Dying with cancer: patients' function, symptoms, and care preferences as death approaches

OBJECTIVE

To characterize the dying experience of patients with cancer over the last 6 months of life.

STUDY DESIGN

A retrospective analysis of the last 6 months of life among patients with colon cancer and non-small cell lung cancer enrolled in a prospective cohort study from June 1989 to June 1991 and from January 1992 to January 1994.

SETTING

Five geographically diverse tertiary care academic medical centers participating in the Study to Understand Patient Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) Project.

PARTICIPANTS

All patients enrolled in SUPPORT who had either colon cancer, metastatic to the liver or stage III or stage IV non-small cell lung cancer and died within 1 year of their index hospitalization. This report examines 316 of 520 patients with metastatic colon cancer and 747 of 939 patients with lung cancer enrolled in SUPPORT.

METHODS

Data were collected by interview and chart abstraction at several time points in the SUPPORT Project. To describe progression to death, we constructed four observational windows backward in time beginning with patients' date of death and ending with their date of entry into the SUPPORT Project or 6 months before their death, whichever came first: (1) 3 days before death, (2) 3 days to 1 month before death, (3) 1 month to 3 months before death, and (4) 3 months to 6 months before death. For each outcome, patients contributed information to all windows during which they had data collected. We describe the frequency distributions of each outcome over time and report tests for trend.

OUTCOME MEASURES

We examined several outcomes over time, including: percentage of days spent in a hospital; prognosis as measured by model-based prognostic estimates of 6-month survival; severity of illness as measured by the acute physiology score; functional status as measured by dependencies in activities of daily living (ADLs); severe physical and emotional symptoms, including pain, depression, and anxiety; patients' preferences for care; and the financial impact on patients' families.

RESULTS

The death rate within 1 year of study entry was high among patients with metastatic colon cancer and advanced non-small cell lung cancer enrolled in SUPPORT (61% and 80%, respectively). As patients with cancer progress toward death, their estimated 6-month prognosis decreases significantly and the severity of their disease worsens. Patients' functional status also declines significantly as they approach death, such that most patients have four or more impairments within the 3 days before death. Patients with cancer experience significantly more pain and confusion as death approaches. Severe pain is common; more than one-quarter of patients with cancer experience serious pain 3 to 6 months before death and more than 40% were in serious pain during their last 3 days of life. However, dying patients are only modestly depressed and anxious during their last 3 days of life. As death approaches, patients favor comfort measures over life-extension, and about two-thirds want to forego resuscitation within 3 days of death. Families of patients dying with cancer incurred significant financial burdens during the last 6 months of life, and much of this burden was already experienced by 3 to 6 months before death.

CONCLUSIONS

The last 6 months of life for patients with cancer is characterized by functional decline and poorly controlled severe pain and confusion. Although patients increasingly prefer comfort care as they near death, many die in severe pain. These findings highlight important opportunities to improve the quality of care at the end of life for patients dying with cancer.

Prediction of survival for older hospitalized patients: the HELP survival model. Hospitalized Elderly Longitudinal Project

OBJECTIVE

To develop and validate a model estimating the survival time of hospitalized persons aged 80 years and older.

DESIGN

A prospective cohort study with mortality follow-up using the National Death Index.

SETTING

Four teaching hospitals in the US.

PARTICIPANTS

Hospitalized patients enrolled between January 1993 and November 1994 in the Hospitalized Elderly Longitudinal Project (HELP). Patients were excluded if their length of hospital stay was 48 hours or less or if admitted electively for planned surgery.

MEASUREMENTS

A log-normal model of survival time up to 711 days was developed with the following variables: patient demographics, disease category, nursing home residence, severity of physiologic imbalance, chart documentation of weight loss, current quality of life, exercise capacity, and functional status. We assessed whether model accuracy could be improved by including symptoms of depression or history of recent fall, serum albumin, physician's subjective estimate of prognosis, and physician and patient preferences for general approach to care.

RESULTS

A total of 1266 patients were enrolled over a 10-month period, (median age 84.9, 61% female, 68% with one or more dependency), and 505 (40%) died during an average follow-up of more than 2 years. Important prognostic factors included the Acute Physiology Score of APACHE III collected on the third hospital day, modified Glasgow coma score, major diagnosis (ICU categories together, congestive heart failure, cancer, orthopedic, and all other), age, activities of daily living, exercise capacity, chart documentation of weight loss, and global quality of life. The Somers' Dxy for a model including these factors was 0.48 (equivalent to a receiver-operator curve (ROC) area of 0.74, suggesting good discrimination). Bootstrap estimation indicated good model validation (corrected Dxy of 0.46, ROC of 0.73). A nomogram based on this log-normal model is presented to facilitate calculation of median survival time and 10th and 90th percentile of survival time. A count of geriatric syndromes or comorbidities did not add explanatory power to the model, nor did the hospital of patient recruitment, depression, or the patient preferences for general approach to care. The physician's perception of the patient's preferences and the physician's subjective estimate of the patient's prognosis improved the estimate of survival time significantly.

CONCLUSIONS

Accurate estimation of length of life for older hospitalized persons may be calculated using a limited amount of clinical information available from the medical chart plus a brief interview with the patient or surrogate. The accuracy of this model can be improved by including measures of the physician's perception of the patient's preferences for care and the physician's subjective estimate of prognosis.

A prospective study of patient-physician communication about resuscitation

OBJECTIVE

To evaluate prospectively seriously ill patients' characteristics, perceptions, and preferences associated with discussing resuscitation (CPR) with their physicians.

