Hospice care: what services do patients and their families receive?

OBJECTIVE

To determine the degree to which patients and families enrolled with hospice received services across key categories of palliative care, the extent of hospice-level variability in services delivered, and changes over time in services delivered.

DATA SOURCE

Nationally representative sample of 9,409 discharged patients from 2,066 hospices in the National Home and Hospice Care Survey.

STUDY DESIGN

Observational, cross-sectional study conducted from 1992 to 2000. The primary outcome is the receipt of services across five key categories of palliative care: nursing care, physician care, medication management, psychosocial care, and caregiver support.

DATA COLLECTION

Data were obtained via interview with the hospice staff member most familiar with the patient's care, in conjunction with medical record review.

PRINCIPLE FINDINGS

In 2000, 22 percent of patients enrolled with hospice received services across five key categories of palliative care. There was marked variation across hospices in service delivery. One-third of hospices provided patients and families services in one or two of the five key categories of palliative care, whereas 14 percent of hospices provided services across five key categories of palliative care. In multivariable analysis, the odds of receiving any additional hospice service was significantly greater in later compared with earlier years (odds ratio=1.10, 95 percent confidence interval 1.01-1.20). Nevertheless, the percentages of patients in 2000 receiving medication management (59 percent), respite care (7 percent), and physician services (30 percent) remained low.

CONCLUSIONS

Hospice care for patients and families varies substantially across hospices. Whereas some hospices provide services across the key categories of palliative care, other hospices do not provide this breadth of services. Greater understanding of the causes of variation in service delivery as well as its impact on patient and family outcomes and satisfaction with end-of-life care is a critical subject for future research. Changes in Medicare's reimbursement policies may help hospices increase the range of services provided to patients and families.

Pain management in hospitalized cancer patients: a systematic review

PURPOSE

To assist cancer centers in improving pain management, we conducted a systematic review of institutional interventions designed to improve the assessment and treatment of pain in hospitalized cancer patients.

METHODS

We performed a MEDLINE search for all English-language articles published from January 1966 through February 2006 using the medical subject headings terms of pain or pain measurement and outcome assessment (health care) or quality assurance (health care). Selected bibliographies were also searched. Studies were reviewed if they included clinical interventions directed at improving the treatment of cancer pain across an institution or nursing unit. Meta-analyses and randomized controlled trials or other controlled studies were included where possible. If no such trials were identified, then the best evidence available from studies with other designs was included.

RESULTS

Five interventions were identified. These interventions included professional and patient education, instituting regular pain assessment (pain as a vital sign), audit of pain results and feedback to clinical staff, computerized decisional support systems, and specialist-level pain consultation services. Most studies were small in size and used quasiexperimental pre-post test designs. Successes were reported in increasing patient satisfaction, increasing documentation of pain intensity, and improving nurses' knowledge and attitudes. No study reported successful interventions that consistently improved patients' pain severity.

CONCLUSION

Although professional knowledge and attitudes about pain and nursing pain assessment rates have been shown to be improvable, no systematic, hospital-wide intervention has yet to be associated with improvement in pain severity. Future research on the development of new interventions, perhaps targeted specifically at physicians, is urgently needed.

Association of age with analgesic use for back and joint disorders in outpatient settings

BACKGROUND

Pain is a common, troubling symptom of various disorders, chronically affecting up to 11% of adults in the general public. Despite a growing emphasis on improving the quality of pain management and the increasing use of analgesics over the past 20 years, pain remains undertreated for patients in a variety of clinical settings. Elderly patients, in particular, have disproportionately low rates of adequate pain control compared with younger patients.

OBJECTIVE

The goal of this article was to determine the association of age with analgesic use in outpatient settings.

METHODS

Cross-sectional analyses of data from the 1999-2002 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were conducted. We modeled use of NSAIDs or opioids as a function of age using multivariable logistic regression. Adults (aged > or =18 years) with pain and an inflammatory or mechanical disorder of the back or joint seen in outpatient settings in the United States were included in the study.

