1
|
Yip WKA, Chung PMB, Christensen M. End-of-life conversations for the older person: A concept analysis. Scand J Caring Sci 2024. [PMID: 38778516 DOI: 10.1111/scs.13263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/29/2024] [Accepted: 04/07/2024] [Indexed: 05/25/2024]
Abstract
AIM The aim of this concept analysis is to seek clarity as to what end-of-life conversations involve by developing a clear working definition and using model cases to conceptualise the defining attributes of an end-of-life conversations with the older person. DESIGN Walker and Avant's eight step approach to Concept Analysis. DATA SOURCES Four databases were searched, including PubMed, CINAHL, PsycINFO, and Scopus. A total of 339 publications were identified with 30 papers meeting the inclusion criteria and put forward for the final conceptual analysis. RESULTS The defining attributes associated with end-of life conversations included (1) an ongoing process of older person empowerment, (2) discussion's concerning values and preferences concerning end-of-life issues, and (3) maintaining an open dialogue between all concerned individuals. Antecedents were associated with the older person is their readiness to talk openly about death and dying. Consequences were identified as having a better understanding of what death and dying may mean to the older person in a more specific manner. CONCLUSIONS End-of-life conversations are vital in understanding an individual's values and preferences at the end of life, and yet, the concept of the end-of-life conversation has not been well defined in the literature. End-of-life conversations with the older person encompass ongoing discussions and maintaining open dialogue around end-of-life care while developing strategies to promote individual empowerment in making informed choices. Using a conceptual model, aides in addressing aspects of end-of-life conversations and an acknowledgment of the dynamic process of end-of-life conversations.
Collapse
Affiliation(s)
- Wing Ki Agnes Yip
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong
- School of Nursing, Tung Wah College, Kowloon, Hong Kong
| | - Pui Man Betty Chung
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong
- Interdisciplinary Centre for Qualitative Research, Hong Kong Polytechnic University, Kowloon, Hong Kong
| | - Martin Christensen
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong
- Interdisciplinary Centre for Qualitative Research, Hong Kong Polytechnic University, Kowloon, Hong Kong
| |
Collapse
|
2
|
Umberfield EE, Fields MC, Lenko R, Morgan TP, Adair ES, Fromme EK, Lum HD, Moss AH, Wenger NS, Sudore RL, Hickman SE. An Integrative Review of the State of POLST Science: What Do We Know and Where Do We Go? J Am Med Dir Assoc 2024; 25:557-564.e8. [PMID: 38395413 PMCID: PMC10996838 DOI: 10.1016/j.jamda.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES POLST is widely used in the care of seriously ill patients to document decisions made during advance care planning (ACP) conversations as actionable medical orders. We conducted an integrative review of existing research to better understand associations between POLST use and key ACP outcomes as well as to identify directions for future research. DESIGN Integrative review. SETTING AND PARTICIPANTS Not applicable. METHODS We queried PubMed and CINAHL databases using names of POLST programs to identify research on POLST. We abstracted study information and assessed study design quality. Study outcomes were categorized using the international ACP Outcomes Framework: Process, Action, Quality of Care, Health Status, and Healthcare Utilization. RESULTS Of 94 POLST studies identified, 38 (40%) had at least a moderate level of study design quality and 15 (16%) included comparisons between POLST vs non-POLST patient groups. There was a significant difference between groups for 40 of 70 (57%) ACP outcomes. The highest proportion of significant outcomes was in Quality of Care (15 of 19 or 79%). In subdomain analyses of Quality of Care, POLST use was significantly associated with concordance between treatment and documentation (14 of 18 or 78%) and preferences concordant with documentation (1 of 1 or 100%). The Action outcome domain had the second highest positive rate among outcome domains; 9 of 12 (75%) Action outcomes were significant. Healthcare Utilization outcomes were the most frequently assessed and approximately half (16 of 35 or 46%) were significant. Health Status outcomes were not significant (0 of 4 or 0%), and no Process outcomes were identified. CONCLUSIONS AND IMPLICATIONS Findings of this review indicate that POLST use is significantly associated with a Quality of Care and Action outcomes, albeit in nonrandomized studies. Future research on POLST should focus on prospective mixed methods studies and high-quality pragmatic trials that assess a broad range of person and health system-level outcomes.
