several patient and caregiver factors were associated with patient-caregiver disagreement about prognostic estimates. Future studies should examine the effects of prognostic disagreement on patient and caregiver outcomes.

Feasibility of Early Application of an Advance Directive at the Time of First-Line Palliative Chemotherapy in Patients With Incurable Cancer: A Prospective Study

CONTEXT

This study aimed to evaluate the feasibility of an advance directive (AD) at the time of starting first-line palliative chemotherapy. We investigated changes in emotional distress, quality of life (QoL), and attitudes toward anticancer treatments between before and after AD.

METHODS

Patients with advanced cancer who had just started palliative chemotherapy were prospectively enrolled. We assessed attitudes toward chemotherapy, Hospital Anxiety and Depression Scale (HADS), and European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ) before conducting the AD and subsequently performed the AD after the first cycle of chemotherapy. Follow-up evaluations using same parameters were performed in the next cycle visit.

RESULTS

During the study period, 104 patients started palliative chemotherapy. Among them, 41 patients (11 with cognitive impairment at baseline, 14 with clinical deteriorations after the first cycle of chemotherapy, 6 with follow-up loss, 7 without proxy, 3 with protocol violations) were excluded, and the AD were recommended in the remaining 64 patients (proportion of AD recommendation: 62%). Among the 64 patients, 44 agreed to conduct the AD (proportion of AD consent: 69%). There were no significant changes before and after AD in terms of HADS and EORTC-QLQ. Attitudes regarding chemotherapy were also unchanged (P = .773). A total of 36 (82%) patients followed physician's recommendations, with the exception of 8 patients who terminated chemotherapy due to refusal or loss to follow-up.

CONCLUSIONS

Considering our results showing no significant changes in depression and anxiety scores, QoL, and attitudes toward anticancer treatments after the AD, early integration of the AD at initiation of first-line palliative chemotherapy might be feasible.

“Am I Going to Die Now?” Prognostication of Survival Time by Members of the Care Team

To get a real chance to make autonomous decisions in the final phase of their life, people who are soon going to die have a right to be informed concerning available knowledge about their prognosis and condition. The aim of this study is to describe how different members of the care team make prognostications about patients' survival time, and what motivates their prognostications. Doctors and registered nurses made prognostications to a greater extent, and were also somewhat more successful, than practical nurses and social workers. Different professions seem to differ in some respects concerning the criteria included in their motivations and the knowledge upon which they base their motivations.

A Decade of Changes in Family Caregivers' Preferences for Life-Sustaining Treatments for Terminally Ill Cancer Patients at End of Life in the Context of a Family-Oriented Society

CONTEXT

Temporal changes in different family caregiver cohorts' preferences for life-sustaining treatments (LSTs) at end of life (EOL) have not been examined nor have the concept of whether caregivers' LST preferences represent a homogeneous or heterogeneous construct. Furthermore, LST preferences are frequently assessed from multiple treatments, making clinical applications difficult/infeasible.

OBJECTIVES

To identify parsimonious patterns and changes in the pattern of LST preferences for two independent cohorts of family caregivers for terminally ill Taiwanese cancer patients.

METHODS

Preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis were assessed among 1617 and 2056 family caregivers in 2003-2004 and 2011-2012, respectively. Patterns and changes in LST preferences were examined by multigroup latent class analysis.

RESULTS

Five distinct classes were identified: uniformly preferring, uniformly rejecting, uniformly uncertain, and favoring nutritional support but rejecting or uncertain about other treatments. Class probability significantly decreased from 29.3% to 23.7% for the uniformly rejecting class, remained largely unchanged for the uniformly preferring (16.9%-18.6%), and favoring nutritional support but rejecting (37.1%-37.5%) or uncertain about other treatments (8.0%-10.4%) classes, but significantly increased from 7.0% to 11.5% for the uniformly uncertain class over time.

CONCLUSION

Family caregivers' LST preferences for terminally ill cancer patients are a heterogeneous construct and shifted from uniformly rejecting all LSTs toward greater uncertainty. Surrogate EOL-care decision making may be facilitated by earlier and thorough assessments of caregivers' LST preferences and tailoring interventions to the unique needs of caregivers in each class identified in this study.

Management of the hopelessly ill patient: to stop or not to start?

The paper discusses the subject of futile treatment in the case of a hopelessly ill patient. The topic has many facets, among them the ethical precepts of preventing futile treatment, but also the economic and logistic impact of treating patients who do not have a fair chance of benefitting from managing their medical condition. A 75-year old patient, suffering from an advanced stage of Alzheimer's disease and a clinical picture of acute surgical abdomen, is presented and two approaches are discussed. The first scenario is the aggressive management, including immediate laparotomy and admission to an intensive care unit, a solution without a fair chance of saving the patient's life. The most favorable, but theoretical, output in this case would be the patient's return to his previous mental condition, without any connection with the reality and surroundings and in permanent need for help, supervision and assistance. The second option is letting the patient die in dignity, alleviating pain and surrounded by family. The role of the primary care physician and family is discussed and some ethical principles are presented in order to emphasize the importance of preventing futile treatment in a case of a terminally ill patient.

Association between the emotional status of family caregivers and length of stay in a palliative care unit: A retrospective study

OBJECTIVE

Several factors associated with referral time to hospice and/or palliative care services have been identified, but there is no literature on the association between these services and the emotional status of the family caregivers (FCs). This article is intended to address that issue.

METHOD

A semistructured interview was employed to collect data for a retrospective cohort study. The primary FCs of terminally ill cancer patients were interviewed at the time of the patient's referral to the palliative care unit. Interview data were combined with patients' medical record data for our analysis. The emotional status of the FCs was categorized into one of three groups according to their responses to the anticipated death of their family member: acceptance, anxious/depressed, and denial/angry. A Cox proportional hazard model was used to examine and identify the factors related to the length of stay (LOS) in the palliative care unit.

RESULTS

A total of 198 patient-FC pairs were identified. The median LOS was 18 days. A multivariate analysis with adjustment for potential variables revealed significant differences in LOS according to cancer type and time since cancer diagnosis. The denial/angry FC category was independently associated with a shorter LOS (vs. acceptance, adjusted hazard ratio (aHR) 2.11; 95% confidence interval (CI), 1.11-4.03).