RESULTS

From 1999 to 2002, 7273 outpatient hospital and community-based visits to physicians were recorded for adults with pain and a diagnosis of a back or joint disorder, representing approximately 34 million visits per year. Acetaminophen, NSAIDs, and opioids were reported for 3.7%, 28.8%, and 17.3% of visits, respectively. Individuals aged > or =75 years were more likely than those aged 18 to 54 years to use NSAIDs (adjusted odds ratio, 1.50; 95% CI, 1.15-1.97), an effect of the increasing use of cyclooxygenase-2 inhibitors among older patients. Older patients were less likely to use opioids (adjusted odds ratio, 0.49; 95% CI, 0.32-0.75).

CONCLUSIONS

In outpatient settings, elderly patients with pain and back or joint disorders tend to use NSAIDs more often and opioids less often than younger patients, suggesting that older patients may be receiving a poorer quality of pain management in outpatient settings.

Pain and ethnicity in the United States: A systematic review

BACKGROUND

Evidence suggests that racial and ethnic disparities exist in access to effective pain treatment.

PURPOSE

To review evidence of these disparities and provide recommendations for care and further research.

DESIGN

Systematic review.

METHODS

We conducted a MEDLINE search using the MeSH terms of ethnic groups, minority groups, pain, analgesia, and analgesics. We included studies describing current practice patterns, utilization of available treatments, treatment outcomes, and patient and provider knowledge, attitudes, and behaviors.

RESULTS

Our search identified 35 journal articles describing the effect of patient race and ethnicity on pain assessment and management. Three studies on pain assessment revealed that minority patients are more likely to have their pain underestimated by providers and less likely to have pain scores documented in the medical record compared to whites. Eleven of 17 studies found that African Americans and Hispanics are less likely to receive opioid analgesics and more likely to have their pain untreated compared to white patients. Three studies revealed that minority patients are more likely to have negative pain management index (PMI) scores-undertreated pain-compared to whites. Patient-related, provider-related, and pharmacy-related barriers to effective pain management were identified.

CONCLUSION

The majority of studies reveal racial and ethnic disparities in access to effective pain treatment akin to disparities found in other medical services. Quality improvement initiatives that improve treatment of pain for all patients according to established guidelines should decrease disparities by race or ethnicity. Educational interventions should aim to improve patient-provider communication regarding pain and its treatment and should provide support around substance abuse issues. Further research is needed to examine pain treatment outcomes and to determine whether health care system factors lead to these disparities.

Cost and utilization outcomes of patients receiving hospital-based palliative care consultation

OBJECTIVE

To compare per diem total direct, ancillary (laboratory and radiology) and pharmacy costs of palliative care (PC) compared to usual care (UC) patients during a terminal hospitalization; to examine the association between PC and ICU admission.

DESIGN

Retrospective, observational cost analysis using a VA (payer) perspective.

SETTING

Two urban VA medical centers.

MEASUREMENTS

Demographic and health characteristics of 314 veterans admitted during two years were obtained from VA administrative data. Hospital costs came from the VA cost accounting system.

ANALYSIS

Generalized linear models (GLM) were estimated for total direct, ancillary and pharmacy costs. Predictors included patient age, principal diagnosis, comorbidity, whether patient stay was medical or surgical, site and whether the patient was seen by the palliative care consultation team. A probit regression was used to analyze probability of ICU admission. Propensity score matching was used to improve balance in observed covariates.

RESULTS

PC patients were 42 percentage points (95% CI, -56% [corrected] to -31%) less likely to be admitted to ICU. Total direct costs per day were $239 (95% CI, -387 to -122) lower and ancillary costs were $98 (95% CI, -133 to -57) lower than costs for UC patients. There was no difference in pharmacy costs. The results were similar using propensity score matching.

CONCLUSION

PC was associated with significantly lower likelihood of ICU use and lower inpatient costs compared to UC. Our findings coupled with those indicating better patient and family outcomes with PC suggest both a cost and quality incentive for hospitals to develop PC programs.