Collapse
Affiliation(s)
- Elizabeth E Umberfield
- Division of Nursing Research, Department of Nursing, Mayo Clinic, Rochester, MN, USA; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA.
| | - Matthew C Fields
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA
| | - Rachel Lenko
- Department of Nursing, School of Health, Calvin University, Grand Rapids, MI, USA
| | - Teryn P Morgan
- Center for Biomedical Informatics, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of BioHealth Informatics, School of Informatics and Computing, Indiana University, Indianapolis, IN, USA
| | | | - Erik K Fromme
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA; Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alvin H Moss
- Center for Health Ethics and Law, West Virginia University Health Sciences Center, Morgantown, WV, USA; Divisions of Nephrology and Palliative Medicine, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, CA, USA; San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, IN, USA; Research in Palliative and End-of-Life Communication and Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
| |
Collapse
|
3
|
Hickman SE, Sudore RL, Torke AM, Tang Q, Bakoyannis G, Heim Smith N, Myers AL, Hammes BJ. POLST recall, concordance, and decision quality outcomes among nursing home residents and surrogate decision-makers. J Am Geriatr Soc 2023. [PMID: 36929327 DOI: 10.1111/jgs.18330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND POLST orders are actionable in an emergency, so it is important that the decisions be of high quality and concordant with current preferences. The goal of this study is to determine the relationship between concordance and decision quality outcomes, including decision satisfaction and decisional conflict, among nursing facility residents and surrogates who recall POLST. METHODS We completed structured interviews in 29 nursing facilities with 275 participants who had previously signed a POLST form. This included residents who were still making their own medical decisions (n = 123) and surrogate decision-makers for residents without decisional capacity (n = 152). POLST recall was defined as remembering talking about and/or completing the POLST form previously signed by the participant. Concordance was determined by comparing preferences elicited during a standardized interview with the POLST form on file. Decisional conflict, decision satisfaction, and conversation quality were assessed with standardized tools. RESULTS Half of participants (50%) remembered talking about or completing the POLST form, but recall was not associated with the length of time since POLST completion or concordance with existing preferences. In multivariable analyses, there was no association between POLST recall, concordance, and decision quality outcomes, though satisfaction was associated with conversation quality. CONCLUSIONS Half of the residents and surrogates in this study recalled the POLST they previously signed. Neither the age of the form nor the ability to recall the POLST conversation should be considered indicators of whether existing POLST orders match current preferences. Findings confirm a relationship between POLST conversation quality and satisfaction, underscoring the importance of POLST completion as a communication process.
Collapse
Affiliation(s)
- Susan E Hickman
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA.,Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Rebecca L Sudore
- Division of Geriatrics, School of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Alexia M Torke
- Research in Palliative and End-of-Life Communication & Training (RESPECT) Signature Center, Indiana University Purdue University Indianapolis, Indianapolis, Indiana, USA.,Division of General Internal Medicine & Geriatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, Indiana, USA
| | - Qing Tang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Giorgos Bakoyannis
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Fairbanks School of Public Health, Indiana University, Indianapolis, Indiana, USA
| | - Nicholette Heim Smith
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Anne L Myers
- Department of Community & Health Systems, Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Bernard J Hammes
- Respecting Choices, A Division of C-TAC Innovations, La Crosse, Wisconsin, USA
| |
Collapse
|
4
|
Mallidou AA, Tschanz C, Antifeau E, Lee KY, Mtambo JK, Heckl H. The Medical Orders for Scope of Treatment (MOST) form completion: a retrospective study. BMC Health Serv Res 2022; 22:1186. [PMID: 36131303 PMCID: PMC9492459 DOI: 10.1186/s12913-022-08542-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 09/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Advance care planning (ACP) involves discussions about patient and families’ wishes and preferences for future healthcare respecting autonomy, improving quality of care, and reducing overtreatment. The Medical Orders for Scope of Treatment (MOST) form records person preferred level and types of treatment and intervention. Purpose To examine the MOST form use in inpatient units within a British Columbia (Canada) hospital, estimate and compare its completion rate, and inform health policies for continuous, quality and individualized patient care. Methods About 5,000 patients admitted to the participating tertiary acute care hospital during October 2020. Data from 780 eligible participants in medical, surgical, or psychiatry unit were analyzed with descriptive statistics, the chi-square test for group comparisons, and logistic regression to assess predictors of the MOST form completion. Results Participants’ (54% men) age ranged from 20–97 years (mean = 59.53, SD = 19.54). Mainly physicians (99.1%) completed the MOST form for about 60% of them. A statistically significant difference of MOST completion found among the units [Pearson χ2(df=2, n=780) = 79.53, p < .001, φ = .319]. Multivariate logistic regression analysis demonstrated that age (OR = 1.05, 95% CI 1.04 to 1.06) and unit admission (OR = .60, 95% CI 0.36 to 0.99 in psychiatry; and OR = .21, 95% CI 0.14 to 0.31 in surgery) were independently associated with the MOST form completion. Conclusion Our findings demonstrate a need for consistent and broad completion of the MOST form across all jurisdictions using, desirably, advanced electronic systems. Healthcare providers need to raise awareness of the MOST completion benefits and be prepared to discuss topics relevant to end-of-life. Further research is required on the MOST form completion.
