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High-Intensity Care for Nursing Home Residents with Severe Dementia Hospitalized at the End of Life: A Mixed Methods Study. J Am Med Dir Assoc 2024; 25:871-875. [PMID: 38462230 PMCID: PMC11065599 DOI: 10.1016/j.jamda.2024.02.001] [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: 10/25/2023] [Revised: 01/23/2024] [Accepted: 02/01/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE For nursing home residents with severe dementia, high-intensity medical treatment offers little possibility of benefit but has the potential to cause significant distress. Nevertheless, mechanical ventilation and intensive care unit (ICU) transfers have increased in this population. We sought to understand how and why such care is occurring. DESIGN Mixed methods study, with retrospective collection of qualitative and quantitative data. SETTING Department of Veterans Affairs (VA) hospitals. METHODS Using the Minimum Data Set, we identified veterans aged ≥65 years who had severe dementia, lived in nursing homes, and died in 2013. We selected those who underwent mechanical ventilation or ICU transfer in the last 30 days of life. We restricted our sample to patients receiving care at VA hospitals because these hospitals share an electronic medical record, from which we collected structured information and constructed detailed narratives of how medical decisions were made. We used qualitative content analysis to identify distinct paths to high-intensity treatment in these narratives. RESULTS Among 163 veterans, 41 (25.2%) underwent mechanical ventilation or ICU transfer. Their median age was 85 (IQR, 80-94), 97.6% were male, and 67.5% were non-Hispanic white. More than a quarter had living wills declining some or all treatment. There were 5 paths to high-intensity care. The most common (18 of 41 patients) involved families who struggled with decisions. Other patients (15 of 41) received high-intensity care reflexively, before discussion with a surrogate. Four patients had families who advocated repeatedly for aggressive treatment, against clinical recommendations. In 2 cases, information about the patient's preferences was erroneous or unavailable. In 2 cases, there was difficulty identifying a surrogate. CONCLUSIONS AND IMPLICATIONS Our findings highlight the role of surrogates' difficulty with decision making and of health system-level factors in end-of-life ICU transfers and mechanical ventilation among nursing home residents with severe dementia.
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Aggressive End-of-Life Care in the Veterans Health Administration versus Fee-for-Service Medicare among Patients with Advanced Lung Cancer. J Palliat Med 2022; 25:932-939. [PMID: 35363053 PMCID: PMC9360181 DOI: 10.1089/jpm.2021.0436] [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] [Indexed: 11/12/2022] Open
Abstract
Background: Unlike fee-for-service Medicare, the Veterans Health Administration (VHA) allows for the provision of concurrent care, incorporating cancer treatment while in hospice. Methods: We compared trends of aggressive care at end of life between Medicare and VHA decedents with advanced nonsmall cell lung cancer from 2006 to 2012, and the relation between regional level end-of-life care between Medicare and VHA beneficiaries. Results: Among 18,371 Veterans and 25,283 Medicare beneficiaries, aggressive care at end of life decreased 15% in VHA and 4% in SEER (Surveillance, Epidemiology, and End Results)-Medicare (p < 0.001). Hospice use significantly increased within both cohorts (VHA 28%-41%; SM 60%-73%, p < 0.001). Veterans receiving care in regions with higher hospice admissions among Medicare beneficiaries were significantly less likely to receive aggressive care at end of life (adjusted odds ratio: 0.13, 95% confidence interval: 0.08-0.23, p < 0.001). Conclusions: Patients receiving lung cancer care in the VHA had a greater decline in aggressive care at end of life, perhaps due to increasing concurrent care availability.
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Perceived dementia risk and advance care planning among older adults. J Am Geriatr Soc 2022; 70:1481-1486. [PMID: 35274737 PMCID: PMC9106856 DOI: 10.1111/jgs.17721] [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: 11/01/2021] [Revised: 01/12/2022] [Accepted: 01/16/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although advance care planning (ACP) is beneficial if dementia develops, and virtually all older adults are at risk for this disease, older adults do not consistently engage in ACP. Health behavior models have highlighted the importance of perceived susceptibility to medical conditions in motivating behavior. Following these models, we sought to determine how often older adults believe they are not at risk of developing dementia and to examine the association between perceived dementia risk and ACP participation. METHODS We performed a cross-sectional study of community-dwelling adults without cognitive impairment, aged ≥65 years, who were interviewed for the Health and Retirement Study in 2016 and asked about their perceived dementia risk (n = 711). Perceived dementia risk was ascertained with this question: "on a scale of 0 to 100, what is the percent chance that you will develop dementia sometime in the future?" We used multivariable-adjusted logistic regression to evaluate the association between perceived risk (0% versus >0%) and completion of a living will, appointment of a durable power of attorney for healthcare decisions, and discussion of treatment preferences. RESULTS Among respondents, 10.5% reported a perceived dementia risk of 0%. Perceived risk of 0% was associated with lower odds of completing a living will (OR 0.53; 95% CI, 0.30-0.93) and discussing treatment preferences (OR 0.51; 95% CI, 0.28-0.93) but not appointment of a durable power of attorney (OR 0.77; 95% CI, 0.42-1.39). Many respondents with perceived dementia risk >0% had not completed ACP activities, including a substantial minority of those with perceived risk >50%. CONCLUSIONS Older adults with no perceived dementia risk are less likely to participate in several forms of ACP, but the fact that many older adults with high levels of perceived risk had not completed ACP activities suggests that efforts beyond raising risk awareness are needed to increase engagement.
