Culturally Sensitive Advance Care Planning for African American Advanced Cancer Patients: A Pilot Randomized Controlled Trial

CONTEXT

Racial disparities in advance care planning (ACP) have been consistently identified in the literature. Few interventions have been designed to address the disparities identified.

OBJECTIVES

To assess the feasibility, acceptability, and preliminary efficacy of a culturally sensitive, pilot ACP intervention for African American patients diagnosed with cancer in a safety net healthcare system.

METHODS

Eligible patients with stage II, III, or IV breast, lung, colorectal, or prostate cancer were identified from the electronic health record, recruited, and randomized to the intervention group or usual care control group. Intervention participants met with an African American lay health advisor who assisted them in watching a video that addressed completion of ACP and facilitated ACP discussion. Descriptive analyses were conducted to examine baseline sociodemographic and clinical characteristics, cancer health literacy, and religious coping among participants. Logistic regression analyses were conducted to evaluate predictors of positive change in stage of intent to discuss ACP at 1, 3, and 6-months post intervention.

RESULTS

Seventy-six participants were recruited and randomized (38 intervention, 38 controls). The mean age for participants was 58.8 years (SD 10.8), 62.5% were female, and 90.2% had stage III or IV disease. The intervention proved feasible with 89.5% completion. Intervention participants were more likely to have a positive change in stage of intent to discuss a living will or advance directive than usual care controls at one-month (AOR: 4.57, 95%CI: 1.11, 18.82) and 3-months (AOR: 5.38, 95%CI: 1.05, 27.68) post-intervention. The majority (94.1%) of intervention participants would recommend the intervention to a friend or family member.

CONCLUSION

This culturally sensitive ACP program proved to be feasible, acceptable to participants, and showed some promise in promoting discussion about ACP among participants and members of their healthcare team.

Diversity in research on aging: A new series

This editorial comments on the article by Gilmore et al.

Exploring the intersection of structural racism and ageism in healthcare

The American Geriatrics Society (AGS) has consistently advocated for a healthcare system that meets the needs of older adults, including addressing impacts of ageism in healthcare. The intersection of structural racism and ageism compounds the disadvantage experienced by historically marginalized communities. Structural racism and ageism have long been ingrained in all aspects of US society, including healthcare. This intersection exacerbates disparities in social determinants of health, including poor access to healthcare and poor outcomes. These deeply rooted societal injustices have been brought to the forefront of the collective public consciousness at different points throughout history. The COVID-19 pandemic laid bare and exacerbated existing inequities inflicted on historically marginalized communities. Ageist rhetoric and policies during the COVID-19 pandemic further marginalized older adults. Although the detrimental impact of structural racism on health has been well-documented in the literature, generative research on the intersection of structural racism and ageism is limited. The AGS is working to identify and dismantle the healthcare structures that create and perpetuate these combined injustices and, in so doing, create a more just US healthcare system. This paper is intended to provide an overview of important frameworks and guide future efforts to both identify and eliminate bias within healthcare delivery systems and health professions training with a particular focus on the intersection of structural racism and ageism.

A Review of Race and Ethnicity in Hospice and Palliative Medicine Research: Representation Matters

CONTEXT

Despite documented racial and ethnic disparities in care, there is significant variability in representation, reporting, and analysis of race and ethnic groups in the hospice and palliative medicine (HPM) literature.

OBJECTIVES

To evaluate the race and ethnic diversity of study participants and the reporting of race and ethnicity data in HPM research.

METHODS

Adult patient and/or caregiver-centered research conducted in the U.S. and published as JPSM Original Articles from January 1, 2015, through December 31, 2019, were identified. Descriptive analyses were used to summarize the frequency of variables related to reporting of race and ethnicity.

RESULTS

Of 1253 studies screened, 218 were eligible and reviewed. There were 78 unique race and ethnic group labels. Over 85% of studies included ≥ one non-standard label based on Office of Management and Budget designations. One-quarter of studies lacked an explanation of how race and ethnicity data were collected, and 83% lacked a rationale. Over half did not include race and/or ethnicity in the analysis, and only 14 studies focused on race and/or ethnic health or health disparities. White, Black, Hispanic, Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Islander persons were included in 95%, 71%, 43% 37%,10%, and 4% of studies. In 92% of studies the proportion of White individuals exceeded 57.8%, which is their proportion in the U.S.

CONCLUSION

Our findings suggest there are important opportunities to standardize reporting of race and ethnicity, strive for diversity, equity, and inclusion among research participants, and prioritize the study of racial and ethnic disparities in HPM research.

Early Palliative Care Is Associated With Reduced Emergency Department Utilization in Pancreatic Cancer

OBJECTIVES

Most patients with pancreatic cancer have high symptom burden and poor outcomes. Palliative care (PC) can improve the quality of care through expert symptom management, although the optimal timing of PC referral is still poorly understood. We aimed to assess the association of early PC on health care utilization and charges of care for pancreatic cancer patients.