SIGNIFICANCE OF RESULTS

We found that terminally ill cancer patients who were referred late had FCs who were in denial or were angry about the anticipated death of their loved one. The emotional status of FCs should be considered when patients with terminal cancer are referred to palliative care.

How Dutch neurologists involve families of critically ill patients in end-of-life care and decision-making

When critically ill neurologic patients are cognitively incapacitated, decisions about treatment options are delegated to surrogates, usually family members. We conducted qualitative interviews with 20 Dutch neurologists and residents in neurology varying in age, work experience, and workplace to investigate how they involve their patients' family members in decision-making. Their reports revealed that they ascribed 3 different, yet tightly interwoven roles to families: (1) informants about values and preferences of patients, (2) participants in care and care planning, and (3) sufferers themselves. Neurologists regarded decision-making as an integral part of end-of-life care rather than an isolated process, changing the meaning of what decision-making entails. All different roles of family members were important in end-of-life care and decision-making, instead of the single one of legal surrogate. Neurologists need to support family members in these various roles.

Factors Related to the Differential Preference for Cardiopulmonary Resuscitation Between Patients With Terminal Cancer and That of Their Respective Family Caregivers

There is little information regarding concordance between preferences for end-of-life care of terminally ill patients with cancer and those of their family caregivers. A cross-sectional exploration of cardiopulmonary resuscitation (CPR) preference in 361 dyads was conducted. Patients or family caregivers who were willing to approve CPR were compared with dyads who did not support CPR. The patient's quality of life was more associated with family caregiver's willingness than patient's willingness. A patient was more likely to prefer CPR than their caregiver in dyads of females and emotionally stable patients. A family caregiver showed stronger support for CPR if the patient had controlled pain or stable health and the family caregiver had not been counseled for CPR. Communications should be focused on these individuals to improve the planning of end-of-life care.

Discordance among patient preferences, caregiver preferences, and caregiver predictions of patient preferences regarding disclosure of terminal status and end-of-life choices

BACKGROUND

The complexity of end-of-life (EOL) communication in cancer care is often increased by family caregivers, who frequently affect the information and decision-making process. We assessed cancer patient preferences (PP), family caregiver preferences (FCP), and family caregiver predictions of patient preferences (FCPPP) regarding the disclosure of terminal status, family involvement in the disclosure process, and EOL choices, and we evaluated the concordances among them.

METHODS

A national, multicenter, cross-sectional survey of 990 patient-caregiver dyads (participation rate = 76.2%) was performed. A set of paired questionnaires was independently administered to patients and their caregivers.

RESULTS

While patients and family caregivers had wide spectra of preferences, patients significantly preferred disclosure, direct disclosure by a physician, and palliative care options (all P < 0.001). Family caregiver predictions were similar to PP with regard to terminal disclosure (P = 0.35) but significantly different with regard to family involvement in the disclosure process and EOL choices (P < 0.001). The concordances of PP and FCP (κ = 0.08-0.13), and those of PP and FCPPP (κ = 0.09-0.17), were poor. The concordances of FCP and FCPPP were fair to moderate (κ = 0.35-0.67). Discrepancies between PP and FCP and between PP and FCPPP were associated with dysfunctional family communication.

CONCLUSIONS

Family caregivers do not generally concur with patients in their preferences, nor do they reliably predict PP. Open dialogue between patient and family caregivers would reduce the discrepancy. More emphasis on incorporating family caregivers in EOL communication is needed from clinical, research, and training perspectives.

Spiritual background and its association with the medical decision of, DNR at terminal life stages

In recent years personal and clinical dilemmas relating to terminally ill patient-care medical, decisions have increased significantly. Although understanding the patient's medical, nursing and, social background is important, a comprehensive appraisal essential for treating the "whole patient" is, incomplete without a spirituality assessment. Religious beliefs and practices affect medical and health, care decisions and require recognition as a dynamic in coping with suffering, loss, life, and death. Taking a spiritual background obtains information that is meaningful to the patient's life and may, influence the medical decision-making relating to health. A study was undertaken to determine, whether assessing the spiritual background influences medical decisions-making regarding the use of, DNR. The target population was 46 family-member caregivers of non-communicative patients in the Herzog, Hospital Skilled Nursing ward located in Jerusalem. The spiritual assessment questionnaire was the, acronym FICA (faith, importance, community and addressing). Two-thirds of the families were opposed to a determination utilizing do not resuscitate (DNR). Multivariate, analysis of the findings found that only religious affiliation was statistically significant (p=0.003). The doctors recommend DNR in 67% of the cases while the family caregiver accepted this decision in, only 33% of the cases. The hypothesis was verified. People who are perceived as being religious or as being greatly influenced, by faith/spirituality opposed the recommendation implementing DNR. Obtaining a spiritual background assists the physician to understand the patient or family spirituality, facilitates sensitivity to value frameworks and preferences in making medical and health-related, decisions.

Discrepancies in End-of-life Decisions Between Elderly Patients and Their Named Surrogates

Introduction: This study aims to determine the attitudes of Asian elderly patients towards invasive life support measures, the degree of patient-surrogate concordance in end-of-life decision making, the extent to which patients desire autonomy over end-of-life medical decisions, the reasons behind patients’ and surrogates’ decisions, and the main factors influencing patients’ and surrogates’ decision-making processes. We hypothesize that there is significant patient-surrogate discordance in end-of-life decision making in our community. Materials and Methods: The patient and surrogate were presented with a hypothetical scenario in which the patient experienced gradual functional decline in the community before being admitted for life-threatening pneumonia. It was explained that the outcome was likely to be poor even with intensive care and each patient-surrogate pair was subsequently interviewed separately on their opinions of extraordinary life support using a standardised questionnaire. Both parties were blinded to each other’s replies. Results: In total, 30 patients and their surrogate decision-makers were interviewed. Twenty-eight (93.3%) patients and 20 (66.7%) surrogates rejected intensive care. Patient-surrogate concurrence was found in 20 pairs (66.7%). Twenty-four (80.0%) patients desired autonomy over their decision. The patients’ and surrogates’ top reasons for rejecting intensive treatment were treatment-related discomfort, poor prognosis and financial cost. Surrogates’ top reasons for selecting intensive treatment were the hope of recovery, the need to complete final tasks and the sanctity of life. Conclusion: The majority of patients desire autonomy over critical care issues. Relying on the surrogates’ decisions to initiate treatment may result in treatment against patients’ wishes in up to one-third of critically ill elderly patients. Key words: Advanced medical directive, Intensive care

[Out-of-hospital assessment of elderly patients' preference for ICU care]

OBJECTIVE

To estimate the adequacy between elderly patients' preference for ICU care when treated for a life-threatening pathology, and the strategy proposed by the medical team on scene.