Brain dysfunction: another burden for the chronically critically ill

BACKGROUND

Chronic critical illness is a devastating syndrome of prolonged respiratory failure and other derangements. To our knowledge, no previous research has addressed brain dysfunction in the chronically critically ill, although this topic is important for medical decision making.

METHODS

We studied a prospective cohort of 203 consecutive, chronically critically ill adults transferred to our hospital's respiratory care unit (RCU) after tracheotomy for failure to wean. We measured prevalence and duration of coma and delirium during RCU treatment using the Confusion Assessment Method for the Intensive Care Unit with the Richmond Agitation-Sedation Scale. To assess survivors (at 3 and 6 months after RCU discharge), we used a validated telephone Confusion Assessment Method.

RESULTS

Before hospitalization, most (153 [75.4%]) of the 203 patients in the study were at home, completely independent (115 [56.7%]), and cognitively intact (116 [82.0%]). In the RCU, 61 (30.0%) were comatose throughout the stay. Approximately half of patients (66 of 142) who were not in coma were delirious. Patients spent an average of 17.9 days (range, 1-153 days) in coma or delirium (average RCU stay, 25.6 days). Half of survivors (79 of 160) had one of these disturbances at RCU discharge. At 6 months, three fourths (151) of the study patients were dead or institutionalized; of 85 survivors, 58 (68.2%) were too profoundly impaired to respond to telephone cognitive assessment, and 53 (62.4%) were dependent in all activities of daily living.

CONCLUSIONS

Severe, prolonged, and permanent brain dysfunction is a prominent feature of chronic critical illness. These data, together with previous reports of symptom distress and rates of mortality and institutionalization, describe burdens for chronically critically ill patients receiving continued life-prolonging treatment and for their families.

Effect of inpatient quality of care on functional outcomes in patients with hip fracture

OBJECTIVES

We sought to examine the relationship between functional outcome and process of care for patients with hip fracture.

RESEARCH DESIGN AND PARTICIPANTS

We undertook a prospective cohort study in 4 hospitals of 554 patients treated with surgery for hip fracture.

MEASUREMENTS

Information on patient characteristics and processes of hospital care collected from the medical record, interviews, and bedside observations. Follow-up information obtained at 6 months on function (using the Functional Independence Measure [FIM]), survival, and readmission.

RESULTS

Individual processes of care were generally not associated with adjusted outcomes. A scale of 9 processes related to mobilization was associated with improved adjusted locomotion (P = 0.006), self care (P = 0.022), and transferring (P = 0.007) at 2 months, but the benefits were smaller and not significant by 6 months. These processes were not associated with mortality. The predicted value for the FIM locomotion measure (range, 2-14) at 2 months was 5.9 (95% confidence interval 5.4-6.4) for patients at the 10th percentile of performance on these processes compared with 7.1 (95% confidence interval 6.6, 7.6) at the 90th percentile. Patients who experienced no hospital complications and no readmissions retained the benefits in locomotion at 6 months. Anticoagulation processes were associated with improved transferring at 2 months (P = 0.046) but anticoagulation and other processes of care were not otherwise associated with improved function.

DISCUSSION

Our findings indicate the need to attend to all steps in the care of patients with hip fracture. Additionally, functional outcomes were more sensitive markers of improved process of care, compared with 6-month mortality, in the case of hip fracture.