MATERIALS AND METHODS

We selected patients with pancreatic cancer diagnosed between 2000 and 2009 who received at least 1 PC encounter using the Surveillance, Epidemiology, and End Results (SEER)-Medicare. Patients who had unknown follow-up were excluded. We defined "early PC" if the patients received PC within 30 days of diagnosis.

RESULTS

A total of 3166 patients had a PC encounter; 28% had an early PC. Patients receiving early PC were more likely to be female and have older age compared with patients receiving late PC (P<0.001). Patients receiving early PC had fewer emergency department (ED) visits (2.6 vs. 3.0 visits, P=0.004) and lower total charges of ED care ($3158 vs. $3981, P<0.001) compared with patients receiving late PC. Patients receiving early PC also had lower intensive care unit admissions (0.82 vs. 0.98 visits, P=0.006) and total charges of intensive care unit care ($14,466 vs. $18,687, P=0.01). On multivariable analysis, patients receiving early PC were significantly associated with fewer ED visits (P=0.007) and lower charges of ED care (P=0.018) for all patients.

CONCLUSIONS

Early PC referrals were associated with lower ED visits and ED-related charges. Our findings support oncology society guideline recommendations for early PC in patients with advanced malignancies such as pancreatic cancer.

The Ethnogeriatric Implications of the COVID-19 Pandemic

Disproportionate impact of COVID-19 is another in a long line of racial, ethnic, and socioeconomic disparities throughout the many realms of health care. The reasons for the disparities are manifold, with social determinants of health contributing heavily. Older adults have been identified as being at high risk of significant complications from COVID-19, and age coupled with other factors seems to put older adults belonging to underserved minorities at greatly heightened risk of those complications. The COVID-19 pandemic has magnified yet again racial and ethnic differences in health care that still must be addressed. This will require a multi-pronged approach to move beyond identifying racial, ethnic, and socioeconomic disparities in health care to full-force design and implementation of interventions that address this important issue. The next generation of clinicians, researchers, leaders, and policymakers can help advance the cause of eliminating fundamentally unjust health disparities, and our nation's older adults should not be left behind.

Reducing Disparities in the Quality of Palliative Care for Older African Americans through Improved Advance Care Planning: Study Design and Protocol

Advance care planning (ACP) improves end-of-life care for patients and their caregivers. However, only one-third of adults have participated in ACP and rates are substantially lower among African Americans than among whites. Importantly, ACP improves many domains of care where there are racial disparities in outcomes, including receipt of goal-concordant care, hospice use, and provider communication. Yet, few studies have examined the effectiveness of ACP interventions among African Americans. The objectives of reducing disparities in the quality of palliative care for older African Americans through improved advance care planning (EQUAL ACP) are as follows: to compare the effectiveness of two interventions in (1) increasing ACP among African Americans and whites and (2) reducing racial disparities in both ACP and end-of-life care; and to examine whether racial concordance of the interventionist and patient is associated with ACP. EQUAL ACP is a longitudinal, multisite, cluster randomized trial and a qualitative study describing the ACP experience of participants. The study will include 800 adults ≥65 years of age (half African American and half white) from 10 primary care clinics in the South. Eligible patients have a serious illness (advanced cancer, heart failure, lung disease, etc.), disability in activities of daily living, or recent hospitalization. Patients are followed for one year and participate in either a patient-guided, self-management ACP approach, including a Five Wishes form or structured ACP with Respecting Choices First Steps. The primary outcome is formal or informal ACP-completion of advance directives, documented discussions with clinicians, and other written or verbal communication with surrogate decision makers about care preferences. Secondary outcomes assessed through after-death interviews with surrogates of patients who die during the study include receipt of goal-concordant care, health services use in the last year of life, and satisfaction with care. EQUAL ACP is the first large study to assess which strategies are most effective at both increasing rates of ACP and promoting equitable palliative care outcomes for seriously ill African Americans.

Understanding Underuse of Advance Care Planning Among a Cohort of African American Patients With Advanced Cancer: Formative Research That Examines Gaps in Intent to Discuss Options for Care

BACKGROUND

Advance care planning (ACP), palliative care (PC), and hospice are often underutilized by African Americans (AAs). This study assessed the impact of stage of intent to discuss ACP options as key potential barriers.

METHODS

We examined intent to discuss completion of ACP, PC, and hospice among 22 AA patients with cancer admitted to a local safety net hospital. Participants were asked about intent to discuss an advanced directive or living will (AD/LW), medical power of attorney (MPOA), PC, and hospice with their doctors. Intent to discuss these ACP components was based on the transtheoretical model. Electronic health records were reviewed at various intervals to assess completion of ACP behaviors and survival.