DESIGN

Prospective cohort.

SETTING

Five academic medical centers.

PARTICIPANTS

Patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments who had not communicated with their physicians about CPR at admission to a hospital for life-threatening illness (n = 1288).

MEASUREMENTS

Baseline surveys of patients' characteristics, health status, desires for participation in medical decision making, and cardiopulmonary resuscitation. Two month follow-up surveys of patients' communication of resuscitation preference. Chart reviews for clinical indicators.

RESULTS

Thirty percent of patients communicated their resuscitation preference to their physician during a 2 month-period following hospital admission. Patients whose preference was to forego CPR (odds ratio (OR) 2.9;(95% CI, 1.9-4.2)) and whose preference had changed from desiring to foregoing CPR (OR 1.6; (95% CI, 1.1-2.4)) were more likely to communicate their preference than patients who continued to prefer to receive CPR. However, only 50% of patients who maintained a preference to forego CPR communicated this over a 2-month period. Having an advance directive and remaining in the hospital at 2-month follow-up were also independently associated with communication, whereas patients' preference for participation in decision-making, health status, and prognostic estimate were not.

CONCLUSIONS

Communication about resuscitation preferences occurred infrequently after hospital admission for a serious illness, even among patients wishing to forego resuscitation. Factors such as declining quality of life, which were expected to be associated with communication, were not. An invitation to communicate about CPR preference is important after hospital admission for a serious illness. Novel approaches are needed to promote physician-patient discussions about resuscitation.

Patients who want their family and physician to make resuscitation decisions for them: observations from SUPPORT and HELP. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Hospitalized Elderly Longitudinal Project

OBJECTIVE

To determine the extent to which older or seriously ill inpatients would prefer to have their family and physician make resuscitation decisions for them rather than having their own stated preferences followed if they were unable to decide themselves.

DESIGN

Analysis of existing data from the Hospitalized Elderly Longitudinal Project (HELP) and the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT).

SETTING

Five teaching hospitals in the United States.

PARTICIPANTS

2203 seriously ill adult inpatients (SUPPORT) and 1226 older inpatients (HELP) who expressed preferences about resuscitation and about advance decision-making.

MEASURES

We used a logistic regression model to determine which factors predicted preferences for family and physician decision-making.

RESULTS

Of the 513 HELP patients in this analysis, 363 (70.8%) would prefer to have their family and physician make resuscitation decisions for them whereas 29.2% would prefer to have their own stated preferences followed if they were to lose decision-making capacity. Of the 646 SUPPORT patients, 504 (78.0%) would prefer to have their family and physician decide and 22.0% would prefer to have their advance preferences followed. Independent predictors of preference for family and physician decision-making included not wanting to be resuscitated and having a surrogate decision-maker.

CONCLUSIONS

Most inpatients who are older or have serious illnesses would not want their stated resuscitation preferences followed if they were to lose decision-making capacity. Most patients in both groups would prefer that their family and physician make resuscitation decisions for them. These results underscore the need to understand resuscitation preferences within a broader context of patient values.

Physician understanding of patient resuscitation preferences: insights and clinical implications

OBJECTIVE

To describe physician understanding of patient preferences concerning cardiopulmonary resuscitation (CPR) and to assess the relationship of physician understanding of patient preferences with do not resuscitate (DNR) orders and in-hospital CPR.

DESIGN

We evaluated physician understanding of patient CPR preference and the association of patient characteristics and physician-patient communication with physician understanding of patient CPR preferences. Among patients preferring to forego CPR, we compared attempted resuscitations and time to receive a DNR order between patients whose preference was understood or misunderstood by their physician.

PATIENTS/SETTING

Seriously ill hospitalized adult patients were enrolled in the Study to Understand Prognoses and Preferences for the Outcomes of Treatments. GENERAL RESULTS: Physicians understood 86% of patient preferences for CPR, but only 46% of patient preferences to forego CPR. Younger patient age, higher physician-estimated quality of life, and higher physician prediction of 6-month survival were independently associated with both physician understanding when a patient preferred to receive CPR and physician misunderstanding when a patient preferred to forego CPR. Physicians who spoke with patients about resuscitation and had longer physician-patient relationships understood patients' preferences to forego CPR more often. Patients whose physicians understood their preference to forego CPR more often received DNR orders, received them earlier, and were significantly less likely to undergo resuscitation.

CONCLUSIONS

Physicians often misunderstand seriously ill, hospitalized patients' resuscitation preferences, especially preferences to forego CPR. Factors associated with misunderstanding suggest that physicians infer patients' preferences without asking the patient. Patients who prefer to forego CPR but whose wishes are not understood by their physician may receive unwanted treatment.

Withholding versus withdrawing life-sustaining treatment: patient factors and documentation associated with dialysis decisions

OBJECTIVE

We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn.

DESIGN

Prospective cohort study.

SETTING

Five teaching hospitals.

PATIENTS

Five hundred sixty-five seriously ill hospitalized patients who had not previously undergone dialysis who developed renal failure.

MAIN OUTCOME MEASURES

Patient demographics, clinical characteristics, preferences, and prognostic estimates associated with having dialysis withheld rather than initiated and withdrawn rather than continued. Differences in chart documentation concerning decision-making for dialysis withheld, withdrawn, and continued.