Palliative care and pain management

Palliative care aims to improve quality of life and relieve suffering for patients with advanced illness and those close to them by specifically addressing communication, symptom management, coordination of care, psychosocial and spiritual realms, grief and bereavement support, and legal and ethical concerns. It has an interdisciplinary focus and may co-exist with curative and life-prolonging treatment. Palliative care is a key component of appropriate, routine medical care, especially for clinicians caring for older adults. In revisiting Mrs. B, the many needs of a typical elderly patient are apparent, as are the gaps in the current level of care. A discussion of prognosis and goals of care is a potential starting point. This includes obtaining input from an oncologist with regard to treatment options for Mrs. B's metastatic breast cancer and her pathologic hip fracture. Soliciting her treatment goals in the context of her chronic obstructive pulmonary disease and significant recent decline is the next challenge. Pain, dyspnea, constipation, anorexia, and anxiety could then be addressed with pointed assessment and symptom-specific management. Code status discussion, communication with her support network, and care coordination for her increased care needs would follow. Hospice should be introduced as a potential option. Advance care planning might also be initiated. Psychological and spiritual support needs could also be explored in time. Clearly, there is much to be done for Mrs. B and her loved ones in clarifying and coordinating whatever path comes to be. Older patients and their families face prolonged courses of chronic disease and gradual decline. Physicians caring for these patients need to be expert in the domains of palliative care so these patients and their families can receive the best quality of care while they are still living full lives and later as they approach the end of life.

Medication utilization in an urban homebound population

BACKGROUND

The number of medically homebound adults has grown with the aging of the U.S. population, yet little is known about their health care utilization. We sought to characterize the health status and medication utilization of an urban cohort of homebound adults and to identify factors associated with medication use in this population.

METHODS

We performed a retrospective cross-sectional analysis of 415 patients enrolled in a primary care program for homebound adults in New York City during October 2002. Numbers of medications were obtained from formularies corroborated by home visits. For patients without prescription insurance, medication out-of-pocket costs were estimated according to average wholesale pricing. Sociodemographic and disease characteristics were obtained by chart abstraction.

RESULTS

The median age was 83 years (range 25-106 years). Seventy-seven percent of patients were female, 63% were non-white, and 28% spoke Spanish. Sixty-four percent of patients had Medicaid. The cohort had a mean of 8.2 (range 1-27, standard deviation 4.5) medications prescribed per month. Multivariate analysis showed that increasing age was associated with fewer medications (p <.001). Charlson comorbidity score was positively associated with number of medications (p <.001), whereas Activities of Daily Living score, a measure of functional dependence, was not. Twenty-seven percent of the cohort lacked prescription drug coverage. The total number of medications per month among the uninsured patients was 7.4 (standard deviation 4.4). Estimated median monthly out-of-pocket cost for the uninsured patients was dollar 223 (range dollar 1-dollar 1512).

CONCLUSIONS

For homebound patients without prescription drug coverage, medication use may represent substantial financial burden. Additional research is needed to determine whether out-of-pocket medication costs represent a barrier to care in this population.

Health care system factors affecting end-of-life care

The field of palliative care in the United States developed in response to a public health crisis--namely, poor quality of life for patients with serious illness and their families--and most palliative care research to date has been appropriately focused on identifying patient and family needs and identifying gaps in the current health care system and in the education of our health care professionals. Research has also begun to develop and evaluate new interventions and systems to address these care gaps. Preliminary studies suggest modest benefits of an array of programs designed to deliver palliative care services. These benefits include improved pain and other symptoms, increased family satisfaction, and lower hospital costs. Unfortunately, the validity and reliability of these findings are limited by important methodological weaknesses including small sample sizes, poorly described and nongeneralizable interventions, diverse and nonstandardized outcome measures, and poor study designs (i.e., lack of appropriate control groups, nonblinded designs). Comprehensive and rigorous research is needed to evaluate the effect of well-delineated and generalizable palliative care structures and processes on important clinical and use outcomes. Large multisite studies that have adequate power to detect meaningful differences in clinical and use outcomes, and that use well-defined and generalizable structures and evidence-based care processes, well-defined uniform outcome measures, and analyses that link the outcomes of interest to individual components of the interventions, are needed to guide further development of the field.

Improving the management of pain in hospitalized adults

BACKGROUND

Pain is a major quality issue. The objective of this study was to evaluate the effectiveness of a series of interventions on pain management.

METHODS

This controlled clinical trial (April 1, 2002, to February 28, 2003) involved the staggered implementation of 3 interventions into 2 blocks of matched hospital units. The setting was an 1171-bed hospital. A total of 3964 adults were studied. Interventions included education, standardized pain assessment using a 1- or 4-item (enhanced) pain scale, audit and feedback of pain scores to nursing staff, and a computerized decision support system. The main outcome measures were pain assessment and severity and analgesic prescribing.