RESULTS

Participants had colorectal (33%), breast (44%), and lung (23%) cancer, and 82% had stage III/IV disease. Low percentages of patients were in the precontemplation stage for AD/LW completion (4.6%), MPOA completion (13.6%), and PC discussions (27.2%), but 77.2% were in the precontemplation stage for hospice discussions. At 1 year, only 5% completed an AD/LW, 36.4% appointed an MPOA, 42.9% were referred to PC, and 12.5% were referred to hospice. More than half (54.6%) were deceased by the study's conclusion. Most (81%) of these died within 6 months of their baseline study assessment.

CONCLUSIONS

Despite being hospitalized with advanced cancer and having poor prognosis, intent to discuss ACP options, PC, and hospice in this population was variable, and completion of these activities was low. This formative research is needed to develop education and counseling interventions for this high-risk, vulnerable population.

Examining the Association between Healthcare Utilization and Clinical Characteristics among Cancer Patients in a Safety Net Health System

OBJECTIVE

The goal of this study was to examine the association between available patient and clinical characteristics and healthcare utilization in a cohort of breast, lung, and colorectal cancer patients within a safety-net hospital system.

METHODS

Data for 979 breast, lung, and colorectal cancer patients admitted to a large, urban hospital for the year 2010 were extracted from the electronic medical record (EMR). Univariate and multivariate logistic regression analyses were performed to examine the association between relevant independent variables that were able to be captured from the EMR in discrete fields, emergency room (ER) utilization, and hospitalizations among members of the cohort. Spearman correlation coefficients to test the correlations between nonsteroidal anti-inflammatory drug and opioid prescriptions and healthcare utilization were also calculated.

RESULTS

Of the 979 patients, 22% were 65 years and older, 43% were non-Hispanic black, 42% had Medicare, and 56% had colorectal cancer. Patient and clinical characteristics that were associated with increased ER utilization, included Hispanic ethnicity (adjusted odds ratio; AOR: 2.21, 95% confidence interval; CI: 1.52-3.21), non-Hispanic black race (AOR: 2.01, 95% CI: 1.43-2.82), and referral to palliative care (AOR: 2.15, 95% CI: 1.36-3.41). Referral to palliative care (AOR: 3.84, 95% CI: 1.47-10.0), low albumin (AOR: 2.42, 95% CI: 1.20-4.89), and presence of metastases (AOR: 1.98, 95% CI: 1.29-3.06) were associated with greater odds of hospitalization. Number of opioids prescribed strongly correlated with number of hospitalizations (ρ correlation = 0.74). Only 10.6% of patients had been referred to outpatient palliative care during the study period.

CONCLUSIONS

Some patient and clinical characteristics associated with increased ER visits and hospitalizations in this cohort include race/ethnicity, palliative care referral, markers of advanced disease, and number opioids prescribed. Increasing knowledge of palliative care and access to palliative care among the underserved should be a focus of future research.

Predictors of Placement of Inpatient Palliative Care Consult Orders Among Patients With Breast, Lung, and Colon Cancer in a Safety Net Hospital System

BACKGROUND

The provision of palliative and end-of-life care to patients who are underrepresented and underserved provides unique challenges and opportunities.

OBJECTIVES

To examine predictors of placement of inpatient palliative care consult orders among patients with breast, lung, and colorectal cancer hospitalized in a safety net hospital in 2010.

METHODS

Simple and multivariable logistic regression of data on selected patients with cancer was performed to identify predictors of placement of inpatient palliative care consult orders.

RESULTS

Of 979 patients, 56% had colorectal cancer, 23% had lung cancer, and 21% had breast cancer. Of those patients, 16% received an order for inpatient palliative care consultation during the study period. Patients who had more than 20 prescriptions for opioids ordered (adjusted odds ratio [AOR]: 9.10, 95% confidence interval [CI]: 4.62-17.95), had an order for a radiation oncology consult (AOR: 2.60, 95% CI: 1.50-4.49), or had low albumin (AOR: 2.75, 95% CI: 4.71) were more likely to have an order for an inpatient palliative care consult placed. Race and ethnicity were not statistically significant predictors.

CONCLUSION

In this cohort of patients in a safety net hospital, markers of pain, advanced disease, and poor prognosis were associated with placement of inpatient palliative care consult orders.

Validation of a Geriatric Trauma Prognosis Calculator: A P.A.L.Li.A.T.E. Consortium Study

BACKGROUND/OBJECTIVES

The P.A.L.Li.A.T.E. (prognostic assessment of life and limitations after trauma in the elderly) consortium has previously created a prognosis calculator for mortality after geriatric injury based on age, injury severity, and transfusion requirement called the geriatric trauma outcome score (GTOS). Here, we sought to create and validate a prognosis calculator called the geriatric trauma outcome score ii (GTOS II) estimating probability of unfavorable discharge.