RESULTS

Older patient age, cancer diagnosis, and male gender were associated with dialysis withheld rather than withdrawn. Age and gender differences persisted after adjustment for patients' aggressiveness of care preference. Worse 2-month prognosis was associated with both withholding and withdrawing dialysis. Chart documentation of decision-making was lacking more often for patients with dialysis withheld than for dialysis withdrawn.

CONCLUSIONS

Measuring the equity of life-sustaining treatment use will require evaluation of care withheld, not just care withdrawn. Older patients and men, after accounting for prognosis and function, are more likely to have dialysis withheld than withdrawn after a trial. Further exploration is needed into this disparity and the inadequate chart documentation for patients with dialysis withheld.

Rethinking fundamental assumptions: SUPPORT's implications for future reform. Study to Understand Prognoses and Preferences and Risks of Treatment

BACKGROUND

The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects.

OBJECTIVE

To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective.

DESIGN

This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change.

RESULTS

Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform.

CONCLUSIONS

SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.

Dying with lung cancer or chronic obstructive pulmonary disease: insights from SUPPORT. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

CONTEXT

Many are calling for patients with advanced chronic obstructive pulmonary disease (COPD) to receive hospice care, but the traditional hospice model may be insufficient.

OBJECTIVE

To compare the course of illness and patterns of care for patients with non-small cell lung cancer and severe COPD.

DESIGN

Prospective cohort study of seriously ill, hospitalized adults.

SETTING

Five teaching hospitals in the United States.

PATIENTS

Patients with Stage III or IV non-small cell lung cancer (n = 939) or acute exacerbation of severe COPD (n = 1008).

MAIN OUTCOME MEASURES

Patients' preferences for pattern of care and for ventilator use; symptoms; life-sustaining interventions; and survival prognoses.

RESULTS

Sixty percent in each group wanted comfort-focused care; 81% with lung cancer and 78% with COPD were extremely unwilling to have mechanical ventilation indefinitely. Severe dyspnea occurred in 32% of patients with lung cancer and 56% of patients with COPD and severe pain in 28 % of patients with lung cancer and 21% of patients with COPD. Patients with COPD who died during index hospitalization were more likely than patients with lung cancer to receive mechanical ventilation (70.4% vs 19.8%), tube feeding (38.7% vs 18.5%), and cardiopulmonary resuscitation (25.2% vs 7.8%). Mechanical ventilation had greater short term effectiveness in patients with COPD, based on survival to hospital discharge (76% vs 38%). Patients with COPD maintained higher median 2-month and 6-month survival prognoses, even days before death.

CONCLUSIONS

Hospitalized patients with lung cancer or COPD preferred comfort-focused care, yet dyspnea and pain were problematic in both groups. Patients with COPD were more often treated with life-sustaining interventions, and short-term effectiveness was comparatively better than in patients with lung cancer. In caring for patients with severe COPD, consideration should be given to implementing palliative treatments more aggressively, even while remaining open to provision of life-sustaining interventions.

Age differences in care practices and outcomes for hospitalized patients with cancer

OBJECTIVE

To identify age group differences in care practices and outcomes for seriously ill hospitalized patients with malignancy.

DESIGN

Prospective cohort study (SUPPORT project).

SETTING

Five United States teaching hospitals; data was gathered between 1989 and 1994.

SUBJECTS

Nine hundred twenty five older (age > or = 65 years), 983 middle aged (age = 45-64 years), and 274 younger (age = 18-44 years) hospitalized patients receiving care for non-small cell lung cancer, colon cancer metastasized to the liver, or multi-organ system failure associated with malignancy.

MEASUREMENTS

Care practices and patient outcomes were determined from hospital records. Length of survival was identified using the National Death Index. After adjusting for important variables, including severity of illness (i.e., SUPPORT model estimate for 2-month survival, cancer condition), hospital site, selection to intervention and sociodemographic variables, age group differences in care practices and outcomes were identified using general linear models.

RESULTS

Older patients with cancer had lower resource utilization during hospitalization (P < .04) and were less likely to receive cancer-related treatments (i.e., chemotherapy, platelet infusions, scheduled intravenous medications) than middle-aged and young-adult patients in the first week of hospitalization (P < or = .01). More care topics were discussed with older patients and their families then with younger patients and their families (P < .001). Length of stay and total hospital costs were lower for older and middle-aged patients than for younger patients. Although more older patients had discussions about transfer to hospice (P < .001), older patients were no more likely to be discharged with supportive care (inpatient hospice or home with home/ hospice care). Older patients died sooner than middle-aged patients (P < .01).

CONCLUSIONS

Patient age influenced care decisions and outcomes. Older patients (age > or = 65 years) received less aggressive care, had more discussions about care decisions, and died sooner than younger patients with cancer. Younger patients had longer stays, higher hospital costs, and greater probability of rehospitalization. Although well over half of patients died within 6 months of hospitalization, few patients in any age group were discharged with supportive care. Future studies should examine age differences in palliation, as well as acute care of cancer patients across inpatient and ambulatory care settings and should assess quality of care at the end of life.

The effect of nutritional supplementation on survival in seriously ill hospitalized adults: an evaluation of the SUPPORT data. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

BACKGROUND

Enteral tube and parenteral hyperalimentation are widely used nutritional support systems. Few studies examine the relation between nutritional support and patient outcomes in seriously ill hospitalized adults.

OBJECTIVE

To explore the association between nutritional support and survival in seriously ill patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

DESIGN

A prospective study of preferences, decision-making, and outcomes.