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Effect of the STAMP (Sharing and Talking About My Preferences) Intervention on Completing Multiple Advance Care Planning Activities in Ambulatory Care : A Cluster Randomized Controlled Trial. Ann Intern Med 2021; 174:1519-1527. [PMID: 34461035 PMCID: PMC8711627 DOI: 10.7326/m21-1007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Interventions with the potential for broad reach in ambulatory settings are necessary to achieve a life course approach to advance care planning. OBJECTIVE To examine the effect of a computer-tailored, behavioral health model-based intervention on the engagement of adults in advance care planning recruited from ambulatory care settings. DESIGN Cluster randomized controlled trial with participant-level analysis. (ClinicalTrials.gov: NCT03137459). SETTING 10 pairs of primary and selected specialty care practices matched on patient sociodemographic information. PARTICIPANTS English-speaking adults aged 55 years or older; 454 adults at practices randomly assigned to usual care and 455 at practices randomly assigned to intervention. INTERVENTION Brief telephone or web-based assessment generating a mailed, individually tailored feedback report with a stage-matched brochure at baseline, 2 months, and 4 months. MEASUREMENTS The primary outcome was completion of the following 4 advance care planning activities at 6 months: identifying and communicating with a trusted person about views on quality versus quantity of life, assignment of a health care agent, completion of a living will, and ensuring that the documents are in the medical record-assessed by a blinded interviewer. Secondary outcomes were completion of individual advance care planning activities. RESULTS Participants were 64% women and 76% White. The mean age was 68.3 years (SD, 8.3). The predicted probability of completing all advance care planning activities in usual care sites was 8.2% (95% CI, 4.9% to 11.4%) versus 14.1% (CI, 11.0% to 17.2%) in intervention sites (adjusted risk difference, 5.2 percentage points [CI, 1.6 to 8.8 percentage points]). Prespecified subgroup analysis found no statistically significant interactions between the intervention and age, education, or race. LIMITATIONS The study was done in a single region and excluded non-English speaking participants. No information was collected about nonparticipants. CONCLUSION A brief, easily delivered, tailored print intervention increased participation in advance care planning in ambulatory care settings. PRIMARY FUNDING SOURCE National Institute of Nursing Research and National Institute of Aging.
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Engagement in Non-Medical End-of-Life Planning by Older Adults. J Pain Symptom Manage 2021; 62:805-812. [PMID: 33716035 PMCID: PMC8435038 DOI: 10.1016/j.jpainsymman.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/03/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT While medical end-of-life planning has been well characterized, less is known about non-medical planning to prepare for the end of life. OBJECTIVES To determine the prevalence of engagement in non-medical end-of-life (EOL) planning and its relationship to medical EOL planning. METHODS Three hundred and four persons age 65 and older recruited from physician offices and a senior center were administered an in-person interview asking about participation in the following non-medical EOL planning behaviors: moving to a location with more help, teaching someone to do things around the house, purchasing long-term care insurance, telling someone the location of important documents, preparing a financial will, conveying wishes for funeral arrangements, purchasing a cemetery plot, and prepaying for a funeral. RESULTS Prevalence of participation in the different non-medical EOL planning activities varied widely, from 8% for prepaying for a funeral to 84% for telling someone the location of important documents. There was little overlap in the factors associated with participation in each activity. Conveying wishes for funeral arrangements and completing a financial will were associated with completing a living will (OR 2.69, 95% CI 1.51, 4.78; OR 6.70, 95% CI 3.18, 14.15) and communication about quality versus quantity of life (OR 4.52, 95% CI 2.54, 8.04; OR 2.47, 95% CI 1.25, 4.86). CONCLUSION There is variability in both the prevalence of and factors associated with engagement in non-medical EOL planning activities. The association of non-medical with medical planning activities supports the utility of programs assisting individuals with broad engagement in EOL planning.
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Abstract
This cross-sectional study evaluates the degree of anticoagulant use among nursing home residents with advanced dementia and atrial fibrillation at the end of life.
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Aggressive care at end-of-life in the Veteran’s Health Administration versus fee-for-service Medicare among patients with advanced lung cancer. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.12025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12025 Background: The Veteran’s Health Administration (VHA) allows simultaneous receipt of cancer treatment and hospice care, termed concurrent care, while fee-for-service Medicare does not. Although many physicians who care for patients in the VHA also care for private sector patients, it is unclear whether there is a “spillover” relation between end of life (EOL) care in the VHA and Medicare systems at the regional level. We examined temporal trends, as well as regional-level associations between Medicare and VHA EOL practice for patients with advanced lung cancer. Methods: We conducted a retrospective study on VHA and SEER-Medicare (SM) decedents from 2006-2012 with stage IV non-small cell lung cancer (NSCLC) who received any lung cancer care. Aggressive care (AC) at EOL was defined as any of the following within 30 days of death– intensive care unit (ICU) admission, no-hospice care, cardiopulmonary resuscitation(CPR), mechanical ventilation (MV), > 1 inpatient admission and receipt of chemotherapy. Descriptive statistics were used to compare outcomes. We also analyzed the association between Medicare hospital referral region (HRR) hospice admissions, Medicare HRR EOL spending, and VHA AC use adjusted for patient’s characteristics using a random intercept mixed effect logistic regression model after matching VHA facilities with Medicare facilities in a particular HRR. Results: AC use significantly decreased during the study period, from 46% to 31% among 18,371 Veterans and from 42% to 38% among 25,283 in the SM cohort, (t-test P < .05). Hospice use significantly increased within both cohorts (p < .001). The receipt of chemotherapy at EOL was similar for both cohorts throughout the study period. Veterans who received care in regions with higher hospice admissions among Medicare beneficiaries were significantly less likely to receive AC at EOL (adjusted Odds Ratio (aOR): 0.13 95%CI: 0.08-0.23, P < .001) than veterans in regions with lower Medicare hospice use. Medicare HRR spending at the EOL was not associated with receipt of AC among Medicare beneficiaries (aOR): 1.004 95%CI: 1.00-1.009, P = 0.07). Conclusions: Perhaps due to availability of concurrent care, VHA patients received less aggressive care at EOL as compared to SM patients. At the regional level, greater hospice use among Medicare beneficiaries was significantly associated with reduced AC within the VHA.
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Concurrent Hospice Care and Cancer-Directed Treatment for Advanced Lung Cancer and Receipt of Aggressive Care at the End of Life in the Veteran's Health Administration. J Palliat Med 2020; 23:1038-1044. [PMID: 32119800 DOI: 10.1089/jpm.2019.0485] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background: Aggressive care at the end of life (EOL) is a persistent issue for patients with stage IV nonsmall cell lung cancer (NSCLC). We evaluated the use of concurrent care (CC) with hospice care and cancer-directed treatment simultaneously within the Veteran's Health Administration (VHA) and aggressive care at the EOL. Objective: To determine whether VHA facility-level CC is associated with changes in aggressive care at the EOL. Design/Setting: Veterans with stage IV NSCLC who died between 2006 and 2012 and received lung cancer care within the VHA. Measurements: The primary outcome was aggressive care at EOL (i.e., hospital admissions, chemotherapy, and intensive care unit) within the last month of life. To compare aggressive care across VHA facilities, we used a random intercept multilevel logistic regression model to examine the association between facility-level CC within each study year (<10%, 10% to 19%, and ≥20%) and aggressive care at the EOL among the decedents as a binary outcome. Results: In total, 18,371 veterans with NSCLC at 154 VHA facilities were identified. Facilities delivering CC for ≥20% of veterans (high CC) increased from 20.0% in 2006 to 43.2% in 2012 (p < 0.001). Overall, hospice care significantly increased and aggressive care at EOL decreased over the study period. However, facility-level CC adoption was not associated with any difference in aggressive care at EOL (adjusted odds ratio high CC vs. low CC: 0.91 [95% CI, 0.79 to 1.05], p = 0.21). Conclusions: Although the VHA adoption of CC increased hospice use among patients with NSCLC, additional measures may be needed to decrease aggressive care at the EOL.