DESIGN

Retrospective cohort.

SETTING

Four geographically diverse Level 1 trauma centers.

PARTICIPANTS

Trauma admissions aged 65 to 102 years surviving to discharge from 2000 to 2013.

INTERVENTION

None.

MEASUREMENTS

Age, injury severity score (ISS), transfusion at 24 hours post-admission, discharge dichotomized as favorable (home/rehabilitation) or unfavorable (skilled nursing/long term acute care/hospice). Training and testing samples were created using the holdout method. A multiple logistic mixed model (GTOS II) was created to estimate the odds of unfavorable disposition then re-specified using the GTOS II as the sole predictor in a logistic mixed model using the testing sample.

RESULTS

The final dataset was 16,114 subjects (unfavorable discharge status = 15.4%). Training (n = 8,057) and testing (n = 8,057) samples had similar demographics. The formula based on the training sample was (GTOS II = Age + [0.71 × ISS] + 8.79 [if transfused by 24 hours]). Misclassification rate and AUC were 15.63% and 0.67 for the training sample, respectively, and 15.85% and 0.67 for the testing sample.

CONCLUSION

GTOS II estimates the probability of unfavorable discharge in injured elders with moderate accuracy. With the GTOS mortality calculator, it can help in goal setting conversations after geriatric injury.

Initial Development of a Computer Algorithm to Identify Patients With Breast and Lung Cancer Having Poor Prognosis in a Safety Net Hospital

BACKGROUND

Physicians often have difficulty with prognostication and identification of patients who are in need of counseling about options for care at the end of life. Consequently, the objective of this study was to describe the initial stages in development of a computerized algorithm that will identify breast and lung cancer patients most in need of counseling about care options, including advance care planning, palliative care, and hospice.

METHODS

Clinical and non-clinical data were extracted from the electronic medical record of breast and lung cancer patients admitted to a large, urban hospital for the year 2010. These data were used to create an electronic (e-EOL) algorithm designed to identify advanced cancer patients who could benefit from in-depth discussion about end-of-life care options.

RESULTS

There were 369 eligible breast (42%) and lung (58%) cancer patients identified by ICD-9 code. The e-EOL algorithm identified 53 (14%) patients that met assigned criteria (presence of metastatic disease and albumin < 2.5 g/dl). The sensitivity, specificity, and positive predictive value of the first generation algorithm were 21%, 96%, and 91% when compared to physician expert chart review. Survival analysis showed that 6-month survival for algorithm positive cases was 46% versus 78% for algorithm negative cases, and 1-year survival was 32% versus 72%, respectively.

CONCLUSIONS

Initial testing of the e-EOL algorithm appears to be promising. Other markers of advanced illness will added to the algorithm to improve its test operating characteristics so it may be used to identify patients with poor prognosis in real time.

The Desires of Their Hearts: The Multidisciplinary Perspectives of African Americans on End-of-Life Care in the African American Community

BACKGROUND

Studies have identified racial differences in advance care planning and use of hospice for care at the end of life. Multiple reasons for underuse among African American patients and their families have been proposed and deserve further exploration.

OBJECTIVE

The goal of this study was to examine perceptions of advance care planning, palliative care, and hospice among a diverse sample of African Americans with varying degrees of personal and professional experience with end-of-life care and use these responses to inform a culturally sensitive intervention to promote awareness of these options.

METHODS

Semistructured interviews and focus groups were conducted with African Americans who had varying degrees of experience and exposure to end-of-life care both personally and professionally. We conducted in-depth qualitative analyses of these interviews and focus group transcripts and determined that thematic saturation had been achieved.

RESULTS

Several themes emerged. Participants felt that advance care planning, palliative care, and hospice can be beneficial to African American patients and their families but identified specific barriers to completion of advance directives and hospice enrollment, including lack of knowledge, fear that these measures may hasten death or cause providers to deliver inadequate care, and perceived conflict with patients' faith and religious beliefs. Providers described approaches they use to address these barriers in their practices.

CONCLUSION

Findings, which are consistent with and further elucidate those identified from previous research, will inform design of a culturally sensitive intervention to increase awareness and understanding of advance care planning, palliative care, and hospice among members of the African American community.

Feeling Heard and Understood: A Patient-Reported Quality Measure for the Inpatient Palliative Care Setting

CONTEXT

As endorsed by the palliative care "Measuring What Matters" initiative, capturing patients' direct assessment of their care is essential for ongoing quality reporting and improvement. Fostering an environment where seriously ill patients feel heard and understood is of crucial importance to modern health care.