STUDY DESIGN

Prospective, observational study.

PATIENTS AND METHODS

All patients older than 80 treated out-of-hospital for a life threatening pathology were included, except in case of language barrier, or when patients were unable to answer and absence of next-of-kin. The results of the questionnaire on quality of life and patients' preference concerning ICU care were compared to the responses provided blindly by the medical team.

RESULTS

Fifty-five patients were included. Quality of life as expressed by the patients was 7 (5-10) and by the physician 7 (6-8) (P=0.69). Thirty-six patients (65%) expressed the wish to be resuscitated, while ICU admission would have been proposed for 44 patients (80%) by the doctors (P=0.01). Among the 14 patients reluctant to ICU admission, 11 would have been proposed for ICU admission. In multivariate analysis, age (OR: 1.55 [1.04-2.32], P=0.03) and history of neurological pathology (OR: 11,91 [5.68->100], P=0.04) were associated with such an inadequacy.

CONCLUSION

The inadequacy between elderly patients' preferences and doctors' opinion concerning ICU cares is frequent. The present results support a more systematic collection of patients' preferences when treated on scene for a life-threatening pathology.

Factors influencing older adults to complete advance directives

Objective:

The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults.

Method:

Direct interviews of hospitalized and community-dwelling cognitively intact patients >65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives. We identified five variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables.

Results:

Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p < 0.0002), age (p < 0.0161), race (p < 0.0001), education (p < 0.0039), and religion (p < 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3,p < 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2,p < 0.0001), having undergone major surgery (OR 6.3,p < 0.0017), female gender (OR 11.1,p < 0.0001) and increasing age (76–85vs.59–75: OR 3.4,p < 0.0543; <85vs. 59–75: OR 6.3,p < 0.0263).

Significance of results:

This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.

Contradictions in end-of-life decisions for self and other, expressed by relatives of chronically ventilated patients

OBJECTIVES

In certain populations, social, legal, and religious factors may influence end-of-life decisions in ventilator-dependent patients. This study aims to evaluate attitudes of first-degree relatives of chronically ventilated patients in Israel, toward end-of-life decisions regarding their loved ones, themselves, and unrelated others.

MATERIALS AND METHODS

The study was conducted in a chronic ventilation unit. First-degree family members of chronically ventilated patients were interviewed about their end-of-life attitudes for patients with end-stage diseases. Distinctions were made between attitudes in the case of their ventilated relatives, themselves, and unrelated others; between conscious and unconscious patients; and between a variety of interventions.

RESULTS

Thirty-one family members of 25 patients were interviewed. Median length of ventilation at the time of the interview was 13.4 months. Most interviewees wanted further interventions for their ventilated relatives, yet, for themselves, only 21% and 18% supported chronic ventilation and resuscitation, respectively, and 48% would want to be disconnected from the ventilator. Interventions were more likely to be endorsed for others (vs self), for the conscious self (vs unconscious self), and for artificial feeding (vs chronic ventilation and resuscitation). Interviewees were reluctant to disconnect patients from a ventilator.

CONCLUSIONS

Family members often want escalation of treatment for their ventilated relatives; however, most would not wish to be chronically ventilated or resuscitated under similar circumstances. Advance directives may reconcile people's wishes at the end of their own lives with their reticence to make decisions regarding others.

Patient awareness of prognosis, patient-family caregiver congruence on the preferred place of death, and caregiving burden of families contribute to the quality of life for terminally ill cancer patients in Taiwan

OBJECTIVES

The main goal of end-of-life care is to achieve the best quality of life (QOL) for patients. The purpose of this study was to investigate the impact of (1) the patients' awareness of their prognosis, (2) the extent of patient-family caregiver congruence on the preferences for end-of-life care options, and (3) the perceived caregiving burden of family caregivers when they provide end-of-life care to their dying relative, on the QOL for terminally ill cancer patients in Taiwan.

METHODS

A total of 1108 dyads of patient-family caregiver from 24 hospitals throughout Taiwan were one-time surveyed. Predictors of the QOL were identified by multiple regression analysis.

RESULTS

Controlling for the effects of age, financial status, and symptom distress, a novel finding of this study was that the patient awareness of prognosis, patient-family caregiver congruence on the preferred place of death, and the subjective family caregiving burden had a significant impact on the QOL of Taiwanese terminally ill cancer patients.

CONCLUSIONS

QOL is not only related to the unavoidable decline in physical condition and daily functioning of the dying patient but is also related to domains that, as death approaches, have the potential to show improvement through the efforts of health-care professionals, such as presenting prognostic information to optimize the patients' understanding and assists them with psychological adjustments, facilitating patient-family caregiver congruence on the end-of-life care decision regarding the place of death and lightening the caregiving burden of family caregivers.

Widowhood and Spirituality: Coping Responses to Bereavement

Nearly half of women age 65 or older are widows and nearly 70% of these women live alone. Because older women are three times more likely than their male counterparts to be widowed, widowhood has been labeled a primarily female phenomenon. This review article has two aims: (a) to discuss the impact of widowhood on the lives of older women and (b) to discuss how religion and spirituality may be used as coping methods for conjugal loss. After reviewing the literature the authors conclude that older women use religious coping as well as religious and spiritual beliefs and behaviors to facilitate positive adjustment to the loss of a spouse.

Treatment decisions regarding hospitalization and surgery for nursing home residents with advanced dementia: the CareAD Study

BACKGROUND

Dementia differs from other terminal illnesses both in its slow progression and the fact that patients and family members often do not perceive it as a cause of death. Furthermore, because decisional incapacity is almost universal in patients with advanced dementia, decisions must be made by surrogates. However, little is known about the factors that influence how surrogates make decisions for persons with late-stage dementia.