Collapse
Affiliation(s)
- Anastasia A Mallidou
- School of Nursing, University of Victoria, B236 - HSD Building, 3800 Finnerty (Ring) Road, Victoria, BC, V8P 5C2, Canada.
| | - Coby Tschanz
- School of Nursing, University of Victoria, B236 - HSD Building, 3800 Finnerty (Ring) Road, Victoria, BC, V8P 5C2, Canada
| | - Elisabeth Antifeau
- Palliative Care and End of Life Services, Interior Health, Vancouver, VIC, Canada
| | | | | | - Holly Heckl
- School of Nursing, University of Victoria, B236 - HSD Building, 3800 Finnerty (Ring) Road, Victoria, BC, V8P 5C2, Canada
| |
Collapse
|
5
|
Young M, Peterson AH. Neuroethics across the Disorders of Consciousness Care Continuum. Semin Neurol 2022; 42:375-392. [PMID: 35738293 DOI: 10.1055/a-1883-0701] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
6
|
Jennings LA, Wenger NS, Liang LJ, Parikh P, Powell D, Escarce JJ, Zingmond D. Care preferences in physician orders for life sustaining treatment in California nursing homes. J Am Geriatr Soc 2022; 70:2040-2050. [PMID: 35275398 DOI: 10.1111/jgs.17737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/02/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Physician Orders for Life-Sustaining Treatment (POLST) facilitates documentation and transition of patients' life-sustaining treatment orders across care settings. Little is known about patient and facility factors related to care preferences within POLST across a large, diverse nursing home population. We describe the orders within POLST among all nursing home (NH) residents in California from 2011 to 2016. METHODS California requires NHs to document in the Minimum Data Set whether residents complete a POLST and orders within POLST. Using a serial cross-sectional design for each year, we describe POLST completion and orders for all California NH residents from 2011 to 2016 (N = 1,112,668). We used logistic mixed-effects regression models to estimate POLST completion and resuscitation orders to understand the relationship with resident and facility characteristics, including Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare overall five-star quality rating. RESULTS POLST completion significantly increased from 2011 to 2016 with most residents having a POLST in 2016 (short-stay:68%; long-stay:81%). Among those with a POLST in 2016, 54% of long-stay and 41% of short-stay residents had a DNR order. Among residents with DNR, >90% had orders for limited medical interventions or comfort measures. Few residents (<6%) had a POLST with contradictory orders. In regression analyses, POLST completion was greater among residents with more functional dependence, but was lower among those with more cognitive impairment. Greater functional and cognitive impairment were associated with DNR orders. Racial and ethnic minorities indicated more aggressive care preferences. Higher CMS five-star facility quality rating was associated with greater POLST completion. CONCLUSIONS Six years after a state mandate to document POLST completion in NHs, most California NH residents have a POLST, and about half of long-stay residents have orders to limit life-sustaining treatment. Future work should focus on determining the quality of care preference decisions documented in POLST.