OBJECTIVES

To describe the development and performance of a self-report field measure for seriously ill patients to report how well they feel heard and understood in the hospital environment.

METHODS

As part of a larger ongoing cohort study of inpatient palliative care, we developed and administered the following point-of-care item: "Over the past two days, how much have you felt heard and understood by the doctors, nurses and hospital staff?" (completely, quite a bit, moderately, slightly, not at all). Participants completed the measure before and the day after palliative care consultation. For the postconsultation version, we changed the time frame from "past two days" to "today."

RESULTS

One hundred sixty patients with advanced cancer completed the preconsultation assessment, and 87% of them completed the postconsultation version. Responses encompassed full use of the ordinal scale, did not exhibit ceiling or floor effects, and showed improvement from preassessment to postassessment. The item was quick to administer and easy for patients to complete.

CONCLUSION

The "Heard & Understood" item is a promising self-report quality measure for the inpatient palliative care setting.

Use and Predictors of End-of-Life Care Among HIV Patients in a Safety Net Health System

CONTEXT

Although highly active antiretroviral therapy has improved survival among many HIV patients, there are still those with advanced illness and limited access to care who may benefit from palliative care and hospice.

OBJECTIVES

To examine completion of advance directives, use of palliative care, and enrollment in hospice among HIV patients who receive care at an urban safety net hospital.

METHODS

This was a retrospective cohort study of HIV patients in a large, urban safety net hospital in 2010. Physicians abstracted data from the electronic medical record on patient and clinical factors and end-of-life care use. Logistic regression examined predictors of hospice use.

RESULTS

Overall, 367 HIV patients identified electronically by International Classification of Disease (ICD)-9 code were hospitalized in 2010. The mean age was 42 years, and 57% were African American. Although 28% died, only 6% of the sample received palliative care consultation, and 6% of the sample enrolled in hospice. Those who received hospice had lower albumin levels (adjusted odds ratio [AOR] 4.53, 95% CI 1.19-17.34) had received palliative care (AOR 9.73, 95% CI 2.10-45.09) and completed an advance directive (AOR 16.33, 95% CI 4.23-61.68). Of those patients who received hospice, the mean time to death after enrollment was 11 days.

CONCLUSION

Among an urban cohort of HIV patients, the rates of advance directive completion, palliative care use, and hospice use were low. Despite advancements in the treatment of HIV, many patients with advanced illness may benefit from palliative care and hospice services. Advances should be made in identifying those patients earlier in their disease trajectories.

Estimating Geriatric Mortality after Injury Using Age, Injury Severity, and Performance of a Transfusion: The Geriatric Trauma Outcome Score

BACKGROUND

A tool to determine the probability of mortality for severely injured geriatric patients is needed.

OBJECTIVE

We sought to create an easily calculated geriatric trauma prognostic score based on parameters available at the bedside to aid in mortality probability determination.

METHODS

All patients ≥ 65 years of age were identified from our Level I trauma center's registry between January 1, 2000 and December 31, 2013. Measurements included age, Injury Severity score (ISS), units of packed red blood cells (PRBCs) transfused in the first 24 hours, and patients' mortality status at the end of their index hospitalization. As a first step, a logistic regression model with maximum likelihood estimation and robust standard errors was used to estimate the odds of mortality from age, ISS, and PRBCs after dichotomizing PRBCs as yes/no. We then constructed a Geriatric Trauma Outcome (GTO) score that became the sole predictor in the re-specified logistic regression model.

RESULTS

The sample (n = 3841) mean age was 76.5 ± 8.1 years and the mean ISS was 12.4 ± 9.8. In-hospital mortality was 10.8%, and 11.9% received a transfusion by 24 hours. Based on the logistic regression model, the equation with the highest discriminatory ability to estimate probability of mortality was GTO Score = age + (2.5 × ISS) + 22 (if given PRBCs). The area under the receiver operating characteristic curve (AUC) for this model was 0.82. Selected GTO scores and their related probability of dying were: 205 = 75%, 233 = 90%, 252 = 95%, 310 = 99%. The range of GTO scores was 67.5 (survivor) to 275.1 (died).

CONCLUSION

The GTO model accurately estimates the probability of dying, and can be calculated at bedside by those possessing a working knowledge of ISS calculation.

Communication About Advance Directives and End-of-Life Care Options Among Internal Medicine Residents

BACKGROUND

Despite increasing awareness about the importance of discussing end-of-life (EOL) care options with terminally ill patients and families, many physicians remain uncomfortable with these discussions.

OBJECTIVE

The objective of the study was to examine perceptions of and comfort with EOL care discussions among a group of internal medicine residents and the extent to which comfort with these discussions has improved over time.

METHODS

In 2013, internal medicine residents at a large academic medical center were asked to participate in an on-line survey that assessed their attitudes and experiences with discussing EOL care with terminally-ill patients. These results were compared to data from a similar survey residents in the same program completed in 2006.