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Feasibility of Delivering a Tailored Intervention for Advance Care Planning in Primary Care Practice. J Am Geriatr Soc 2019; 67:1917-1921. [PMID: 31271654 DOI: 10.1111/jgs.16035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/11/2019] [Accepted: 05/21/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND/OBJECTIVES To determine the feasibility of conducting a cluster randomized controlled trial providing individualized feedback reports to increase advance care planning (ACP) engagement in the primary care setting. DESIGN Pilot cluster randomized controlled trial. SETTING Two primary care practices selected for geographic colocation. PARTICIPANTS Adults aged 55 years and older. INTERVENTION Brief assessment of readiness to engage in (stage of change for) three ACP behaviors (healthcare agent assignment, communication with agent about quality vs quantity of life, and living will completion) generating an individualized feedback report, plus a stage-matched brochure. MEASURES Patient recruitment and retention, intervention delivery, baseline characteristics, and stage of change movement. RESULTS Recruitment rates differed by practice. Several baseline sociodemographic characteristics differed between the 38 intervention and 41 control participants, including employment status, education, and communication with healthcare agent. Feedback was successfully delivered to all intervention participants, and over 90% of participants completed a 2-month follow-up. More intervention participants demonstrated progression in readiness than did control participants, without testing for statistical significance. CONCLUSIONS This pilot demonstrates opportunities and challenges of performing a clustered randomized controlled trial in primary care practices. Differences in the two practice populations highlight the challenges of matching sites. There was a signal for behavior change in the intervention group. J Am Geriatr Soc 67:1917-1921, 2019.
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Assessment of Surrogates' Knowledge of Patients' Treatment Goals and Confidence in Their Ability to Make Surrogate Treatment Decisions. JAMA Intern Med 2019; 179:267-268. [PMID: 30477019 PMCID: PMC6440224 DOI: 10.1001/jamainternmed.2018.5299] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study uses telephone interviews of patients and their surrogates to evaluate surrogates’ knowledge of patients’ treatment goals and confidence in their ability to make patients’ treatment decisions.
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Abstract
BACKGROUND Patients with ischemic stroke or transient ischemic attack (TIA) are at increased risk for future cardiovascular events despite current preventive therapies. The identification of insulin resistance as a risk factor for stroke and myocardial infarction raised the possibility that pioglitazone, which improves insulin sensitivity, might benefit patients with cerebrovascular disease. METHODS In this multicenter, double-blind trial, we randomly assigned 3876 patients who had had a recent ischemic stroke or TIA to receive either pioglitazone (target dose, 45 mg daily) or placebo. Eligible patients did not have diabetes but were found to have insulin resistance on the basis of a score of more than 3.0 on the homeostasis model assessment of insulin resistance (HOMA-IR) index. The primary outcome was fatal or nonfatal stroke or myocardial infarction. RESULTS By 4.8 years, a primary outcome had occurred in 175 of 1939 patients (9.0%) in the pioglitazone group and in 228 of 1937 (11.8%) in the placebo group (hazard ratio in the pioglitazone group, 0.76; 95% confidence interval [CI], 0.62 to 0.93; P=0.007). Diabetes developed in 73 patients (3.8%) and 149 patients (7.7%), respectively (hazard ratio, 0.48; 95% CI, 0.33 to 0.69; P<0.001). There was no significant between-group difference in all-cause mortality (hazard ratio, 0.93; 95% CI, 0.73 to 1.17; P=0.52). Pioglitazone was associated with a greater frequency of weight gain exceeding 4.5 kg than was placebo (52.2% vs. 33.7%, P<0.001), edema (35.6% vs. 24.9%, P<0.001), and bone fracture requiring surgery or hospitalization (5.1% vs. 3.2%, P=0.003). CONCLUSIONS In this trial involving patients without diabetes who had insulin resistance along with a recent history of ischemic stroke or TIA, the risk of stroke or myocardial infarction was lower among patients who received pioglitazone than among those who received placebo. Pioglitazone was also associated with a lower risk of diabetes but with higher risks of weight gain, edema, and fracture. (Funded by the National Institute of Neurological Disorders and Stroke; ClinicalTrials.gov number, NCT00091949.).
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Development of Personalized Health Messages to Promote Engagement in Advance Care Planning. J Am Geriatr Soc 2016; 64:359-64. [PMID: 26804791 DOI: 10.1111/jgs.13934] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To develop and test the acceptability of personalized intervention materials to promote advance care planning (ACP) based on the Transtheoretical Model (TTM), in which readiness to change is a critical organizing construct. DESIGN Development study creating an expert system delivering TTM-personalized feedback reports and stage-matched brochures with more-general information on ACP and modifications based on participant reviews. SETTING Senior centers. PARTICIPANTS Community-living persons aged 65 and older (N = 77). MEASUREMENTS Participant ratings of length, attractiveness, and trustworthiness of and reactions to reports and brochures. RESULTS The expert system assessed participants' readiness to engage in each of four ACP behaviors: completion of a living will, naming a health care proxy, communication with loved ones about quality vs quantity of life, and communication with clinicians about quality vs quantity of life. The system also assessed pros and cons of engagement and values and beliefs that influence engagement. The system provided individualized feedback based on the assessment, with brochures providing additional general information. Initial participant review indicating unacceptable length led to revision of feedback reports from full-sentence paragraph format to bulleted format. After review, the majority of participants rated the materials as easy to read, trustworthy, providing new information, making them more comfortable reading about ACP, and increasing interest in participating in ACP. CONCLUSION Older adults found an expert system individualized feedback report and accompanying brochure to promote ACP engagement to highly acceptable and engaging. Additional research is necessary to examine the effects of these materials on behavior change.