Collapse
Affiliation(s)
- Lee A Jennings
- Reynolds Section of Geriatrics, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Neil S Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Li-Jung Liang
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Punam Parikh
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Jose J Escarce
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - David Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| |
Collapse
|
7
|
Vranas KC, Plinke W, Bourne D, Kansagara D, Lee RY, Kross EK, Slatore CG, Sullivan DR. The influence of POLST on treatment intensity at the end of life: A systematic review. J Am Geriatr Soc 2021; 69:3661-3674. [PMID: 34549418 DOI: 10.1111/jgs.17447] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/04/2021] [Accepted: 08/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Despite its widespread implementation, it is unclear whether Physician Orders for Life-Sustaining Treatment (POLST) are safe and improve the delivery of care that patients desire. We sought to systematically review the influence of POLST on treatment intensity among patients with serious illness and/or frailty. METHODS We performed a systematic review of POLST and similar programs using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, Cochrane Database for Systematic Reviews, and PsycINFO, from inception through February 28, 2020. We included adults with serious illness and/or frailty with life expectancy <1 year. Primary outcomes included place of death and receipt of high-intensity treatment (i.e., hospitalization in the last 30- and 90-days of life, ICU admission in the last 30-days of life, and number of care setting transitions in last week of life). RESULTS Among 104,554 patients across 20 observational studies, 27,090 had POLST. No randomized controlled trials were identified. The mean age of POLST users was 78.7 years, 55.3% were female, and 93.0% were white. The majority of POLST users (55.3%) had orders for comfort measures only. Most studies showed that, compared to full treatment orders on POLST, treatment limitations were associated with decreased in-hospital death and receipt of high-intensity treatment, particularly in pre-hospital settings. However, in the acute care setting, a sizable number of patients likely received POLST-discordant care. The overall strength of evidence was moderate based on eight retrospective cohort studies of good quality that showed a consistent, similar direction of outcomes with moderate-to-large effect sizes. CONCLUSION We found moderate strength of evidence that treatment limitations on POLST may reduce treatment intensity among patients with serious illness. However, the evidence base is limited and demonstrates potential unintended consequences of POLST. We identify several important knowledge gaps that should be addressed to help maximize benefits and minimize risks of POLST.
Collapse
Affiliation(s)
- Kelly C Vranas
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Wesley Plinke
- Oregon Health & Science University School of Medicine, Portland, Oregon, USA
| | - Donald Bourne
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Devan Kansagara
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Christopher G Slatore
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Section of Pulmonary and Critical Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Donald R Sullivan
- Health Services Research & Development, VA Portland Health Care System, Portland, Oregon, USA.,Division of Pulmonary and Critical Care, Oregon Health & Science University, Portland, Oregon, USA.,Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
8
|
Hickman SE, Steinberg K, Carney J, Lum HD. POLST Is More Than a Code Status Order Form: Suggestions for Appropriate POLST Use in Long-Term Care. J Am Med Dir Assoc 2021; 22:1672-1677. [PMID: 34029523 DOI: 10.1016/j.jamda.2021.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/16/2021] [Accepted: 04/18/2021] [Indexed: 11/25/2022]
Abstract
POLST (Physician Orders for Life-Sustaining Treatment) is a medical order form used to document preferences about cardiopulmonary resuscitation (CPR), medical interventions such as hospitalization, care in the intensive care unit, and/or ventilation, as well as artificial nutrition. Programs based on the POLST paradigm are used in virtually every state under names that include POST (Physician Orders for Scope of Treatment), MOLST (Medical Orders for Life-Sustaining Treatment), and MOST (Medical Orders for Scope of Treatment), and these forms are used in the care of hundreds of thousands of geriatric patients every year. Although POLST is intended for persons who are at risk of a life-threatening clinical event due to a serious life-limiting medical condition, some nursing homes and residential care settings use POLST to document CPR preferences for all residents, resulting in potentially inappropriate use with patients who are ineligible because they are too healthy. This article focuses on reasons that POLST is used as a default code status order form, the risks associated with this practice, and recommendations for nursing homes to implement appropriate use of POLST.
Collapse
Affiliation(s)
- Susan E Hickman
- Indiana University School of Nursing, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA.
| | - Karl Steinberg
- California State University, Institute for Palliative Care, Oceanside, CA, USA
| | - John Carney
- Center for Practical Bioethics, Kansas City, MO, USA
| | - Hillary D Lum
- VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, CO, USA; Division of Geriatric Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
9
|
Tolle SW. Aligning POLST orders with wishes: Time to put evidence into practice. J Am Geriatr Soc 2021; 69:1801-1804. [PMID: 33826762 PMCID: PMC8360100 DOI: 10.1111/jgs.17150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 01/31/2023]
Affiliation(s)
- Susan W Tolle
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University Center for Ethics in Health Care, Portland, Oregon, USA
| |
Collapse
|