SETTING

Five teaching hospitals

PARTICIPANTS

6298 patients aged 18 or older meeting diagnostic and illness severity criteria.

MEASUREMENT

Demographic characteristics, diagnoses, comorbid conditions, acute physiology score, nutritional support, and functional status before hospitalization.

RESULTS

A total of 2149 patients received nutritional support. In patients who received artificial nutrition on hospital days 1 or 3 (Cohort 1), enteral feeding was associated with improved survival in coma (hazard: 0.53; 95%CI, 0.42-0.66), and reduced survival in COPD (hazard: 1.57; 95%CI, 1.18-2.08). In patients who were hospitalized on Day 7 and received artificial nutrition on days 1, 3, or 7 (Cohort 2), enteral tube feeding (hazard: 0.35; 95%CI, 0.27-0.46) or hyperalimentation (hazard: 0.58; 95%CI, 0.38-0.90) was associated with improved survival in coma. Tube feeding was associated with decreased survival in acute respiratory failure (ARF) or multiorgan system failure (MOSF) with sepsis (hazard: 1.21; 95%CI, 10.4-1.41), cirrhosis (hazard: 2.15; 95%CI, 1.35-3.42), and COPD (hazard: 1.37; 95%CI, 1.04-1.80). Hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis (hazard: 1.34; 95%CI, 1.12-1.59).

CONCLUSIONS

Nutritional support was associated with improved survival in coma. Enteral feeding and hyperalimentation was associated with decreased survival in ARF or MOSF with sepsis. Tube feeding was associated with decreased survival in cirrhosis and COPD. Except for patients in coma, artificial nutrition was not associated with a survival advantage.

Communication and decision-making in seriously ill patients: findings of the SUPPORT project. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

OBJECTIVES

The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) represents one of the largest and most comprehensive efforts to describe patient preferences in seriously ill patients, and to evaluate how effectively patient preferences are communicated. Our objective was to review findings from SUPPORT describing the communication of seriously ill patients' preferences for end-of-life care.

METHODS

We identified published reports from SUPPORT describing patient preferences and the communication of those preferences. We abstracted findings that addressed each of the following questions: What patient characteristics predict patient preferences for end of life care? How well do physicians, nurses, and surrogates understand their patients' preferences, and what variables are correlated with this understanding? Does increasing the documentation of existing advance directives result in care more consistent with patients' preferences?

RESULTS

Patients who are older, have cancer, are women, believe their prognoses are poor, and are more dependent in ADL function are less likely to want CPR. However, there is considerable variability and geographic variation in these preferences. Physician, nurse, and surrogate understanding of their patient's preferences is only moderately better than chance. Most patients do not discuss their preferences with their physicians, and only about half of patients who do not wish to receive CPR receive DNR orders. Factors other than the patients' preferences and prognoses, including the patient's age, the physician's specialty, and the geographic site of care were strong determinants of whether DNR orders were written. In SUPPORT patients, there was no evidence that increasing the rates of documentation of advance directives results in care that is more consistent with patients' preferences.

CONCLUSIONS

SUPPORT documents that physicians and surrogates are often unaware of seriously ill patients' preferences. The care provided to patients is often not consistent with their preferences and is often associated with factors other than preferences or prognoses. Improving these deficiencies in end-of-life care may require systematic change rather than simple interventions.

Predicting functional status outcomes in hospitalized patients aged 80 years and older

OBJECTIVE

To develop a model estimating the probability of a patient aged 80 years or older having functional limitations 2 months and 12 months after being hospitalized.

DESIGN

A prospective cohort study.

SETTING

Four teaching hospitals in the US.

PARTICIPANTS

Enrolled patients were nonelective hospital admissions aged 80 years or older who stayed in hospital at least 48 hours. The 804 patients who survived and completed an interview at 2 months and the 450 who completed an interview at 12 months were from the 1266 patients in the Hospitalized Elderly Longitudinal Project (HELP) (76% and 47% of survivors, respectively). Median age of the 2-month survivors was 84.7 years.

MEASUREMENTS AND MAIN OUTCOMES

Patient function 2 and 12 months after enrollment was defined by the number of dependencies in Activities of Daily Living (ADLs). Ordinal logistic regression models were constructed to predict functional status. Predictors included demographic characteristics, disease category, geriatric conditions, severity of physiologic imbalance, current quality of life, and exercise capacity and ADLs 2 weeks before study admission.

RESULTS

Before admission, 39% of patients were functionally independent in ADLs. Of patients who survived and were interviewed at 2 months, 32% were functionally independent, and at 12 months, 36% were independent. Among patients with no baseline dependencies, 42% had developed one or more limitations 2 months later, and 41 % had limitations 12 months later. The patient's ability to perform activities of daily living at baseline was the most important predictor of functional status at both 2 and 12 months. In a multivariable predictive model, independent predictors of poorer functional status at 2 months included: worse baseline functional status and quality of life; depth of coma, if any; lower serum albumin level; presence of dementia, depression, or incontinence; being bedridden; medical record documentation of need for nursing home; and older age. Model performance, assessed using Somers' D, was 0.61 for 2 months and 0.57 for 12 months (Receiver Operating Characteristic (ROC) area = 0.81 and .79, respectively.) Bootstrap validation of the month 2 model also yielded a Somers' D = 0.60. The models were well calibrated over the entire risk range. The ROC area for prediction of the loss of independence was 0.76 for 2 months and 0.68 for 12 months.