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Modifiable risk factors for pneumonia requiring hospitalization of community-dwelling older adults: the Health, Aging, and Body Composition Study. J Am Geriatr Soc 2013; 61:1111-8. [PMID: 23772872 DOI: 10.1111/jgs.12325] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To identify novel modifiable risk factors, focusing on oral hygiene, for pneumonia requiring hospitalization of community-dwelling older adults. DESIGN Prospective observational cohort study. SETTING Memphis, Tennessee, and Pittsburgh, Pennsylvania. PARTICIPANTS Of 3,075 well-functioning community-dwelling adults aged 70 to 79 enrolled in the Health, Aging, and Body Composition Study from 1997 to 1998, 1,441 had complete data in the data set of all variables used, a dental examination within 6 months of baseline, and were eligible for this study. MEASUREMENTS The primary outcome was pneumonia requiring hospitalization through 2008. RESULTS Of 1,441 participants, 193 were hospitalized for pneumonia. In a multivariable model, male sex (hazard ratio (HR) = 2.07, 95% confidence interval (CI) = 1.51-2.83), white race (HR = 1.44, 95% CI = 1.03-2.01), history of pneumonia (HR = 3.09, 95% CI = 1.86-5.14), pack-years of smoking (HR = 1.006, 95% CI = 1.001-1.011), and percentage of predicted forced expiratory volume in 1 minute (moderate vs mild lung disease or normal lung function, HR = 1.78, 95% CI = 1.28-2.48; severe lung disease vs mild lung disease or normal lung function, HR = 2.90, 95% CI = 1.51-5.57) were nonmodifiable risk factors for pneumonia. Incident mobility limitation (HR = 1.77, 95% CI = 1.32-2.38) and higher mean oral plaque score (HR = 1.29, 95% CI = 1.02-1.64) were modifiable risk factors for pneumonia. Average attributable fractions revealed that 11.5% of cases of pneumonia were attributed to incident mobility limitation and 10.3% to a mean oral plaque score of 1 or greater. CONCLUSION Incident mobility limitation and higher mean oral plaque score were two modifiable risk factors that 22% of pneumonia requiring hospitalization could be attributed to. These data suggest innovative opportunities for pneumonia prevention among community-dwelling older adults.
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A pilot randomized controlled trial of a decision support tool to improve the quality of communication and decision-making in individuals with atrial fibrillation. J Am Geriatr Soc 2012; 60:1434-41. [PMID: 22861171 DOI: 10.1111/j.1532-5415.2012.04080.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To design a tool for nonvalvular atrial fibrillation (NVAF) to inform individuals of their individual stroke and bleeding risks, assist in clarifying priorities, and promote communication. DESIGN Clustered randomized controlled trial. SETTING Primary care clinics. PARTICIPANTS Individuals with NVAF (N = 135). INTERVENTION Completion of tool before regularly scheduled visit. MEASUREMENTS Primary outcomes included the 100-point informed and values clarity subscales of the decisional conflict scale (lower scores indicate individual is more informed and has greater clarity). Secondary outcomes included knowledge, patient-clinician communication, and change in treatment. RESULTS Sixty-nine individuals were enrolled in the intervention group and 66 in the control group. After their visit, intervention participants had lower scores on the informed (mean difference = -11.9, 95% confidence interval (CI) = -21.1 to -2.7) and values clarity subscales (mean difference = -14.6, 95% CI = -22.6 to -6.6). Greater proportions of intervention participants knew medications for reducing stroke risk (61% vs 31%, P < .001) and side effects (49% vs 37%, P = .07). Stroke (71% vs 12%) and bleeding risk (69% vs 20%) were discussed more frequently in the intervention than control group (P < .001). Five intervention participants expressed a preference for medication that was not concordant with their current treatment plan. There was no change in treatment plan in either group. CONCLUSION The tool was effective in improving perceived and actual knowledge and values clarity and in increasing physician-patient communication but did not change treatment.
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Promoting advance care planning as health behavior change: development of scales to assess Decisional Balance, Medical and Religious Beliefs, and Processes of Change. PATIENT EDUCATION AND COUNSELING 2012; 86:25-32. [PMID: 21741194 PMCID: PMC3192927 DOI: 10.1016/j.pec.2011.04.035] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 03/22/2011] [Accepted: 04/27/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To develop measures representing key constructs of the Transtheoretical Model (TTM) of behavior change as applied to advance care planning (ACP) and to examine whether associations between these measures replicate the relationships posited by the TTM. METHODS Sequential scale development techniques were used to develop measures for Decisional Balance (Pros and Cons of behavior change), ACP Values/Beliefs (religious beliefs and medical misconceptions serving as barriers to participation), Processes of Change (behavioral and cognitive processes used to foster participation) based on responses of 304 persons age≥65 years. RESULTS Items for each scale/subscale demonstrated high factor loading (>.5) and good to excellent internal consistency (Cronbach α .76-.93). Results of MANOVA examining scores on the Pros, Cons, ACP Values/Beliefs, and POC subscales by stage of change for each of the six behaviors were significant, Wilks'λ=.555-.809, η(2)=.068-.178, p≤.001 for all models. CONCLUSION Core constructs of the TTM as applied to ACP can be measured with high reliability and validity. PRACTICE IMPLICATIONS Cross-sectional relationships between these constructs and stage of behavior change support the use of TTM-tailored interventions to change perceptions of the Pros and Cons of participation in ACP and promote the use of certain Processes of Change in order to promote older persons' engagement in ACP.