RESULTS

Units using enhanced pain scales had significantly higher pain assessment rates than units using 1-item pain scales (64% vs 32%; P<.001), audit and feedback of pain results was associated with increases in pain assessment rates compared with units in which audit and feedback was not used (85% vs 64%; P<.001), and the addition of the computerized decision support system was associated with significant increases in pain assessment only when compared with units without audit and feedback (79% vs 64%; P<.001). The enhanced pain scale was associated with significant increases in prescribing of World Health Organization step 2 or 3 analgesic for patients with moderate or severe pain compared with the 1-item scale (83% vs 66%; P=.01). The interventions did not improve pain scores.

CONCLUSIONS

A clinically meaningful pain assessment instrument combined with either audit and feedback or a computerized decision support system improved pain documentation to more than 80%. The enhanced pain scale was associated with improved analgesic prescribing. Future interventions should be directed toward altering physician behavior related to titration of opioid analgesics.

Early ambulation after hip fracture: effects on function and mortality

BACKGROUND

Few studies have examined the relationship between inpatient bed rest and functional outcomes. We examined how immobility is associated with function and mortality in patients with hip fracture.

METHODS

We conducted a prospective cohort study of 532 patients 50 years and older, who were treated with surgery after hip fracture in 4 hospitals in New York. We collected information from hospital visits, medical records, and interviews. "Days of immobility" was defined as days until the patient moved out of bed beyond a chair. Follow-up was obtained on function (using the Functional Independence Measure) at 2 and 6 months and on survival at 6 months.

RESULTS

Patients with hip fracture experienced an average of 5.2 days of immobility. Compared with patients with a longer duration of immobility (ie, at the 90th percentile) in adjusted analyses, patients at the 10th percentile of immobility had lower 6-month mortality (-5.4%; 95% confidence interval [CI], -10.9% to -1.0%) and better Functional Independence Measure score for locomotion (0.99 points; 95% CI, 0.3 to 1.7 points, with higher values indicating better function), but there was no significant difference in locomotion by 6 months (0.58 points; 95% CI, -0.3 to 1.4 points). The adverse association of immobility was strongest in patients using personal assistance or supervision with locomotion at baseline (difference in 6-month mortality between the 90th and 10th percentile of immobility was -17.1% [P = .004] for this group and only 1.2% [P = .38] for patients independent in locomotion at baseline).

CONCLUSION

In patients with hip fracture, delay in getting the patient out of bed is associated with poor function at 2 months and worsened 6-month survival.

Preoperative status and risk of complications in patients with hip fracture

BACKGROUND

Limited information is available on preoperative status and risks for complications for older patients having surgery for hip fracture. Our objective was to identify potentially modifiable clinical findings that should be considered in decisions about the timing of surgery.

METHODS

We conducted a prospective cohort study with data obtained from medical records and through structured interviews with patients. A total of 571 adults with hip fracture who were admitted to 4 metropolitan hospitals were included.

RESULTS

Multiple logistic regression was used to identify risk factors (including 11 categories of physical and laboratory findings, classified as mild and severe abnormalities) for in-hospital complications. The presence of more than 1 (odds ratio [OR] 9.7, 95% confidence interval [CI] 2.8 to 33.0) major abnormality before surgery or the presence of major abnormalities on admission that were not corrected prior to surgery (OR 2.8, 95% CI 1.2 to 6.4) was independently associated with the development of postoperative complications. We also found that minor abnormalities, while warranting correction, did not increase risk (OR 0.70, 95% CI 0.28 to 1.73).

CONCLUSIONS

In this study of older adults undergoing urgent surgery, potentially reversible abnormalities in laboratory and physical examination occurred frequently and significantly increased the risk of postoperative complications. Major clinical abnormalities should be corrected prior to surgery, but patients with minor abnormalities may proceed to surgery with attention to these medical problems perioperatively.