METHODS

The setting was the first wave of a study of patients with advanced dementia in three Maryland nursing homes (The Care of Nursing Home Residents with Advanced Dementia Study). Of 125 consented participants, 123 residents and their surrogates provided adequate information and agreed to interviews and medical record reviews. Bivariate analysis and logistic regression models were used to explore whether variables related to demographics, illness, communication and surrogate background were associated with surrogate decisions to not provide aggressive treatments (i.e. hospitalization or surgery).

RESULTS

Treatment decisions regarding aggressive medical care had been made by 81% of surrogates over the preceding 6 months. In bivariate analysis the following factors were significantly associated with not providing aggressive care: resident and surrogate of white race, older surrogate age, worse resident medical illness, worse surrogate perception of resident quality of life, presence of a 'do not hospitalize' order (DNH), and more contact with nurses. In the multivariate analysis, resident white race and presence of a DNH were significant predictors of surrogate decisions to not provide aggressive treatments. Treatment decisions were not associated with surrogate relationship or religiosity.

CONCLUSIONS

Treatment decisions for individuals with advanced dementia are mostly strongly associated with the patient's race and presence of DNH and less so with changeable features of illness or environment.

Do-not-resuscitate orders and/or hospice care, psychological health, and quality of life among children/adolescents with acquired immune deficiency syndrome

OBJECTIVE

The frequency of do-not-resuscitate (DNR) orders and hospice enrollment in children/adolescents living with acquired immune deficiency syndrome (AIDS) and followed in Pediatric AIDS Clinical Trials Group (PACTG) Study 219C was examined, and evaluated for any association with racial disparities or enhanced quality of life (QOL), particularly psychological adjustment.

METHODS

A cross-sectional analysis of children with AIDS enrolled in this prospective multicenter observational study between 2000 and 2005 was conducted to evaluate the incidence of DNR/hospice overall and by calendar time. Linear regression models were used to compare caregivers' reported QOL scores within 6 domains between those with and without DNR/hospice care, adjusting for confounders.

RESULTS

Seven hundred twenty-six (726) children with AIDS had a mean age of 12.9 years (standard deviation [SD]=4.5), 51% were male, 60% black, 25% Hispanic. Twenty-one (2.9%) had either a DNR order (n=16), hospice enrollment (n=7), or both (n=2). Of 41 children who died, 80% had no DNR/hospice care. Increased odds of DNR/hospice were observed for those with CD4% less than 15%, no current antiretroviral use, and prior hospitalization. No differences by race were detected. Adjusted mean QOL scores were significantly lower for those with DNR/hospice enrollment than those without across all domains except for psychological status and health care utilization. Poorer psychological status correlated with higher symptom distress, but not with DNR/hospice enrollment after adjusting for symptoms.

CONCLUSIONS

Children who died of AIDS rarely had DNR/hospice enrollment. National guidelines recommend that quality palliative care be integrated routinely with HIV care. Further research is needed to explore the barriers to palliative care and advance care planning in this population.

Concordance of preferences for end-of-life care between terminally ill cancer patients and their family caregivers in Taiwan

There is a dearth of information in the literature about the concordance of preferences for end-of-life care between terminally ill patients and their family surrogates outside the Western countries. The purpose of this study was to examine the extent of concordance in preferences for end-of-life care goals and life-sustaining treatments between Taiwanese terminally ill cancer patients and their primary family caregivers. A total of 617 dyads of patients-family caregivers across 21 hospitals throughout Taiwan were surveyed. Overall agreements on the goals for end-of-life care and preferences for initiating life-sustaining treatments ranged from 62.4% to 96.9% (average: 71.0%). Kappa values for the extent of concordance ranged from 0.13 to 0.46 (average: 0.29), indicating poor to moderate consistency in personal preferences. Family caregivers had a significantly more aggressive attitude toward each examined life-sustaining treatment for their ill family members than the patients' own stated preferences. In societies, such as in Asian countries, where physicians' respect for patient autonomy is frequently subordinate to the power of family, disagreements between a patient and family about end-of-life care may result in the patient's preferences being overridden at the end of life. To effect real change and to gain increased agreement on preferences for end-of-life care, an open dialogue between patients and their primary family caregivers should become standard.

Predictors of Site of Death of End-of-Life Patients: The Importance of Specificity in Advance Directives

Despite the compelling reasons for advance directives and their endorsement by the public and medical professions, little is known about their actual use and impact on site of death. This study was conducted to examine the role of advance directives and other "drivers" of hospitalization of the long-term care end-of-life patient. The medical records of 100 deceased consecutive nursing home residents, stratified by site of death (skilled nursing facility or acute care hospital), were reviewed by a team of geriatric researchers to obtain patient information in the following domains: sociodemographic, advance directives, transfer and death information, patient diagnoses at admission, discharge, and other time intervals; medication usage and signs and symptoms precipitating death. Severity of illness was assessed using the Cumulative Illness Rating Scale-G (CIRS-G). In testing for differences between patients by site of death, sociodemographic variables (gender, age, race, payer at discharge, cognitive capacity) did not significantly differ between the two groups of patients. Strong similarities between the groups were also found in terms of severity of illness and medication usage. Significantly higher proportions of patients dying in the nursing home had specific advance directives (do not resuscitate, do not intubate, do not artificially feed, do not hydrate, and do not hospitalize), as opposed to those dying in the hospital. The findings of this study demonstrate the impact of the explicit advance directive on the decision to transfer the patient to the acute care setting at the end of life.