CONCLUSIONS

Many older patients are functionally impaired at the time of hospitalization, and many develop new functional limitations. A limited amount of readily available clinical information can yield satisfactory predictions of functional status 2 months after hospitalization. Models like this may prove to be useful in clinical care. This work illuminates a potential method for risk adjustment in research studies and for monitoring quality of care.

Citrobacter freundii tyrosine phenol-lyase: the role of asparagine 185 in modulating enzyme function through stabilization of a quinonoid intermediate

Asn185 is an invariant residue in all known sequences of TPL and of closely related tryptophanase and it may be aligned with the Asn194 in aspartate aminotransferase. According to X-ray data, in the holoenzyme and in the Michaelis complex Asn185 does not interact with the cofactor pyridoxal 5'-phosphate, but in the external aldimine a conformational change occurs which is accompanied by formation of a hydrogen bond between Asn185 and the oxygen atom in position 3 of the cofactor. The substitution of Asn185 in TPL by alanine results in a mutant N185A TPL of moderate residual activity (2%) with respect to adequate substrates, L-tyrosine and 3-fluoro-L-tyrosine. The affinities of the mutant enzyme for various amino acid substrates and inhibitors, studied by both steady-state and rapid kinetic techniques, were lower than for the wild-type TPL. This effect mainly results from destabilization of the quinonoid intermediate, and it is therefore concluded that the hydrogen bond between Asn185 and the oxygen at the C-3 position of the cofactor is maintained in the quinonoid intermediate. The relative destabilization of the quinonoid intermediate and external aldimine leads to the formation of large amounts of gem-diamine in reactions of N185A TPL with 3-fluoro-L-tyrosine and L-phenylalanine. For the reaction with 3-fluoro-L-tyrosine it was first possible to determine kinetic parameters of gem-diamine formation by the stopped-flow method. For the reactions of N185A TPL with substrates bearing good leaving groups the observed values of k(cat) could be accounted for by taking into consideration two effects: the decrease in the quinonoid content under steady-state conditions and the increase in the quinonoid reactivity in a beta-elimination reaction. Both effects are due to destabilization of the quinonoid and they counterbalance each other. Multiple kinetic isotope effect studies on the reactions of N185A TPL with suitable substrates, L-tyrosine and 3-fluoro-L-tyrosine, show that the principal mechanism of catalysis, suggested previously for the wild-type enzyme, does not change. In the framework of this mechanism the observed considerable decrease in k(cat) values for reactions of N185A TPL with L-tyrosine and 3-fluoro-L-tyrosine may be ascribed to participation of Asn185 in additional stabilization of the keto quinonoid intermediate.

The effect of nitric oxide on the growth of Plasmodium falciparum, P. chabaudi and P. berghei in vitro

Protective immune mechanisms to the asexual erythrocytic stages of the malaria parasite Plasmodium chabaudi AS strain include antibody-independent mechanisms. Nitric oxide (NO) is produced during the infection and indirect evidence suggests that it can contribute to the antiparasitic mechanisms. We examined the effect of an NO producer, S-nitroso-acetyl-penicillamine (SNAP), on the growth and survival in vitro of P. chabaudi AS, P. berghei and P. falciparum. Growth of the parasites was monitored by the uptake of tritiated hypoxanthine and, in the case of P. falciparum, by morphological examination in stained blood smears. DL-penicillamine and sodium nitrite, as controls, had no inhibitory activity at the concentrations used. The results showed that at SNAP concentrations of approximately 182 microM and above NO was cytotoxic to P. falciparum but, at lower concentrations, there was a cytostatic effect and some parasites resumed growth and division after NO production had ceased. Rings were less susceptible to NO effects than later stages in the asexual cycle. The antimalarial activity of NO from SNAP also extended to the rodent parasites but, under the experimental conditions used, they were less sensitive than the human species. In the cultures of P. chabaudi, increasing the numbers of noninfected erythrocytes present did not diminish the antimalarial activity of SNAP, suggesting that here at least haemoglobin was not scavenging NO significantly.

Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

BACKGROUND

Previous studies suggest that specialty care is more costly but may produce improved outcomes for patients with acute cardiac illnesses.

OBJECTIVE

To determine whether patients with congestive heart failure who are cared for by cardiologists experienced differences in costs, care patterns, and survival compared with patients of generalists.

DESIGN

Prospective cohort study.

SETTING

5 U.S. teaching hospitals between 1989 and 1994.

PATIENTS

1298 patients hospitalized with an exacerbation of congestive heart failure.

MEASUREMENTS

Hospital costs; average daily Therapeutic Intervention Scoring System (TISS) score; and survival censored at 30, 180, and 365 days and 31 December 1994.

RESULTS

Compared with patients of generalists, patients of cardiologists were younger (mean age, 63.3 and 71.4 years; P < 0.001) and had lower Acute Physiology Scores at the time of admission (35.1 and 36.7; P < 0.001) but were more likely to have a history of ventricular arrhythmias (21.0% and 10.2%; P < 0.001). At 6 months, 201 (27%) patients of cardiologists and 149 (27%) patients of generalists had died. After adjustment for sociodemographic characteristics and severity of illness, patients of cardiologists incurred costs that were 42.9% (95% CI, 27.8% to 59.8%) higher and average daily TISS scores that were 2.83 points (CI, 1.96 to 3.68 points) higher than those of patients of generalists. Patients of cardiologists were more likely to undergo right-heart catheterization (adjusted odds ratio, 2.9 [CI, 1.7 to 4.9]) or cardiac catheterization (adjusted odds ratio, 3.9 [CI, 2.4 to 6.2]) and had higher odds for transfer to an intensive care unit and electrocardiographic monitoring. Adjusted survival did not differ significantly between groups at 30 days; however, there was a trend toward improved survival among patients of cardiologists at 1 year (adjusted relative hazard, 0.82 [CI, 0.65 to 1.04]) and at maximum follow-up (adjusted relative hazard, 0.80 [CI, 0.66 to 0.96]).