The Effect of Emergency Department Crowding on the Management of Pain in Older Adults with Hip Fracture

OBJECTIVES

To evaluate the effect of emergency department (ED) crowding on assessment and treatment of pain in older adults.

DESIGN

Retrospective review of ED records from a prospective cohort study.

SETTING

Urban, academically affiliated, tertiary medical center.

PARTICIPANTS

One hundred fifty-eight patients, aged 50 and older, evaluated and hospitalized from the ED with hip fracture.

MEASUREMENTS

Patient-related risk factors: age, sex, nursing home residence, ED triage status, dementia, Acute Physiology in Age and Chronic Health Evaluation II physiological score, and RAND comorbidity score. ED crowding risk factors: ED census and mean length of stay.

OUTCOMES

documentation of pain assessment, time to pain assessment, time to pain treatment, patients reporting pain receiving analgesia, and meperidine use.

RESULTS

Mean age was 83 (range 52-101), 81.0% of patients complained of pain, mean time to pain assessment was 40 minutes (range 0-600), time to treatment was 141 minutes (range 10-525), and mean delay to treatment was 122 minutes (range 0-526). Of those with pain, 35.9% received no analgesia, 7.0% received nonopioids, and 57.0% received opioids. Of those receiving opioids, 32.8% received meperidine. ED crowding at census levels greater than 120% bed capacity was significantly associated with a lower likelihood of documentation of pain assessment (P = .05) and longer times to pain assessment (P = .01).

CONCLUSION

Older adults with hip fracture are at risk for underassessment of pain, considerable delays in analgesic administration after pain is identified, and treatment with inappropriate analgesics (e.g., meperidine) in the ED. Higher levels of ED census are significantly associated with poorer pain management.

Factors Associated with Reductions in Patients' Analgesia at Hospital Discharge

OBJECTIVE

To describe the patterns of opioid prescribing and the factors associated with reductions in the potency of patients' analgesic medications at the time of hospital discharge.

DESIGN

Prospective cohort.

SETTING

Two hundred forty-four patients (171 surgical and 73 nonsurgical) hospitalized in an urban academic medical center who have experienced moderate or severe pain and who are taking opioid analgesics prior to discharge.

OUTCOME

Step-down (or reduction) in the potency of patients' analgesic medication at the time of discharge. A step-down is defined as the analgesic medication that a patient is prescribed for outpatient analgesia at the time of discharge being less potent then the last pain medication administered to that patient just prior to hospital discharge.

RESULTS

Thirty-three percent of all patients had reductions in the potency of their opioid pain medication at the time of discharge (36% for surgical and 26% for nonsurgical patients). For nonsurgical patients, we found a trend toward Hispanic ethnicity being an independent risk factor for having a step-down in analgesic potency at discharge (odds ratio [OR]: 3.7, 95% confidence interval [CI]: 0.9-14.9).

CONCLUSION

Physicians frequently reduce the potency of hospitalized patients' pain medications at discharge and Hispanic patients may be at increased risk of this occurring. Further research is needed to determine if the reductions in analgesic potency we observed are associated with poor posthospital pain outcomes.

The growth of palliative care programs in United States hospitals

BACKGROUND

Palliative care programs are becoming increasingly common in U.S. hospitals.

OBJECTIVE

To quantify the growth of hospital based palliative care programs from 2000-2003 and identify hospital characteristics associated with the development of a palliative care program.

DESIGN AND MEASUREMENTS

Data were obtained from the 2001-2004 American Hospital Association Annual Surveys which covered calendar years 2000-2003. We identified all programs that self-reported the presence of a hospital-owned palliative care program and acute medical and surgical beds. Multivariate logistic regression was used to identify characteristics significantly associated with the presence of a palliative care program in the 2003 survey data.