Attitudes of relatives and nursing staff toward tuboenteral feeding in severely demented patients

Elderly patients with advanced dementia present a challenge with respect to efficient nutrition and hydration because of oropharyngeal dysphagia and lack of patient cooperation. For increasing numbers of patients, long-term tuboenteral feeding (TEF) is an alternative for providing food and fluids, with the hope of reducing the risk of aspiration. The purpose of this study is to learn about the opinions and the attitudes of relatives and nursing staff regarding patients on TEF for at least one year. The study included all the demented patients on TEF in four skilled nursing facilities and four nursing wards. Researchers retrieved clinical data from patients' medical records and prepared a questionnaire to survey the opinions of relatives and staff members. The study included 111 patients: 89 on nasogastric tube (NGT) feeding and 22 on percutaneous endoscopic gastrostomy (PEG) feeding. The clinical condition of both groups was satisfactory, as reflected by albumin, hemoglobin, and Body Mass Index (BMI). Relatives of the demented patients as well as the staff members were ambivalent toward TEF. Although most of them called it an essential procedure for delivering food and fluids for life support, about the same number expressed concerns that TEF prolonged a life of suffering. Nevertheless, most relatives and staff members were resistant to the idea of withholding TEF. The data show that TEF does provide efficient nutrition and hydration to patients with advanced dementia, and it is used in accordance with the will of the relatives. Any change in the present approach regarding TEF in these patients should be preceded by discussions with their relatives.

Discrepancies among patients, family members, and physicians in Korea in terms of values regarding the withholding of treatment from patients with terminal malignancies

BACKGROUND

The role of the physician in end-of-life decision-making is complicated. To analyze the controversies that surround therapeutic decision-making and the withholding of life-sustaining treatments, the authors compared values regarding therapeutic intervention that were held by physicians and family members of patients with terminal malignancies.

METHODS

One hundred fourteen patients with either advanced-stage or terminal disease were enrolled in the current study. Questionnaires were administered to the duty physician and to patients' family members. The questions covered issues such as the use of new anticancer agents with only partial efficacy (15%) and the use of opioid analgesics, intravenous nutrition, feeding tubes, antibiotics, and hemodialysis. In addition, participants were asked about the administration of cardiopulmonary resuscitation (CPR) and the use of ventilators, and when the patient's family consented, the same questionnaire was administered to the patient as well.

RESULTS

Seventeen of 114 families refused to answer the questionnaire. Of the 97 available families, only 14 permitted access to the patient. Of those 14 patients, 5 refused to complete the questionnaire. Overall, 100% of families and 87% of patients had some knowledge regarding malignant disease, but only 69% of families and 37% of patients clearly understood the stage of the patient's disease. The use of a new agent with only partial efficacy (approximately 15%) was accepted by 41% of physicians and by 60% of families. The concordance rate between patients' physicians and family members regarding the same patient was 42%. The rankings of the acceptance of treatment by physicians were as follows: opioid analgesics, 100%; antibiotics, 91%; feeding tube, 87%; and intravenous nutrition, 78%. The rankings of the same items by family members were as follows: opioid analgesics, 92%; antibiotics, 89%; intravenous nutrition, 86%; and feeding tube, 75%. The concordance rates between patients' physicians and families were lowest for ventilator application (39%) and CPR (47%).

CONCLUSIONS

Values held on issues such as therapeutic decision-making and the withholding of life-sustaining treatment for patients with terminal malignancies were discordant between physicians and family members. To resolve controversies regarding the role of the physician in end-of-life decision-making, the values of physicians, patients, and family members should be considered in the final decision-making process.

Culture, demographics, and critical care issues: an overview

The population dynamic and the immigration trends in the United States continue to challenge health care professionals who each day must serve an increasingly diverse population. Today's physicians must not only have a solid background in medical sciences but they must also have knowledge of how culture, race, and ethnicity impact how patients view and accept traditional Western practices. Whether doctors and patients are close in the "context spectrum" will often determine their ability to communicate beyond the spoken language. According to a report of the American Medical Association, by the year 2000, out of a total 812,770 physicians, only 2.5% were Black, 3.5% Hispanic, and 8.9% Asian. Only a fraction of a percent was American Native/Alaskan Native. Therefore, the majority of the physicians are Caucasian, and it could be assumed that they would likely be accustomed to high-context communication styles. The gross of the demographic changes and population increases in the United States during the past 10 years can be attributed to immigration from regions of the world where low-context communication styles are prevalent. Such differences between physicians and patients can create difficult, tense situations in an already charged atmosphere as can be that of a critical care unit.

Advance care planning in nursing homes: correlates of capacity and possession of advance directives

PURPOSE

The identification of nursing home residents who can continue to participate in advance care planning about end-of-life care is a critical clinical and bioethical issue. This study uses high quality observational research to identify correlates of advance care planning in nursing homes, including objective measurement of capacity.

DESIGN AND METHODS

The authors used cross-sectional, cohort study between 1997 and 1999. Seventy-eight residents (M age = 83.97, SD = 8.2) and their proxies (M age = 59.23, SD = 11.77) were included across five nursing homes. The authors obtained data via chart review, proxy interviews, resident assessments, survey completion by certified nursing assistants, and direct observation of residents' daily behaviors.

RESULTS

Capacity assessments revealed that most residents could state a simple treatment preference (82.4%), but a sizable number did not retain capacity to understand treatment alternatives or appreciate the consequences of their choice. Global cognitive ability (Mini-Mental State Examination score) was related to understanding and appreciation. When the authors removed the effects of global cognitive ability, understanding and appreciation were related to time spent by residents in verbal interaction with others. Residents were more likely to possess advance directives when proxies possessed advance directives, proxies were less religious, and residents were socially engaged.

IMPLICATIONS

Assessment of proxy beliefs and direct determination of residents' decisional capacity and social engagement may help nursing home staff identify families who may participate in advance planning for end-of-life medical care. Measures of global cognitive ability offer limited information about resident capacity for decision making. Decisional capacity assessments should enhance the verbal ability of individuals with dementia by reducing reliance on memory in the assessment process. Interventions to engage residents and families in structured discussions for end-of-life planning are needed.

Ethical aspects of cardiopulmonary resuscitation in premature neonates: where do we stand?

Advances in diagnosis, techniques, therapeutic interventions, organisation of perinatal care, and socio-economic factors have all contributed to the survival after resuscitation and intensive care of neonates with extremely low birth weight and gestational age. While morbidity during the first years of life in those infants does not increase, at school age multiple dysfunctions may become apparent. What are the limits of intensive care for the newborn? Is it right to use extreme technical and economic measures for neonates with a borderline chance of survival? What is justifiable for the neonate, the family, the society and how does legislation interfere in a decision process which involves starting, stopping or continuing intensive care? A short historical overview for the care of the newborn is given, followed by the outcome after resuscitation and treatment of the very low birth weight infant. Published management strategies and recommendations are discussed.