CONCLUSIONS

In this observational study of patients hospitalized with congestive heart failure, cardiologist care was associated with greater costs and resource use and no difference in survival at 30 days of follow-up. Whether the trend toward better survival at longer follow-up represents differences in care or unadjusted illness severity is uncertain.

Patient race and decisions to withhold or withdraw life-sustaining treatments for seriously ill hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

PURPOSE

Patient race is associated with decreased resource use for seriously ill hospitalized adults. We studied whether this difference in resource use can be attributed to more frequent or earlier decisions to withhold or withdraw life-sustaining therapies.

SUBJECTS AND METHODS

We studied adults with one of nine illnesses that are associated with an average 6-month mortality of 50% who were hospitalized at five geographically diverse teaching hospitals participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). We examined the presence and timing of decisions to withhold or withdraw ventilator support and dialysis, and decisions to withhold surgery. Analyses were adjusted for demographic characteristics, prognosis, severity of illness, function, and patients' preferences for life-extending care.

RESULTS

The mean (+/- SD) age of the patients was 63 +/- 16 years; 16% were African-American, 44% were women, and 53% survived for 6 months or longer. Of the 9,076 patients, 5,349 (59%) had chart documentation that ventilator support had been considered in the event the patient's condition required such a treatment to sustain life, 2,975 charts (33%) had documentation regarding major surgery, and 1,293 (14%) had documentation of discussions about dialysis. There were no significant differences in the unadjusted rates of decisions to withhold or withdraw treatment among African-Americans compared with non-African-Americans: among African-Americans, 33% had a decision made to withhold or withdraw ventilator support compared with 35% among other patients, 14% had a decision made to withhold major surgery compared with 12% among other patients, and 25% had a decision made to withhold or withdraw dialysis compared with 30% among other patients (P >0.05 for all comparisons). After adjustment for demographic characteristics, prognosis, illness severity, function, and preferences for care, there were no differences in the timing or rate of decisions to withhold or withdraw treatments among African-Americans compared with non-African-American patients.

CONCLUSION

Patient race does not appear to be associated with decisions to withhold or withdraw ventilator support or dialysis, or to withhold major surgery, in seriously ill hospitalized adults.

Factors associated with use of cardiopulmonary resuscitation in seriously ill hospitalized adults

CONTEXT

The epidemiology of do-not-resuscitate (DNR) orders for hospitalized patients has been reported, but little is known about factors associated with the use of cardiopulmonary resuscitation (CPR).

OBJECTIVE

To identify factors associated with an attempt at CPR for patients who experienced cardiopulmonary arrest.

DESIGN

Secondary analysis of data collected in 2 prospective cohort studies: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT, 1989-1994) and the Hospitalized Elderly Longitudinal Project (HELP, 1994). Setting Five teaching hospitals across the United States.

PARTICIPANTS

A total of 2505 seriously ill hospitalized patients and nonelectively admitted persons aged 80 years or older who experienced cardiopulmonary arrest.

MAIN OUTCOME MEASURES

Medical records data on CPR efforts, DNR orders, disease severity, age, race, sex, length of stay, and survival; functional status and preferences concerning CPR obtained by interviews with patients or surrogates; and 2-month survival estimates provided by physicians.

RESULTS

Five hundred fourteen study subjects (21 %) received CPR during their index hospitalization. Among them, 327 (63.6%) had CPR within 2 days of death and 93 (18.1 %) had resuscitation and survived their index hospitalization. Use of CPR was more likely in men (odds ratio [OR], 1.39; 95% confidence interval [CI], 1.12-1.73), younger patients (OR per 10-year increase, 0.90; 95% CI, 0.84-0.96), African Americans (OR, 1.76; 95% CI, 1.33-2.34), patients whose reported preferences were for CPR (OR, 2.60; 95% CI, 1.91-3.55), who reported better quality of life (OR, 1.49; 95% CI, 1.10-2.03), or who had higher physician estimates for 2-month survival (OR per 10% increase, 1.14; 95% CI, 1.09-1.19). Rates varied significantly with geographic location and diagnosis; the adjusted OR for patients with congestive heart failure was 3.31 (95% CI, 2.12-5.15) compared with patients with acute respiratory failure or multiple organ system failure.

CONCLUSIONS

Our data suggest that a resuscitation attempt is more likely when preferred by patients and when death is least expected. Further study is required to understand variation in use of CPR among sites and for patients with different diagnoses, race, sex, or age.