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Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. ACTA ACUST UNITED AC 2011; 171:1854-6. [PMID: 21949032 DOI: 10.1001/archinternmed.2011.424] [Citation(s) in RCA: 283] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Agreement between older persons and their surrogate decision-makers regarding participation in advance care planning. J Am Geriatr Soc 2011; 59:1105-9. [PMID: 21649619 DOI: 10.1111/j.1532-5415.2011.03412.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine agreement between older persons and their surrogates regarding participation in advance care planning (ACP). DESIGN Observational cohort study. SETTING Community. PARTICIPANTS Persons aged 65 and older and the individual they identified as most likely to make treatment decisions on their behalf. MEASUREMENTS Older persons were asked about participation in four activities: completion of living will, completion of healthcare proxy, communication regarding views about life-sustaining treatment, and communication regarding views about quality versus quantity of life. Surrogates were asked whether they believed the older person had completed these activities. RESULTS Of 216 pairs, 81% agreed about whether a living will had been completed (κ=0.61, 95% confidence interval (CI) 0.51-0.72). Only 68% of pairs agreed about whether a healthcare proxy had been completed (κ=0.39, 95% CI 0.29-0.50), 64% agreed about whether they had communicated regarding life-sustaining treatment (κ=0.22, 95% CI 0.09-0.35), and 62% agreed about whether they had communicated regarding quality versus quantity of life (κ=0.23, 95% CI 0.11-0.35). CONCLUSION Although agreement between older persons and their surrogates regarding living will completion was good, agreement about participation in other aspects of ACP was fair to poor. Additional study is necessary to determine who is providing the most accurate report of objective ACP components and whether agreement regarding participation in ACP is associated with greater shared understanding of patient preferences.
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Effects of benefits and harms on older persons' willingness to take medication for primary cardiovascular prevention. ACTA ACUST UNITED AC 2011; 171:923-8. [PMID: 21357797 DOI: 10.1001/archinternmed.2011.32] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Quality-assurance initiatives encourage adherence to evidenced-based guidelines based on a consideration of treatment benefit. We examined older persons' willingness to take medication for primary cardiovascular disease prevention according to benefits and harms. METHODS In-person interviews were performed with 356 community-living older persons. Participants were asked about their willingness to take medication for primary prevention of myocardial infarction (MI) with varying benefits in terms of absolute 5-year risk reduction and varying harms in terms of type and severity of adverse effects. RESULTS Most (88%) would take medication, providing an absolute benefit of 6 fewer persons with MI out of 100, approximating the average risk reduction of currently available medications. Of participants who would not take it, 17% changed their preference if the absolute benefit was increased to 10 fewer persons with MI, and, of participants who would take it, 82% remained willing if the absolute benefit was decreased to 3 fewer persons with MI. In contrast, large proportions (48%-69%) were unwilling or uncertain about taking medication with average benefit causing mild fatigue, nausea, or fuzzy thinking, and only 3% would take medication with adverse effects severe enough to affect functioning. CONCLUSIONS Older persons' willingness to take medication for primary cardiovascular disease prevention is relatively insensitive to its benefit but highly sensitive to its adverse effects. These results suggest that clinical guidelines and decisions about prescribing these medications to older persons need to place emphasis on both benefits and harms.
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Abstract
OBJECTIVES To develop stages-of-change measures for advance care planning (ACP), conceptualized as a group of interrelated but separate behaviors, and to use these measures to characterize older persons' engagement in and factors associated with readiness to participate in ACP. DESIGN Observational cohort study. SETTING Community. PARTICIPANTS Persons aged 65 and older recruited from physician offices and a senior center. MEASUREMENTS Stages of change for six ACP behaviors: completion of a living will and healthcare proxy, communication with loved ones regarding use of life-sustaining treatments and quantity versus quality of life, and communication with physicians about these same issues. RESULTS Readiness to participate in ACP varied widely across behaviors. Whereas between approximately 50% and 60% of participants were in the action or maintenance stage for communicating with loved ones about life-sustaining treatment and completing a living will, 40% were in the precontemplation stage for communicating with loved ones about quantity versus quality of life, and 70% and 75% were in the precontemplation stage for communicating with physicians. Participants were frequently in different stages for different behaviors. Few sociodemographic, health, or psychosocial factors were associated with stages of change for completing a living will, but a broader range of factors was associated with stages of change for communication with loved ones about quantity versus quality of life. CONCLUSION Older persons show a range of readiness to engage in different aspects of ACP. Individualized assessment and interventions targeted to stage of behavior change for each component of ACP may be an effective strategy to increase participation in ACP.
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Abstract
OBJECTIVES To examine caregiver burden over time in caregivers of patients with advanced chronic disease. DESIGN Observational cohort with interviews over 12 months. SETTING Community. PARTICIPANTS Caregivers of 179 community-living persons aged 60 and older with advanced cancer, heart failure (HF), or chronic obstructive pulmonary disease (COPD). MEASUREMENTS Caregiver burden was assessed using a short-form of the Zarit Burden Inventory to measure psychosocial distress. RESULTS At baseline, the median caregiver burden was 5 (interquartile range (IQR) 1-11), which indicates that the caregiver endorsed having at least two of 10 distressing concerns at least some of the time. Only 10% reported no burden. Although scores increased modestly over time, the association between time and burden was not significant in longitudinal multivariable analysis. High burden was associated with caregiver need for more help with daily tasks (odds ratio (OR)=23.13, 95% confidence interval (CI)=5.94-90.06) and desire for greater communication with the patient (OR=2.53, 95% CI=1.16-5.53). The longitudinal multivariable analysis did not yield evidence of associations between burden and patient sociodemographic or health characteristics. CONCLUSION Caregiver burden was common in caregivers of patients with cancer, HF, and COPD. High burden was associated with the caregiver's report of need for greater help with daily tasks but not with objective measures of the patient's need for assistance, such as symptoms or functional status, suggesting that burden may be a measure of the caregiver's ability to adapt to the caregiving role.
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Abstract
OBJECTIVES To explore whether models of health behavior change can help to inform interventions for advance care planning (ACP). DESIGN Qualitative cross-sectional study. SETTING Community. PARTICIPANTS Sixty-three community-dwelling persons aged 65 and older and 30 caregivers with experience as surrogate decision-makers. MEASUREMENTS In focus groups conducted separately with older persons and caregivers, participants were asked to discuss ways they had planned for future declines in health and why they had or had not engaged in such planning. Transcripts were analyzed using grounded theory. RESULTS Four themes illustrated the potential of applying models of health behavior change to improve ACP. (1) Participants demonstrated variable readiness to engage in ACP and could be in different stages of readiness for different components of ACP, including consideration of treatment goals, completion of advance directives, and communication with families and physicians. (2) Participants identified a wide range of benefits of and barriers to ACP. (3) Participants used a variety of processes of change to progress through stages of readiness, and ACP was only one of a broader set of behaviors that participants engaged in to prepare for declines in their health or for death. (4) Experience with healthcare decision-making for loved ones was a strong influence on perceptions of susceptibility and engagement in ACP. DISCUSSION The variability in participants' readiness, barriers and benefits, perceptions of susceptibility, and use of processes to increase readiness for participating in each component of ACP suggests the utility of customized, stage-specific interventions based on individualized assessments to improve ACP.