RESULTS

Eighty-three (50%) residents completed the 2013 survey. About half (52%) felt strongly that they were able to have open, honest discussions with patients and families, while 71% felt conflicted about whether CPR was in the patient's best interest. About half (53%) felt strongly that it was okay for them to tell a patient/family member whether or not CPR was a good idea for them. Compared to 2006 respondents, the 2013 cohort felt they had more lectures about EOL communication, and had watched an attending have an EOL discussion more often.

CONCLUSIONS

Modest improvements were made over time in trainees' exposure to EOL discussions; however, many residents remain uncomfortable and conflicted with having EOL care discussions with their patients. More effective training approaches in EOL communication are needed to train the next generation of internists.

Injury severity and comorbidities alone do not predict futility of care after geriatric trauma

BACKGROUND

When counseling surrogates of massively injured elderly trauma patients, the prognostic information they desire is rarely evidence based.

OBJECTIVE

We sought to objectively predict futility of care in the massively injured elderly trauma patient using easily available parameters: age, Injury Severity Score (ISS), and preinjury comorbidities.

METHODS

Two cohorts (70-79 years and ≥80 years) were constructed from The National Trauma Data Bank (NTDB) for years 2007-2011. Comorbidities were tabulated for each patient. Mortality rates at every ISS score were tabulated for subjects with 0, 1, or ≥2 comorbidities. Futility was defined a priori as an in-hospital mortality rate of ≥95% in a cell with ≥5 subjects.

RESULTS

A total of 570,442 subjects were identified (age 70-79 years, n=217,384; age ≥80 years, n=352,608). Overall mortality was 5.3% for ages 70-79 and 6.6% for ≥80 years. No individual ISS score was found to have a mortality rate of ≥95% for any number of comorbidities in either age cohort. The highest mortality rate seen in any cell was for an ISS of 66 in the ≥80 year-old cohort with no listed comorbidities (93.3%). When upper extremes of ISS were aggregated into deciles, mortality for both cohorts across all number of comorbidities was 45.5%-60.9% for ISS 40-49, 56.6%-81.4% for ISS 50-59, and 73.9%-93.3% for ISS ≥60.

CONCLUSIONS

ISS and preinjury comorbidities alone cannot be used to predict futility in massively injured elderly trauma patients. Future attempts to predict futility in these age groups may benefit from incorporating measures of physiologic distress.

An examination of end-of-life care in a safety net hospital system: a decade in review

OBJECTIVES

To examine patterns of use of end-of-life care in patients receiving treatment at a large, urban safety-net hospital from 2000 to 2010.

METHODS

Data from the Parkland Hospital palliative care database, which tracked all consults for this period, were analyzed. Logistic regression was used to identify predictors of hospice use, and Cox proportional hazards modeling to examine survival.

RESULTS

There were 5,083 palliative care consults over the study period. More patients were Black (41%) or White (31%), and younger than 65 years old (75%). Cancer patients or those who received palliative care services longer were more likely to receive hospice; those who had no form of health care assistance were less likely. There were no racial/ethnic differences in hospice use.

CONCLUSION

In this cohort, there were no racial/ethnic disparities in hospice use. Those who had no form of health care assistance were less likely to receive hospice.

Barriers to end-of-life care for African Americans from the providers' perspective: opportunity for intervention development

Research has shown that African Americans (AAs) are less likely to complete advance directives and enroll in hospice. We examined barriers to use of these end-of-life (EOL) care options by conducting semi-structured interviews with hospice and palliative medicine providers and leaders of a national health care organization. Barriers identified included: lack of knowledge about prognosis, desires for aggressive treatment, family members resistance to accepting hospice, and lack of insurance. Providers believed that acceptance of EOL care options among AAs could be improved by increasing cultural sensitivity though education and training initiatives, and increasing staff diversity. Respondents did not have programs currently in place to increase awareness of EOL care options for underrepresented minorities, but felt that there was a need to develop these types of programs. These data can be used in future research endeavors to create interventions designed to increase awareness of EOL care options for AAs and other underrepresented minorities.

African American bereaved family members' perceptions of hospice quality: do hospices with high proportions of African Americans do better?

BACKGROUND

Research suggests that racial differences in end-of-life care persist even among patients enrolled in hospice.

OBJECTIVE

The objective of the study was to examine the association between bereaved family members' satisfaction with hospice services and the proportion of African American (AA) patients in hospice.

METHODS

The 2007 and 2008 Family Evaluation of Hospice Care (FEHC) Survey examined family members' perceptions of the quality of care on several dimensions including: unmet need for pain, dyspnea, and emotional support; being informed about the patient's condition and what to expect as the patient was dying; being informed about medications and treatments for symptoms; coordination of care; and overall satisfaction with care. We examined the association between family members' perception along each domain and the proportion of AAs served by hospices surveyed.