Influence of steric bulk and electrostatics on the hydroxylation regiospecificity of tryptophan hydroxylase: characterization of methyltryptophans and azatryptophans as substrates

Tryptophan hydroxylase is a pterin-dependent amino acid hydroxylase that catalyzes the incorporation of one atom of molecular oxygen into tryptophan to form 5-hydroxytryptophan. The substrate specificity and hydroxylation regiospecificity of tryptophan hydroxylase have been investigated using tryptophan analogues that have methyl substituents or nitrogens incorporated into the indole ring. The products of the reactions show that the regiospecificity of tryptophan hydroxylase is stringent. Hydroxylation does not occur at the 4 or 6 carbon in response to changes in substrate topology or atomic charge. 5-Hydroxymethyltryptophan and 5-hydroxy-4-methyltryptophan are the products from 5-methyltryptophan. These products establish that the hydroxylating intermediate is sufficiently potent to hydroxylate benzylic carbons and that the direction of the NIH shift in tryptophan hydroxylase is from carbon 5 to carbon 4. The effects on the V/K values for the amino acids indicate that the enzyme is most sensitive to changes at position 5 of the indole ring. The V(max) values for amino acid hydroxylation differ at most by a factor of 3 from that observed for tryptophan, while the efficiencies of hydroxylation with respect to tetrahydropterin consumption vary 6-fold, consistent with oxygen transfer to the amino acid being partially or fully rate limiting in productive catalysis.

Older age, aggressiveness of care, and survival for seriously ill, hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

BACKGROUND

Older age is associated with less aggressive treatment and higher short-term mortality due to serious illness. It is not known whether less aggressive care contributes to this survival disadvantage in elderly persons.

OBJECTIVE

To determine the effect of age on short-term survival, independent of baseline patient characteristics and aggressiveness of care.

DESIGN

Secondary analysis of data from a prospective cohort study.

SETTING

Five academic medical centers participating in SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments).

PATIENTS

9105 adults hospitalized with one of nine serious illnesses associated with an average 6-month mortality rate of 50%.

MEASUREMENTS

Survival through 180 days of follow-up. In Cox proportional hazards modeling, adjustment was made for patient sex; ethnicity; income; baseline physical function; severity of illness; intensity of hospital resource use; presence of do-not-resuscitate orders on study day 1; and presence and timing of decisions to withhold transfer to the intensive care unit, major surgery, dialysis, blood transfusion, vasopressors, and tube feeding.

RESULTS

The mean (+/- SD) patient age was 63 +/- 16 years, 44% of patients were female, and 16% were black. Overall survival to 6 months was 53%. In analyses that adjusted for sex, ethnicity, income, baseline functional status, severity of illness, and aggressiveness of care, each additional year of age increased the hazard of death by 1.0% (hazard ratio, 1.010 [95% CI, 1.007 to 1.013]) for patients 18 to 70 years of age and by 2.0% (hazard ratio, 1.020 [CI, 1.013 to 1.026]) for patients older than 70 years of age. Adjusted estimates of age-specific 6-month mortality rates were 44% for 55-year-old patients, 48% for 65-year-old patients, 53% for 75-year-old patients, and 60% for 85-year-old patients. Similar results were obtained in analyses that did not adjust for aggressiveness of care. Acute physiology and diagnosis had much larger relative contributions to prognosis than age.

CONCLUSIONS

We found a modest independent association between patient age and short-term survival of serious illness. This age effect was not explained by the current practice of providing less aggressive care to elderly patients.

Physician counseling about exercise

CONTEXT

The increase in sedentary lifestyle may contribute to the rise in obesity nationally. Although guidelines suggest that physicians counsel all patients about exercise, physicians counsel only a minority of their patients. Whether patient factors influence physician counseling is not well established.

OBJECTIVES

To examine and to identify factors associated with exercise counseling by US physicians.

DESIGN AND SETTING

National population-based supplemental (Year 2000) survey to the 1995 National Health Interview Survey.

PARTICIPANTS

Of the 17317 respondents to the Year 2000 supplemental survey, 9711 adults had seen a physician in the previous year, and 9299 responded when asked about physician counseling on exercise.

MAIN OUTCOME MEASURE

Physician counseling to begin or to continue to exercise.

RESULTS

Of 9299 respondents, 34% reported being counseled about exercise at their last visit. After adjustment for other sociodemographic and clinical factors, women were slightly more likely to be counseled, with an adjusted odds ratio (AOR) of 1.15 (95% confidence interval [CI], 1.02-1.29). Physicians counseled older patients (>30 years) more often than younger patients; those aged 40 to 49 years were counseled most often (AOR, 1.71 [95% CI, 1.34-2.20]). Patients with incomes above $50000, those with higher levels of physical activity, college graduates, and patients who were overweight to obese (body mass index: 25 to > or =30 kg/m2) were more likely to be counseled, as were patients with cardiac disease (AOR, 1.81 [95% CI, 1.52-2.14]) and diabetes (AOR, 1.87 [95% CI, 1.46-2.38]). Counseling did not vary by physician specialty or patient race.

CONCLUSION

The rate of physician counseling about exercise is low nationally. Physicians appear to counsel as secondary prevention and are less likely to counsel patients at risk for obesity. The failure to counsel younger, disease-free adults and those from lower socioeconomic groups may represent important missed opportunities for primary prevention.

Stereospecificity of Pseudomonas fluorescens kynureninase for diastereomers of beta-methylkynurenine

The diastereomers of beta-methyl-L-kynurenine were prepared by preparative ozonolysis of the respective diastereomers of beta-methyl-L-tryptophan. A practical method for preparative enzymatic resolution of the diastereomers of beta-methyltryptophan was developed using carboxypeptidase A digestion of the N-trifluoroacetyl derivatives. The stereochemical assignment was confirmed by X-ray crystal structure determination of (2S, 3R)-threo-beta-methyl-L-tryptophan. (2S,3S)-erythro-beta-Methyl-L-kynurenine is a slow substrate for kynureninase from Pseudomonas fluorescens (k(cat)/K(m) = 0.1% that of L-kynurenine), producing anthranilic acid, while (2S,3R)-threo-L-kynurenine is about 390-fold less reactive than erythro. Rapid-scanning stopped-flow measurements show that beta-methyl substitution affects the rate of alpha-deprotonation of the L-kynurenine-pyridoxal-5'-phosphate Schiffs base. This is consistent with the stereoelectronic requirements of the reaction. These results are the first demonstration that beta-substituted kynurenines can be substrates for kynureninase, and may be useful in the design of mechanism-based inhibitors.