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Using the experiences of bereaved caregivers to inform patient- and caregiver-centered advance care planning. J Gen Intern Med 2008; 23:1602-7. [PMID: 18665427 PMCID: PMC2533358 DOI: 10.1007/s11606-008-0748-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Revised: 05/14/2008] [Accepted: 06/16/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Traditional approaches to advance care planning (ACP) have many limitations; new approaches are being developed with the goal of improving end-of-life care. OBJECTIVE To understand how the end-of-life care experiences of older patients and their caregivers can inform the development of new approaches to ACP. DESIGN Qualitative cross-sectional study. PARTICIPANTS Caregivers of community-dwelling persons age > or = 60 years who died with advanced cancer, chronic obstructive pulmonary disease, or heart failure during follow-up in a longitudinal study. APPROACH In-depth interviews were conducted 6 months after the patient's death with 64 caregivers. Interviews began with open-ended questions to encourage the caregiver to tell the story of the patient's experiences at the end of life. Additional questions asked about how decisions were made, patient-caregiver, patient-clinician, and caregiver-clinician communication. MAIN RESULTS Although the experiences recounted by caregivers were highly individual, several common themes emerged from the interviews. These included the following: 1) the lack of availability of treatment options for certain patients, prompting patients and caregivers to consider broader end-of-life issues, 2) changes in preferences at the very end of an illness, 3) variability in patient and caregiver desire for and readiness to hear information about the patient's illness, and 4) difficulties with patient-caregiver communication. DISCUSSION The experiences of older patients at the end of life and their caregivers support a form of ACP that includes a broader set of issues than treatment decision-making alone, recognizes the dynamic nature of preferences, and focuses on addressing barriers to patient-caregiver communication.
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Abstract
OBJECTIVE The purpose of this study is to present empirical evidence about whether religious patients are more or less willing to undergo the risks associated with potentially life-sustaining treatment. METHODS At least every 4 months 226 older community-dwelling persons with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease were asked questions about several dimensions of religiousness and about their willingness to accept potentially life-sustaining treatment. RESULTS Results were mixed but persons who said that during their illness they grew closer to God (odds ratio [OR] = 1.79; 95% confidence intervals [CI] = 1.15, 2.78) or those grew spiritually (OR = 1.61; 95% CI = 1.03, 2.52) were more willing to accept risk associated with potentially life-sustaining treatment than were persons who did not report such growth. DISCUSSION Not all dimensions of religiousness have the same association with willingness to undergo potentially life-sustaining treatment. Seriously ill older, religious patients are not especially predisposed to avoid risk and resist treatment.
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Refusal of medical and surgical interventions by older persons with advanced chronic disease. J Gen Intern Med 2007; 22:982-7. [PMID: 17483977 PMCID: PMC1948844 DOI: 10.1007/s11606-007-0222-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2006] [Revised: 03/13/2007] [Accepted: 04/16/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Patients with advanced chronic disease are frequently offered medical and surgical interventions with potentially large trade-offs between benefits and burdens. Little is known about the frequency or outcomes of treatment refusal among these patients. OBJECTIVE To assess the frequency of, reasons for, factors associated with, and outcomes of treatment refusal among older persons with advanced chronic disease. DESIGN Observational cohort study. PARTICIPANTS Two hundred twenty-six community-dwelling persons with advanced cancer, chronic obstructive pulmonary disease, or congestive heart failure, interviewed at least every 4 months for up to 2 years. MEASUREMENTS Participants were asked if they had refused any treatments recommended by their physicians, and why. RESULTS Thirty-six of 226 patients (16%) reported refusing 1 or more medical or surgical treatments recommended by their physician. The most frequently refused interventions were cardiac catheterization and surgery. The most common reason for refusal was fear of side effects (41%). Treatment refusal was more frequent among patients who wanted prognostic information (10% vs 2%, p = .02) or estimated their own longevity at 2 years or less (18% vs 5%, p = .02). There was an increased risk of mortality among refusers compared with non-refusers (HR 1.98, 95% CI 1.02-3.86). CONCLUSIONS Refusal of medical and surgical interventions other than medications is common among persons with advanced chronic disease, and is associated with a greater desire for, and understanding of, prognostic information.
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Resident-to-Resident Elder Mistreatment and Police Contact in Nursing Homes: Findings from a Population-Based Cohort. J Am Geriatr Soc 2007; 55:840-5. [PMID: 17537083 DOI: 10.1111/j.1532-5415.2007.01195.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To determine the frequency and nature of police contact with a well-characterized cohort of originally community-dwelling older adults who were subsequently placed in long-term care facilities and to describe in more quantitative and qualitative detail episodes of resident-to-resident elder mistreatment (RREM), which constituted the most common reason for police involvement in long-term care facilities. DESIGN Qualitative and quantitative study of the characteristics of nursing home residents who engaged in resident-to-resident mistreatment. The study melded longitudinal data from an observational cohort of community-dwelling older adults subsequently placed in long-term care facilities and cross-sectional data from nursing home and police records. SETTING Nursing homes. PARTICIPANTS Forty-two of 747 older adults placed in long-term care facilities who were members of the original New Haven Established Populations for Epidemiological Studies in the Elderly (EPESE) were involved in 79 separate incidents. These 747 nursing home residents were derived from 2,321 subjects in the study who were alive and community dwelling in 1985 and then subsequently placed in nursing homes between 1985 and 1995. EPESE cohort members who were placed in nursing homes were identified through a linkage to the Connecticut Long-Term Care Registry. The cohort was also linked to police records in the same community for the follow-up years 1985 to 1995. MEASUREMENTS Simple descriptive statistics were used to explicate reasons for police calls to the long-term care facilities where these individuals resided. Demographic and clinical data were obtained from annual EPESE interviews, which continued after long-term care placement. Police incident reports were abstracted to determine the reasons for police involvement; transcripts of police reports were reviewed qualitatively for episodes of RREM. RESULTS During the follow-up period, police were called to investigate 79 incidents involving 42 cohort members placed in nursing homes. The most common reason (89% of incidents) for police to investigate an episode involving a cohort member was for simple assault in which the subject was the perpetrator or victim of resident-to-resident mistreatment. Several qualitative typologies of this phenomenon emerged. Less common causes for police interdiction were elopement, theft, and alleged staff abuse. Cohort members were more likely to interact with police when community dwelling than after they entered the nursing home (30.2% vs 5.6%, P<.001). When police contact occurred with nursing home residents, it was much more likely to be for violent episodes than in community-dwelling subjects (90% vs 17%, P<.001). CONCLUSION Police had substantial contact with cohort members who became nursing home residents in this study, primarily to investigate RREM but also for other incidents. Further research should be conducted on the epidemiology, causes, and prevention of resident-to-resident aggressive behaviors in long-term care facilities, which were the major reason for police involvement.