Synthesis of research and evidence on factors affecting the desire of terminally ill or seriously chronically ill persons to hasten death

Review of empirical studies indicates that suicide is more common in persons suffering from some physical illnesses (e.g., epilepsy, head injuries, Huntington's Chorea, gastrointestinal diseases, AIDS, and cancer), but other chronic diseases and disabilities have not been linked to increased suicide risk (e.g., blindness, senile dementia, multiple sclerosis, and other physical handicaps). The timing of increased suicide risk varies in different illnesses from early presymptomatic stages to the terminal phase. Difficulties in reliably determining when someone is “terminally ill” and problems of the competence of persons with a poor prognosis complicate empirical investigations of euthanasia, assisted suicide, and the desire to hasten death. The role of family and caregivers in end of life decisions needs further clarification. Researchers have found that pain and suffering and quality of life variables may be linked to the desire to die prematurely, particularly in cancer patients. Others find that clinical depression is a major factor. But, since depression is often present, we do not know why a small minority of depressed patients desire and choose to hasten death. Support for alternative hypotheses is examined, including the role of pre-morbid suicidality and depression, individual differences in coping strategies and indirect consequences of the illness. There is a need to clarify links between attitudes, which is the major variable studied, and actual behaviors and decisions. Furthermore, we need theoretical and empirical links between studies of suicide, which is linked to clinical depression and characterized by ambivalence and studies of euthanasia, which is often depicted as rational and with little ambivalence. Evaluative research should be conducted to determine if interventions to reduce the desire for a premature death by suicide, euthanasia, or assisted suicide are effective. In the light of this review, we present several considerations for those involved in proposing changes in public policy concerning euthanasia and assisted suicide.

Measuring quality in end-of-life care

Scrutiny of the quality of medical care near the end of life is increasing. Experts have begun to define and conceptualize quality of care for dying patients and are developing measurement tools to assess quality of care in this population. Definitions and conceptual models of quality of care at the end of life are reviewed. Approaches for measuring the processes and outcomes of end-of-life care are discussed. Approaches for initiating quality assessment of end-of-life care among geriatric patients are suggested.

Life-sustaining treatments: what doctors do, what they want for themselves and what elderly persons want

In view of the current social dilemmas regarding the use of life-sustaining treatments (LST) at the end of life, the purpose of the study was to reveal sources of interpersonal and intrapersonal conflict among the most involved parties, in a society where open doctor-patient communication about end-of-life treatment is rare. Two comparative analyses were conducted: (a) between physicians' practice and elderly persons' preferences regarding the use of different life-sustaining treatments in different illness conditions, and (b) between physicians' hypothetical practice for an elderly person in a metastatic cancer condition, elderly persons' preferences and physicians' preferences for themselves, should they be in the same illness condition. Data were collected in Israel from 339 physicians working in two medical centers, and from a random sample of 987 elderly persons. Attitudes and practice regarding artificial tube feeding, mechanical ventilation and cardiopulmonary resuscitation (CPR) in three different illness conditions were evaluated by close-ended questions. The findings indicate disagreements between the elderly and the physicians on a number of issues: in general, physicians report that they would use more LST than what the elderly report that they would want. Physicians differentiate among different illness conditions and different LST more than elderly persons do. Physicians are more likely to use artificial feeding than CPR, while elderly persons prefer the use of CPR more than artificial feeding. The comparison of physicians' hypothetical practice, the wishes of the elderly, and physicians' wishes for themselves regarding the use of LST in a metastatic cancer condition, shows that physicians would use LST differently from what the elderly want, and that they want less LST for themselves than they would order for elderly patients. The discrepancies found between the physicians' practice and the elderly persons preferences reflect differences in perceptions of artificial feeding and a lack of public knowledge regarding the effectiveness of CPR. They also reflect differences in attitudes regarding the prolongation of life in various illness conditions. The discrepancy between physicians' practice and their preferences for themselves underscores the personal and professional dilemmas related to these issues, which are faced daily by many physicians, and impede their compassionate behavior toward patients. Increasing the awareness of physicians of such discrepancies, and providing them with appropriate behavioral tools, including communication skills, is a timely need which should be addressed by the medical profession, medical services and medical schools.

Longitudinal changes in attitudes of offspring concerning life-sustaining measures for their terminally ill parents

OBJECTIVES

To define longitudinal changes in the attitudes of offspring concerning life-sustaining measures for their older, terminally ill parents and to determine whether experience of a "life event" influences such decisions.

DESIGN

An attitudinal survey of three groups.

SETTING

The geriatric department of a university-affiliated general hospital.

PARTICIPANTS

Fifty-one subjects who had been interviewed regarding life-sustaining treatment for their terminally ill parents were reinterviewed 6 years later. In addition, a control group composed of 116 participants was generated from patients visiting hospital outpatient clinics. The control group had no prior experience involving hospitalization of a first-degree relative as a result of a life-threatening situation.

INTERVENTIONS

Each subject took part in a personal interview.

MAIN OUTCOME MEASURES

Attitudes regarding life-sustaining measures were assessed, and the subjects' sociodemographic and religious characteristics were noted.

RESULTS

The attitudes of offspring in the acute phase situation and after the passage of 6 years were strikingly consistent. Twenty-one percent had requested the initiation of resuscitation in the acute phase ("real time"), and 27.4% said the same 6 years later. The provision of nutrition and medication was requested by approximately 70% of participants both at the acute phase and 6 years later. When comparing each individual's personal views at the interviews with all others, consistency in attitude was found among answers to most questions. When comparing the acute phase group with the control group, a significantly higher percentage of the former requested the initiation of resuscitation (48.3% vs 25%), whereas a smaller percentage preferred that the decision be made by the physician (3.5% vs 21.3%). Active euthanasia was requested by 6.5% of the acute phase group and 12.9% of the control group.