Evidence that tristetraprolin binds to AU-rich elements and promotes the deadenylation and destabilization of tumor necrosis factor alpha mRNA

Mice deficient in tristetraprolin (TTP), the prototype of a family of CCCH zinc finger proteins, develop an inflammatory syndrome mediated by excess tumor necrosis factor alpha (TNF-alpha). Macrophages derived from these mice oversecrete TNF-alpha, by a mechanism that involves stabilization of TNF-alpha mRNA, and TTP can bind directly to the AU-rich element (ARE) in TNF-alpha mRNA (E. Carballo, W. S. Lai, and P. J. Blackshear, Science 281:1001-1005, 1998). We show here that TTP binding to the TNF-alpha ARE is dependent upon the integrity of both zinc fingers, since mutation of a single cysteine residue in either zinc finger to arginine severely attenuated the binding of TTP to the TNF-alpha ARE. In intact cells, TTP at low expression levels promoted a decrease in size of the TNF-alpha mRNA as well as a decrease in its amount; at higher expression levels, the shift to a smaller TNF-alpha mRNA size persisted, while the accumulation of this smaller species increased. RNase H experiments indicated that the shift to a smaller size was due to TTP-promoted deadenylation of TNF-alpha mRNA. This CCCH protein is likely to be important in the deadenylation and degradation of TNF-alpha mRNA and perhaps other ARE-containing mRNAs, both in normal physiology and in certain pathological conditions.

Health status versus quality of life in older patients: does the distinction matter?

PURPOSE

Although health-related quality of life in older people is generally assessed by measuring specific domains of health status, such as activities of daily living or pain, the association between health-status measures and patients' perceptions of their quality of life is not clear. Indeed, it is controversial whether these health-status measures should be considered measures of quality of life at all. Our objective was to determine the association between health-status measures and older patients' perceptions of their global quality of life.

SUBJECTS AND METHODS

We performed a cross-sectional study of 493 cognitively intact patients 80 years of age and older, interviewed 2 months after a hospitalization. We measured patients' self-assessed global quality of life and four domains of health status: physical capacity, limitations in performing activities of daily living, psychological distress, and pain.

RESULTS

Each of the four scales was significantly correlated with patients' global perceptions of their quality of life (P <0.001). The ability of the health-status scales to discriminate between patients with differing global quality of life was generally good, especially for the physical capacity (c statistic = 0.72) and psychological distress scales (c statistic = 0.70). However, for a substantial minority of patients, scores on the health-status scales did not accurately reflect their global quality of life. For example, global quality of life was described as fair or poor by 15% of patients with the highest (best tertile) physical capacity scores, 25% of patients who were independent in all activities of daily living, 21% of patients with the least psychological distress (best tertile), and by 30% with no pain symptoms. Similarly, global quality of life was described as good or better by 43% of patients with the worst physical capacity (worst tertile), 49% of patients who were dependent in at least two activities of daily living, 47% of patients with the most psychological distress (worst tertile), and 51% of patients with severe pain.

CONCLUSION

On average, health status is a reasonable indicator of global quality of life for groups of older patients with recent illness. However, disagreement between patients' reported health status and their perceptions of their global quality of life was common. Therefore, assumptions about the overall quality of life of individual patients should not be based on measures of their health status alone.

Screening inpatient quality using post-discharge events

BACKGROUND

Decreasing hospital lengths of stay (LOS) hamper efforts to detect and to definitively treat complications of care. Patients leave before some complications are identified.

OBJECTIVES

To develop a computerized method to screen for hospital complications using readily available administrative data from outpatient and nonacute care within 90 days of discharge.

DESIGN

We developed the Complications Screening Program for Outpatient data (CSP-O) by using diagnosis and procedure codes from Medicare Part A and B claims to define 50 complication screens. Seventeen apply to specific procedural cases, and 33 apply to all adult, acute, medical, or surgical hospitalizations. The CSP-O algorithm examined outpatient, physician office, home health agency, and hospice claims within 90 days following discharge.

SUBJECTS

Seven hundred thirty nine thousand, two hundred and forty eight discharges of Medicare beneficiaries (age range, > or = 65 years) were admitted to 515 hospitals nationwide in 1994.

RESULTS

Complete 90-day, post-discharge windows were present for 62.8% of all and 68.5% of procedural cases. The 33 general screens flagged 13.6% of all cases; only 1.8% of procedural cases were flagged by the 17 procedural screens. When we allowed the CSP-O algorithm to scan information from acute hospital readmissions, flag rates rose to 32.8% for general and 8.7% for procedural complications. Controlling for patient and hospital characteristics, flag rates were considerably higher among the very old and at small and for-profit institutions.

CONCLUSIONS

Whereas several CSP-O findings have construct validity, limitations of claims raise concerns. Regardless of the CSPO's ultimate utility, examining post-discharge experiences to identify inpatient complications remains important as LOSs fall.