RESULTS

Overall, the number of programs increased linearly from 632 (15% of hospitals) in 2000 to 1027 (25% of hospitals) in 2003. Significant predictors associated with an increased likelihood of having a palliative care program included greater numbers of hospital beds and critical care beds, geographic region, and being an academic medical center. Compared to notfor- profit hospitals, VA hospitals were significantly more likely to have a palliative care program and city, county or state and for-profit hospitals were significantly less likely to have a program. Hospitals operated by the Catholic Church, and hospitals that owned their own hospice program were significantly more likely to have a palliative care program than non- Catholic Church-operated hospitals and hospitals without hospice programs respectively.

CONCLUSIONS

Our data suggest that although growth in palliative care programs has occurred throughout the nation's hospitals, larger hospitals, academic medical centers, not-for-profit hospitals, and VA hospitals are significantly more likely to develop a program compared to other hospitals.

The Intersection Between Geriatrics and Palliative Care: A Call for a New Research Agenda

Palliative care is interdisciplinary treatment focused on the relief of suffering and achieving the best possible quality of life for patients and their caregivers. It differs for geriatric patients from what is usually appropriate in a younger population because of the nature and duration of chronic illness during old age. In spite of the fact that death occurs far more commonly in older people than in any age group, the evidence base for palliative care in older adults is sparse. Over the coming years, the research foci in the field of geriatrics and palliative care that must be addressed include establishing the prevalence of symptoms in patients with chronic disease; evaluating the association between treatment of symptoms and outcomes; increasing the evidence base for treatment of symptoms; understanding psychological well-being, spiritual well-being, and quality of life of patients and elucidating and alleviating sources of caregiver burden; reevaluating service delivery; adapting research methodologies specifically for geriatric palliative care; and increasing the number of geriatricians trained as investigators in palliative care research. This article discusses specific methods to improve the current situation within each of these seven areas.

Palliative care in advanced dementia: a randomized controlled trial and descriptive analysis

BACKGROUND

Few patients with end-stage dementia are enrolled in hospice care. A palliative care approach would nonetheless seem to be appropriate in various care settings, including the acute care hospital.

METHODS

We conducted a randomized controlled trial of palliative care in patients with advanced dementia (Functional Assessment Staging Tool [FAST] stage 6d-7f) who were hospitalized with acute illness. Intervention patients received recommendations by a palliative care team with the goal of enhancing patient comfort; control patients received usual care without these recommendations.

RESULTS

Among 99 patients enrolled over 3 years, groups were comparable at baseline in terms of gender, age, race, dementia stage, and advance directive status. Outcomes were similar in terms of mean number of hospitalizations, average length of stay, and mortality. Intervention patients were more likely than control patients to receive a palliative care plan (23% versus 4%; p = 0.008), usually on discharge, and more decisions were made to forgo certain medical treatments but the numbers were small. Fewer patients in the intervention group received intravenous therapy throughout the admission (66% vs. 81%, p = 0.025). Overall, additional interventions included daily phlebotomy for at least half of the admission (41%), systemic antibiotics (75%), and new feeding tubes (44%). Including tubes present at the time of randomization, a total of 69% received long-term enteral feeding.

CONCLUSION

It was difficult for a palliative care research team to influence the care of advanced dementia patients in the acute hospital setting. When patients have advanced dementia, there may be unique barriers, including perceived prognostic uncertainty, difficulty assessing comfort level, and perceptions about tube feeding. There must be a reexamination of treatment approaches for this severely impaired group of patients. Further study should attempt to identify patients prior to the need for acute hospitalization so goals can be established when there is less urgency to make life and death decisions.

Treatment of pain in older patients

Pain in older adults is a highly prevalent problem. While the basis of pain management in older individuals is similar to that for younger patients, it may differ in terms of presentation, assessment, and management. This article explores the basic concepts of pain control with a focus on older patients with cancer and highlights issues clinicians should consider when treating these individuals.