CONCLUSIONS

The decisions made by offspring regarding life-sustaining measures for their terminally ill parent at real time remain unchanged 6 years after the event. Exposure to a life event significantly affects the decision-making of the offspring of a terminally ill parent. However, the subject's attitude toward extreme solutions--opposing active euthanasia and requesting the administration of nutrition and medication--was not influenced by the fact that the subject had undergone a life event.

Stability of elderly persons' expressed preferences regarding the use of life-sustaining treatments

The purpose of the study was to assess the stability of expressed preferences for the use of life-sustaining treatments (LST) in severe illness conditions over two years. The two year longitudinal study included three structured interviews with a one-year interval (1994, 1995, and 1996). At baseline, 1138 Israeli elderly persons (70+) were interviewed, 802 and 638 were interviewed in the following stages. Stability over time was assessed on the basis of score differences on two different indices that measured the wish to prolong life. Overall 70% of the respondents had stable preferences for the use of LST over time. This result was similar on both indices. The large majority of those with stable preferences (86%) did not want to prolong life already in the baseline interview. This was the most stable group. Among those who changed their wishes, the group that wanted LST less at stage 3 (20%) was twice as large as the group that wanted LST more (10%). These findings, which are similar to those reported in a study of an American sample, indicate a high level of stability in elderly persons' expressed preferences for LST at the end of life, and, therefore, strengthen the ethical basis for using advance directives. They also indicate that elderly persons of different cultural backgrounds may face similar problems regarding the prolongation of life and respond to them similarly.

Meanings and attitudes toward end-of-life preferences in Israel

Thirty-six elderly people in Israel were interviewed concerning their meanings and attitudes toward end-of-life preferences. The phenomenological analysis method resulted in the identification of six meaning themes and a continuum of favorable to unfavorable attitude positions for each meaning theme. The combination of meaning themes and attitude positions produced 4 patterns of perspectives toward euthanasia, as well as a more holistic and integrative cultural dimension that was labeled Israel ego integrity. The 6 meaning themes were (a) moral perspectives, (b) religious beliefs, (c) mental and physical suffering, (d) family and community implications, (e) gaining control by willingness to trust others, and (f) previous experiences with death. The 4 patterns of perspectives toward euthanasia emphasized consequences for others, religious perspectives, concerns for personal suffering, and concerns for moral choice. The extensive diversity in the meaning-attitude perspectives from a small sample of elderly people suggested challenges for Israeli policy in regard to legalizing the living will to respect patients' rights to make end-of-life decisions.

My parent's dignified death is different from mine: moral problem solving about euthanasia

The purpose of the study was to explore the moral problem solving of Israeli adult children concerning passive euthanasia when considering the death of any citizen in society, one’s own death, a partner’s death, and the impending death of an elderly ill parent. The qualitative analysis of 12 in-depth interview transcripts by analytic induction and constant comparison methods revealed how adults think about moral problems that are of differing distances from the self. A parents’ death, compared with other deaths, elicited strong emotional reactions and was associated with reasoning struggles that involved a wide range of role perspectives; a moral orientation of care; and value priorities of honor through loyalty, compassion and devotion.

Holocaust survivors' perspectives on the euthanasia debate

The paper reports on a qualitative analysis of 15 personal interviews with holocaust survivors in Israel concerning their perceptions of similarities and differences between socially-assisted dying and the holocaust policies. The design of the study was exploratory/descriptive and asked the following questions: "Some discussions have expressed similarities between Nazi Germany and euthanasia. Do you believe the comparison is justified? In what ways are euthanasia and the holocaust similar? In what ways are they different?" Participants concluded that profound differences existed between Nazi Germany and socially assisted dying. These differences were established from four different perspectives in 10 different themes, and demonstrated by 24 different examples of the themes. Informants further cautioned philosophers about comparisons between the holocaust and other human behaviors. The survivors perceived that such a comparison has negative consequences for their own well-being, the dignity of their family members, the next generation and the Israeli society.

Suicide, euthanasia and AIDS

This article critically reviews research on suicide, AIDS, and HIV seropositivity. Studies indicate that men with a diagnosis of AIDS or HIV seropositivity have up to 36 times greater risk of suicide than men without the diagnosis. Yet few studies controlled for independent risk factors such as premorbid or comorbid psychiatric syndromes. Also, control groups may not be appropriate, little data are available on women, and explanations of suicidal dynamics are mostly speculative. After a look at the research on the desire for euthanasia and assisted suicide with other illnesses, the author suggests alternative hypotheses concerning suicidality, the desire for euthanasia, and AIDS.

Surrogates' agreement with patients' resuscitation preferences: effect of age, relationship, and SUPPORT intervention. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment

PURPOSE

The purpose of this study was to evaluate an intervention to improve patient-surrogate agreement on end-of-life resuscitation preferences.

MATERIALS AND METHODS

Seven hundred seventeen patients with a 50% 6-month survival rate and their surrogate decision-makers were recruited for a randomized clinical trial from five teaching hospitals participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Intervention patients (n=386) were assigned specially trained nurses who spent extra time with patients and families explaining prognoses and treatments. Control patients (n=331) received usual care. Patient preferences and surrogate's perception of those preferences at pre- and post-intervention interviews were compared.

RESULTS

Agreement between patients and surrogates was 75.0% at the day 3 interview and 79.6% at the month 2 interview, increasing 4.6% (95% CI: 0.1%, 9.1%). Improvements in agreement from day 3 to month 2 were seen equally in both study groups. A multivariable analysis verified that the intervention did not have an effect on agreement and indicated a decrease in agreement among older patients and among surrogates not in the immediate family.

CONCLUSIONS

The SUPPORT intervention was not successful in increasing agreement between patients and surrogates. Because of the complex issues involved in end-of-life decision-making, a more aggressive intervention may be needed. Other findings suggest that improvements in communication are particularly needed when patients are older and when the surrogate is not a patient's immediate relative.

Promoting patient decision making in life-and-death situations

OBJECTIVES

To review factors in the health care culture that deny seriously ill patients' last wishes regarding care.

DATA SOURCES

Review articles and research studies that pertain to decision making.

CONCLUSIONS

Decision making in palliative care has been identified as an understudied area. Although there are significant benefits to being involved in treatment decision making, long-term follow-up of the consequences of active participation in the final stages of life is lacking.