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Abstract
BACKGROUND There are conflicting assumptions regarding how patients' preferences for life-sustaining treatment change over the course of serious illness. OBJECTIVE To examine changes in treatment preferences over time. DESIGN Longitudinal cohort study with 2-year follow-up. PARTICIPANTS Two hundred twenty-six community-dwelling persons age > or =60 years with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease. MEASUREMENTS Participants were asked, if faced with an illness exacerbation that would be fatal if untreated, whether they would: a) undergo high-burden treatment at a given likelihood of death and b) undergo low-burden treatment at a given likelihood of severe disability, versus a return to current health. RESULTS There was little change in the overall proportions of participants who would undergo therapy at a given likelihood of death or disability from first to final interview. Diversity within the population regarding the highest likelihood of death or disability at which the individual would undergo therapy remained substantial over time. Despite a small magnitude of change, the odds of participants' willingness to undergo high-burden therapy at a given likelihood of death and to undergo low-burden therapy at a given likelihood of severe cognitive disability decreased significantly over time. Greater functional disability, poorer quality of life, and lower self-rated life expectancy were associated with decreased willingness to undergo therapy. CONCLUSIONS Diversity among older persons with advanced illness regarding treatment preferences persists over time. Although the magnitude of change is small, there is a decreased willingness to undergo highly burdensome therapy or to risk severe disability in order to avoid death over time and with declining health status.
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Abstract
PURPOSE We estimate the independent contribution of crime victimization to nursing home placement in a cohort of older adults who were community dwelling at baseline. DESIGN AND METHODS The data come from an observational cohort study of 2,321 community-residing older adults who were members of the New Haven Established Populations for Epidemiological Studies in the Elderly cohort in 1985. Participants had annual evaluations using standardized instruments. We defined the major outcome, custodial nursing home placement, as a stay of at least 30 days; mean length of nursing home stay was 413 days. We determined crime victimization by matching police records in the same catchment area as the cohort for the period 1985-1995. We determined nursing home placement through linkage to the Connecticut Long Term Care Registry. We used growth curve modeling to estimate the risk of placement in victimized and nonvictimized participants, and we used multivariable models to adjust for other factors known to predict nursing home placement. RESULTS There were 482 members of the cohort (21%) who experienced victimization over the 10-year follow-up; 747 (32%) experienced nursing home placement. Most victimization episodes were nonviolent and noninjurious. However, violent victimization conferred an independent increased risk of nursing home placement (odds ratio = 2.1; 95% confidence interval = 1.0-4.6) that exceeded the increased risk associated with other variables traditionally thought to be predictive of placement (such as functional and cognitive impairment, and social network size). IMPLICATIONS Violent crime victimization increases the risk of nursing home placement. Future research should be directed at determining the mechanism of this increased risk and developing interventions directed at victimized older adults that might avert nursing home placement in this uniquely vulnerable population.
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Prospective study of health status preferences and changes in preferences over time in older adults. ACTA ACUST UNITED AC 2006; 166:890-5. [PMID: 16636215 PMCID: PMC1978221 DOI: 10.1001/archinte.166.8.890] [Citation(s) in RCA: 118] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Instructional forms of advance care planning depend on the ability of patients to predict their future treatment preferences. However, preferences may change with changes in patients' health states. METHODS We conducted in-home interviews of 226 older community-dwelling persons with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease at least every 4 months for up to 2 years. Patients were asked to rate whether treatment for their illness would be acceptable if it resulted in 1 of 4 health states. RESULTS The likelihood of rating as acceptable a treatment resulting in mild (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.06-1.16) or severe (OR, 1.06; 95% CI, 1.03-1.09) functional disability increased with each month of participation. Patients who experienced a decline in their ability to perform instrumental activities of daily living were more likely to rate as acceptable treatment resulting in mild (OR, 1.23; 95% CI, 1.08-1.40) or severe (OR, 1.23; 95% CI, 1.11-1.37) disability. Although the overall likelihood of rating treatment resulting in a state of pain as acceptable did not change over time (OR, 0.98; 95% CI, 0.96-1.01), patients who had moderate to severe pain were more likely to rate this treatment as acceptable (OR, 2.55; 95% CI, 1.56-4.19) than were those who did not have moderate to severe pain. CONCLUSIONS For some patients, the acceptability of treatment resulting in certain diminished states of health increases with time, and increased acceptability is more likely among patients experiencing a decline in that same domain. These changes pose a challenge to advance care planning, which asks patients to predict their future treatment preferences.
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Are patient preferences for life-sustaining treatment really a barrier to hospice enrollment for older adults with serious illness? J Am Geriatr Soc 2006; 54:472-8. [PMID: 16551315 DOI: 10.1111/j.1532-5415.2005.00628.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether patient preferences are a barrier to hospice enrollment. DESIGN Prospective cohort study. SETTING Fifteen ambulatory primary care and specialty clinics and three general medicine inpatient units. PARTICIPANTS Two hundred three seriously ill patients with cancer (n=65, 32%), congestive heart failure (n=77, 38%), and chronic obstructive pulmonary disease (n=61, 30%) completed multiple interviews over a period of up to 24 months. MEASUREMENTS Preferences for high- and low-burden life-sustaining treatment and site of death and concern about being kept alive by machines. RESULTS Patients were more likely to enroll in hospice after interviews at which they said that they did not want low-burden treatment (3 patients enrolled/16 interviews at which patients did not want low-burden treatment vs 47 patients enrolled/841 interviews at which patients wanted low-burden treatment; relative risk (RR)=3.36, 95% confidence interval (CI)=1.17-9.66), as were interviews at which patients said they would not want high-burden treatment (5/28 vs 45/826; RR=3.28, 95% CI=1.14-7.62), although most patients whose preferences were consistent with hospice did not enroll before the next interview. In multivariable Cox regression models, patients with noncancer diagnoses who desired low-burden treatment (hazard ratio (HR)=0.46, 95% CI=0.33-0.68) were less likely to enroll in hospice, and those who were concerned that they would be kept alive by machines were more likely to enroll (HR=5.46, 95% CI=1.86-15.88), although in patients with cancer, neither preferences nor concerns about receiving excessive treatment were associated with hospice enrollment. Preference for site of death was not associated with hospice enrollment. CONCLUSION Overall, few patients had treatment preferences that would make them eligible for hospice, although even in patients whose preferences were consistent with hospice, few enrolled. Efforts to improve end-of-life care should offer alternatives to hospice that do not require patients to give up life-sustaining treatment, as well as interventions to improve communication about patients' preferences.