RESULTS

Of the 11,892 AA decedents in 678 hospice programs, 53.7% were female. The leading cause of death was cancer (51.6%). On univariate analysis, family members of decedents who died in hospices that had higher proportions of AAs were less likely to have concerns about unmet pain needs (odds ratio [OR] 0.84, 95% confidence interval [CI] 0.72-0.98), more likely to have concerns about coordination of care (1.28, 1.17-1.40), and less likely to perceive care as excellent or very good (0.73, 0.63-0.84). Coordination-of-care concerns and lower overall rating of care persisted in multivariable analyses. There were no other significant associations between family perceptions and proportions of AAs in hospice.

CONCLUSIONS

Among hospices with higher proportions of AAs, family members have more concerns about coordination of care and have lower overall perceptions of quality.

Does feeding tube insertion and its timing improve survival?

OBJECTIVES

To examine survival with and without a percutaneous endoscopic gastrostomy (PEG) feeding tube using rigorous methods to account for selection bias and to examine whether the timing of feeding tube insertion affected survival.

DESIGN

Prospective cohort study.

SETTING

All U.S. nursing homes (NHs).

PARTICIPANTS

Thirty-six thousand four hundred ninety-two NH residents with advanced cognitive impairment from dementia and new problems eating studied between 1999 and 2007.

MEASUREMENTS

Survival after development of the need for eating assistance and feeding tube insertion.

RESULTS

Of the 36,492 NH residents (88.4% white, mean age 84.9, 87.4% with one feeding tube risk factor), 1,957 (5.4%) had a feeding tube inserted within 1 year of developing eating problems. After multivariate analysis correcting for selection bias with propensity score weights, no difference was found in survival between the two groups (adjusted hazard ratio (AHR) = 1.03, 95% confidence interval (CI) = 0.94-1.13). In residents who were tube-fed, the timing of PEG tube insertion relative to the onset of eating problems was not associated with survival after feeding tube insertion (AHR = 1.01, 95% CI = 0.86-1.20, persons with a PEG tube inserted within 1 month of developing an eating problem versus later (4 months) insertion).

CONCLUSION

Neither insertion of PEG tubes nor timing of insertion affect survival.

Decision-making and outcomes of feeding tube insertion: a five-state study

OBJECTIVES

To examine family member's perceptions of decision-making and outcomes of feeding tubes.

DESIGN

Mortality follow-back survey. Sample weights were used to account for oversampling and survey design. A multivariate model examined the association between feeding tube use and overall quality of care rating regarding the last week of life.

SETTING

Nursing homes, hospitals, and assisted living facilities.

PARTICIPANTS

Respondents whose relative had died from dementia in five states with varying feeding tube use.

MEASUREMENTS

Respondents were asked about discussions, decision-making, and outcomes related to their loved ones' feeding problems.

RESULTS

Of 486 family members surveyed, representing 9,652 relatives dying from dementia, 10.8% reported that the decedent had a feeding tube, 17.6% made a decision not to use a feeding tube, and 71.6% reported that there was no decision about feeding tubes. Of respondents for decedents with a feeding tube, 13.7% stated that there was no discussion about feeding tube insertion, and 41.6% reported a discussion that was shorter than 15 minutes. The risks associated with feeding tube insertion were not discussed in one-third of the cases, 51.8% felt that the healthcare provider was strongly in favor of feeding tube insertion, and 12.6% felt pressured by the physician to insert a feeding tube. The decedent was often physically (25.9%) or pharmacologically restrained (29.2%). Respondents whose loved ones died with a feeding tube were less likely to report excellent end-of-life care (adjusted odds ratio=0.42, 95% confidence interval=0.18-0.97) than those who were not.

CONCLUSION

Based on the perceptions of bereaved family members, important opportunities exist to improve decision-making in feeding tube insertion.

Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia

Feeding and eating difficulties leading to weight loss are common in the advanced stages of dementia. When such problems arise, family members are often faced with making a decision regarding the placement of a percutaneous endoscopic gastrostomy tube. The existing evidence based on observational studies suggests that feeding tubes do not improve survival or reduce the risk of aspiration, yet the use of feeding tubes is prevalent in patients with dementia, and the majority of nursing home residents do not have orders documenting their wishes about the use of artificial hydration and nutrition. One reason is that orders to forgo artificial hydration and nutrition get wrongly interpreted as "do not feed," resulting in a reluctance of families to agree to them. Furthermore, nursing homes fear regulatory scrutiny of weight loss and wrongly believe that the use of feeding tubes signifies that everything possible is being done. These challenges might be overcome with the creation of clear language that stresses the patient's goals of care. A new order, "comfort feeding only," that states what steps are to be taken to ensure the patient's comfort through an individualized feeding care plan, is proposed. Comfort feeding only through careful hand feeding, if possible, offers a clear goal-oriented alternative to tube feeding and eliminates the apparent care-no care dichotomy imposed by current orders to forgo artificial hydration and nutrition.