IMPLICATIONS FOR NURSING PRACTICE

Nurses have a role to play in assisting patients and their families in treatment decision making in both the curative and palliative phase of care. A nursing intervention to promote patient involvement in decision making is described.

Ethnicity and decision-makers in a group of frail older people

OBJECTIVE

To assess the relationship between ethnicity and decision-makers expressing healthcare wishes in a group of frail older persons enrolled in the Program of All-inclusive Care for the Elderly (PACE).

DESIGN

A retrospective chart review of 1193 participants in the PACE program.

SETTING

Program of All-inclusive Care for the Elderly, a comprehensive managed care demonstration program serving frail older participants at 10 sites across the nation.

PARTICIPANTS

A total of 1193 older adults, all of whom met state criteria for nursing home level of care. Three hundred were non-Hispanic whites, 364 were black, 156 were Hispanic, and 288 were Asian.

MEASUREMENTS

Demographic characteristics of the patients and the presence or absence of an alternative decision-maker; the characteristics of alternative decision-makers included the relationship to the participant as recorded in the patient's medical record.

RESULTS

Ninety-one percent of white patients expressed their own healthcare wishes in contrast to only 85% of Hispanic, 83% of Asian, and 67% of black patients. An alternative decision-maker was identified for about 15% of Asians and Hispanics and for one-third of blacks, but only about 8% of whites had an alternative decision-maker. Black and Hispanic patients were most likely to have a daughter as an alternative decision-maker, Asians were most likely to have a son, and whites patients were most likely to have a spouse as an alternative decision-maker. Blacks, particularly black men, were the most likely to have a relative other than a spouse or child as an alternative decision-maker.

CONCLUSIONS

In this population, we found significant ethnic variation in the person identified to be the decision-maker in a group of frail older people. Ethnic variation reflected sociodemographic as well as cultural differences. However, there are important limitations to this study, and caution should be used in extrapolating the results to other populations or in attributing the results to ethnicity alone. An awareness of cross-cultural patterns in identified or de facto decision-makers can be significant for healthcare workers when they approach patients and their families about issues surrounding end of life decisions.

Medical students' attitudes regarding the use of life-sustaining treatments for themselves and for elderly persons

This study investigated students' wishes regarding the use of life-sustaining treatments (LST) in different health conditions compared with their evaluations of the wishes of elderly people, and with reports of a group of elderly people about themselves. Data were collected from two consecutive classes of first year medical students (n = 101), and a random sample of Israeli elderly aged 70+ (n = 987) who responded to fixed-choice questions regarding their will to live and wishes for three kinds of LST in a number of hypothetical illness conditions. The students were also asked to assess elderly's wishes. Students ranked the will to live of elderly persons significantly lower than their own. The elderly ranked their will to live significantly lower than did the students, but higher than the students assumed about them, indicating that although the will to live is weaker among older people, it is stronger than young persons believe. With regard to the use of LST, students believe that old people want less LST than themselves, but the elderly want even less LST than assumed by the students. The best predictors of students' wishes for themselves were fear of dying and religiosity. Fear of dying, the students' self-esteem and religiosity were the best predictors of their evaluations of the elderly's wishes. The results indicate that both the elderly and the students have a relatively strong will to live, but this desire is dependent on quality of life. The implications of this study for medical education are discussed.

Reaching consensus: the process of recommending treatment decisions for Alzheimer's patients

Observational and interview data obtained from nurse caregivers and family members of patients with late-stage Alzheimer's disease were analyzed to explicate the nursing role in advance proxy planning. A four-phase model, Achieving Consensus: Decision Making to Determine Treatment Options for Patients with Alzheimer's Disease, was developed. Patient decline, family coping, professional development of nursing staff, and nursing unit philosophy were community characteristics found to be important antecedents to the process of reaching consensus. Achieving consensus constructs included interactive process components of patient, family, and staff adjustment, caring, and knowing. Timing and trust were influential catalysts to family and staff readiness factors for achieving consensus. Outcomes were the advice provided by staff and the family conference where treatment options were determined. Consequences included the advance proxy plan and patient care.

Clinical ethics committee

An informal clinical ethics committee was set up to advise on ethical problems in prenatal diagnosis in Leeds. It was used twice in six months but was not called on again in the subsequent year, and we describe this experience. In North America similar committees are often used to advise on clinical moral dilemmas, and we review the published evidence from there and discuss some of the advantages and problems. Our committee's advice may have altered clinicians' actions considerably, but perhaps doctors in Britain are not yet ready to surrender this aspect of clinical autonomy.

The WHO objectives for palliative care: to what extent are we achieving them?

This paper examines recent research in palliative care in the light of the guiding principles set out by the World Health Organization. It outlines the gaps in the literature and suggests priorities for future research. Areas of unmet need are documented and it is argued that research comparing outcomes across care settings and relating particular care practices to outcome measures would help to set care targets. Further definition of the expected outcomes of psychological and spiritual care, as well as care for carers, is recommended. Available measures are reviewed and suggestions made for the development of additional measures. Finally, some key methodological problems are discussed, including making cross-setting comparisons, identifying appropriate outcome measures, prioritizing patients' own identification of outcomes, using different methodologies as death approaches, and combining different perspectives offered by patients, lay carers and professional carers. The role of qualitative data as an indicator of rating scale validity is discussed in this context.

The limits of proxy decision making: overtreatment

Traditionally, surrogates have been involved principally in making decisions about life-sustaining treatment for incompetent individuals. Today, surrogates are increasingly called upon to make everyday medical decisions for patients who are incompetent because they are demented. Some of the potential perils of proxy decision making under these circumstances have been identified, including the lack of concordance between patients and their proxies, demands by proxies for technically futile therapy, and actual abuse of patients. We found a significant number of cases in which healthcare providers at a long-term care facility came into conflict with surrogates because the treatment desired by the surrogate was viewed as excessively burdensome when evaluated by an experienced team of nurses, physicians, and social workers. Neither a court-appointed guardian nor an Institutional ethics committee were likely to be able to resolve these conflicts because of lack of clarity about what constitutes the best Interest of Impaired nursing home patients. The following case illustrates this increasingly common conflict.