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Abstract
CONTEXT Although many studies have documented problems in communication between physicians and patients, few have focused on discussions regarding prognosis among community dwelling patients with terminal illness. OBJECTIVE To examine the association of patient race and financial status with patient and clinician reports of discussions about prognosis. DESIGN Cross-sectional survey. SETTING Participants' homes. PARTICIPANTS Two hundred fourteen patients age 60 years or older seriously ill secondary to congestive heart failure, chronic obstructive pulmonary disease, or cancer; and their primary clinicians. MAIN OUTCOME MEASURES Patient/clinician agreement regarding discussions of prognosis. RESULTS In adjusted analysis, patients and clinicians were more likely to agree that discussions about prognosis had taken place when patients had a lower financial status (odds ratio [OR] 2.26, 95% confidence interval [CI] 1.03-4.96), or were nonwhite (OR 2.56, CI 0.85-7.68), compared to patients who had a higher financial status or were white. Agreement about prognosis discussions was also more likely (adjusted OR 4.12, 95% CI 1.15-14.76) when patients were younger (i.e., age < 80). CONCLUSIONS Among a cohort of seriously ill community-dwelling patients, patients and clinicians were more likely to agree that discussions about prognosis had occurred when patients were poorer and nonwhite. These findings contrast with the majority of studies examining the relationship between race or income and patient-physician communication about other end-of-life issues.
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Older person's preferences for home vs hospital care in the treatment of acute illness. ARCHIVES OF INTERNAL MEDICINE 2000; 160:1501-6. [PMID: 10826465 DOI: 10.1001/archinte.160.10.1501] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Although the home is expanding as a potential site for acute illness treatment, little is known about patients' preferences for home vs the hospital. OBJECTIVE To determine older persons' preferences for home or hospital as a treatment site for acute illness and factors associated with preference. METHODS Two hundred forty-six community-dwelling persons aged 65 years or older hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia were identified in 2 urban teaching hospitals and received telephone interviews 2 months after hospitalization. They were asked their preference for home or hospital treatment, given the availability of equivalent therapies and outcomes at the 2 sites and a nursing visit and several hours of home health aide assistance daily in the home. They were also asked about changes in preference with changes in the description of the outcome or the availability of services. RESULTS If home and hospital offered equivalent outcomes, 46% of the sample preferred treatment at home. Preferences were heavily dependent on the outcome of the illness, physician opinion about the best site of care, and the provision of house calls. Higher education, white race, living with a spouse, being deeply religious, and having 2 or more dependencies in activities of daily living were associated with a preference for home treatment. CONCLUSIONS Under conditions of equivalent outcome, preferences for treatment site are almost equally divided between home and hospital. Explicit elucidation of preferences is necessary if patients' preferences are to play a meaningful role in decision making about site of care.
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Abstract
PURPOSE Home care is increasingly being used as a substitute for hospital care. This study examined older patients' perceptions of the home and of the hospital as treatment sites for acute illness and the patient characteristics that are associated with these perceptions. SUBJECTS AND METHODS A series of questions derived from open-ended interviews supplemented by literature review were administered by telephone in a cross-sectional, descriptive study to community-dwelling persons age 65 years or older who had been hospitalized 2 months earlier with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia. RESULTS Among 246 participants, nearly equal proportions agreed with statements that the home and the hospital would be comfortable sites of care (54% versus 55%), that the home and the hospital would provide rapid recovery (41% versus 37%), and that home treatment and hospital treatment would be burdensome on family and friends (40% versus 33%). Although 93% would feel safe in the hospital, only 42% would feel safe at home. Perceptions were not associated with sociodemographic characteristics, primary diagnosis, self-rated health, depression, or social support. Functionally dependent patients had more positive perceptions of treatment at home. CONCLUSIONS Evaluation of perceptions of home and hospital can facilitate assessing the acceptability of shifting acute care from hospital to home. Our findings suggest that successful expansion of acute home care will require flexibility in the use of home and hospital as well as education to change perceptions about the safety and efficacy of treatment at home.
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Abstract
BACKGROUND Little is known about patients' preferences for site of terminal care. OBJECTIVE To describe older persons' preferences for home or hospital as the site of terminal care and to explore potential reasons for their preferences. DESIGN Cross-sectional quantitative and qualitative interviews. SETTING Participants' homes. PATIENTS Community-dwelling persons 65 years of age or older who were recently hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were not selected according to life expectancy; 246 patients participated in quantitative interviews and 29 participated in qualitative interviews. MEASUREMENTS Preference for site of terminal care and the reasons for that preference. RESULTS In quantitative interviews, 118 patients (48%) preferred terminal care in the hospital, 106 (43%) preferred home, and 22 (9%) did not know. One third changed their preference when asked about their preference in the event of a nonterminal illness. Reasons for preference identified during qualitative interviews included the desire to be with family members and concerns about burden to family members and their ability to provide necessary care. Concern about long-term care needs resulted in preference for a nursing home when choice was not constrained to home and hospital. CONCLUSIONS Preference for home as the site of care for terminal illness exceeds existing practice. However, the current debate about home versus hospital as the ideal site for end-of-life care may ignore an important issue to older persons--namely, the care of disabilities that precede death.
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A centralized transport system for inpatient treatments. Hosp Top 1983; 61:20-1. [PMID: 10258675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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