African American bereaved family members' perceptions of the quality of hospice care: lessened disparities, but opportunities to improve remain

Previous research has documented striking disparities in bereaved family members' perceptions of the quality of end-of-life care between African American and white decedents. Using data from the 2005 repository of the Family Evaluation of Hospice Care survey, we examined whether this disparity in quality of end-of-life care persists once an African American is enrolled in hospice. Of the 121,817 decedents whose proxies were surveyed, 4,095 were non-Hispanic black (African American), and 97,525 were non-Hispanic white. There were no statistically significant differences with regard to decedents' gender. Length of stay on hospice was similar across racial groups. Although previous research has demonstrated striking disparities in the perceived quality of end-of-life care, we found that there were either no differences (quality ratings scores) or less of a disparity in perceptions of concerns with the quality of end-of-life care when compared to the results of a previously reported national mortality follow-back survey, suggesting that though disparities in perceptions of care at end of life persist, on hospice they improve to some degree.

Access to Hospice for African Americans: Are They Informed about the Option of Hospice?

OBJECTIVE

To examine whether African Americans are informed about hospice services, and to examine demographic or disease factors that may influence receipt of information about hospice.

DESIGN

Retrospective cohort study.

SETTING

Twenty-two states that accounted for nearly 70% of deaths in the United States in 2000.

MEASUREMENTS

A mortality follow-back survey was conducted. Based on sampled death certificates from 22 states, informants listed on the death certificates were contacted by telephone regarding the decedent's dying experience. Among those persons not receiving hospice services, the respondents were asked if hospice was presented as an option for care at the end of life.

RESULTS

Of 1578 interviews, 111 decedents were non-Hispanic, African Americans (average age, 71.5 years; 56% female). Of those, 32 (30.3%) of the decedents received hospice services, while 77 (68.5%) did not. Slightly more than half of African Americans (60; 53.8%) were not informed about hospice services and 12 (8.9%) were informed but did not enroll. Cancer sufferers were more likely to be counseled about hospice (p = 0.001).

CONCLUSION

Slightly more than half of African Americans were not informed about hospice services, and of those who were informed, cancer was the leading cause of death. Information about hospice should be provided to patients regardless of diagnosis, and dissemination of information should be done aggressively in the African American community in an effort to make hospice a viable option for end-of-life care.

Halo vest effect on balance

OBJECTIVE

To determine the effect of a halo vest, a cervical orthosis, on clinically relevant balance parameters.

DESIGN

Subjects performed unipedal stance (with eyes open and closed, on both firm and soft surfaces) and functional reach, with and without the application of a halo vest.

SUBJECTS

A convenience sample of 12 healthy young subjects, with an equal number of men and women.

OUTCOME MEASURES

Seconds for unipedal stance (maximum 45); inches for functional reach.

RESULTS

Both unipedal stance times and functional reach (mean +/- standard deviation) were significantly decreased with the halo vest as compared to without it (29.1+/-5.8 vs. 32.8+/-6.4 seconds, p = .002; 12.9+/-1.4 vs. 15.1+/-2.1 inches, p<.01).

CONCLUSION

A halo vest causes an acute impairment in balance in the healthy young. It is likely that the impairment would be greater in older or injured patients, thus increasing their risk for a fall, which could have devastating consequences.

Factor analysis of the continuous performance test and parent-teacher reports of attention deficit disorder

The relationships between a computerized measure of attention deficit disorder and scores from two commonly used parent-teacher reports were investigated. A factor analysis of the raw omission and commission scores provided by the Continuous Performance Test and Conners' Parent Rating Scale and the ADD-H Comprehensive Teacher Rating Scale indicated that for a sample of 54 children the Continuous Performance Test was most closely associated with measures of impulsivity and hyperactivity provided by the Conners' rating. This finding was congruent with the use of the Continuous Performance Test in the evaluation as a measure of Attention Deficit Hyperactivity Disorder and suggestive of a positive and significant relation between this computerized measure of behavior and parents' perception of behavior. Little association was detected between scores on the teachers' scale and omission and commission scores.

Interstitial deletion 2q31 leads to q33

We present an 8-month-old female with severe retardation of growth and development, multiple congenital anomalies, and an interstitial deletion del(2)(q31 leads to q33) including results of cytogenetic and gene marker studies. The manifestations of this infant are compared with those of four other known patients with a partial del(2q).

Further Observations Upon Imperforate Anus

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