The effect of age on medical decisions made by patients with chronic illness

Patients are currently encouraged to appoint surrogates to make healthcare decisions for them in the event that they are not able to make those decisions for themselves. Many studies have suggested that in hypothetical situations, surrogates often make different decisions than the still-capacitated patients say they would make. Age difference between patient and appointed surrogate is one possible explanation because many surrogates are next-generation relatives. This study evaluated differences in end-of-life decision making between elderly and younger patients with chronic disease. Two age groups were interviewed: (1) geriatric patients aged 70 and older and; (2) acquired immunodeficiency syndrome (AIDS) patients aged 30-50. Subjects who demonstrated an understanding of cardiopulmonary resuscitation (CPR) and artificial nutrition and hydration (ANH) were asked to choose, on a five-point Likert scale, whether they would want these treatments for themselves in four hypothetical scenarios: (1) an older person in a coma after a car accident; (2) a younger person in a coma after a car accident; (3) an older person with Alzheimer's disease; (4) a younger person with AIDS dementia. One hundred seventy-six subjects were included: 84 geriatric patients and 92 AIDS patients. Differences in the two groups were significant only in the scenario of an older person in a coma after a car accident (p = 0.007), with the geriatric patients wanting more treatment. The lack of significant differences between healthcare decisions made by the two groups under the hypothetical scenarios utilized in this study may indicate that age differences will not prevent a next-generation healthcare agent from making substituted judgement that accurately reflects patient wishes.

Feasibility of a healthcare proxy counseling program for patients with Alzheimer's disease

BACKGROUND

Although significant progress has been made in the implementation of advance directive counseling programs for cognitively intact patients, there is a paucity of information on the outcome of these programs with patients with Alzheimer's disease. This study investigated the prevalence of completed healthcare proxies in a sample of Alzheimer's disease outpatients, and the feasibility of a systematic proxy counseling program for this population.

METHODS

The setting was a geriatric psychiatry clinic. Ninety-four patients with Alzheimer's disease were surveyed for their previous completion of a healthcare proxy. All patients with capacity and without a proxy were approached to complete the advance directive with a lay counselor.

RESULTS

Thirty-two percent (n = 30) of patients had completed a proxy prior to the initiation of a counseling program. Of patients without proxies (n = 64), 89% had capacity to complete one. Seventy-nine percent subsequently completed a proxy through the counseling program. Hispanics were least likely to have had a proxy prior to initiation of the program, yet were very willing to complete the document.

CONCLUSIONS

The majority of patients with Alzheimer's disease in an outpatient setting did not have healthcare proxies, yet had the capacity and motivation to complete this advance directive. With physician input regarding the presence of decisional capacity, a lay counselor successfully implemented the counseling process. These results support the initiation of similar counseling programs for Alzheimer's outpatients.

Physicians' perceptions of procedural pain and discomfort

BACKGROUND

Previous studies have demonstrated that patients with end-stage dementia receive a high rate of painful and uncomfortable procedures. This study was undertaken to determine whether this finding might be related to physicians' misperceptions about the burden of common hospital experiences and procedures.

METHODS

Physicians were administered a survey asking them to rank on a five-point scale the pain and discomfort they perceived to be associated with 16 common hospital procedures. These ratings were compared to those previously obtained using the same instrument with cognitively intact patients who had actually undergone these procedures.

RESULTS

One hundred twenty-three of 123 resident physicians (100%) and 40 of 50 attending physicians (80%) to whom the questionnaire was administered responded. Overall, physicians more often rated both pain and discomfort associated with these procedures/experiences higher than did patients, and residents typically rated pain and discomfort higher than attending physicians. Resident physicians rated 7 procedures/experiences as significantly more painful and 13 as more uncomfortable than did patients. Attending physicians rated 5 procedures/experiences as significantly more painful and 8 more uncomfortable than did patients. Having a nasogastric tube inserted was the only procedure rated more painful by patients as compared to resident or attending physicians.

CONCLUSIONS

Physicians have an accurate perception of pain and discomfort associated with common hospital procedures. Further investigation should scrutinize in greater detail the ubiquity and depth of physician knowledge about the issue of procedural burden and should focus on methods and interventions that would allow physicians to consciously weigh the benefits and burdens of routine interventions in the care of persons with serious and life-threatening illness.