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

Sex-and age-based differences in the delivery and outcomes of critical care

BACKGROUND

Previous studies have suggested that a patient's sex may influence the provision and outcomes of critical care. Our objective was to determine whether sex and age are associated with differences in admission practices, processes of care and clinical outcomes for critically ill patients.

METHODS

We used a retrospective cohort of 466,792 patients, including 24,778 critically ill patients, admitted consecutively to adult hospitals in Ontario between Jan. 1, 2001, and Dec. 31, 2002. We measured associations between sex and age and admission to the intensive care unit (ICU); use of mechanical ventilation, dialysis or pulmonary artery catheterization; length of stay in the ICU and hospital; and death in the ICU, hospital and 1 year after admission.

RESULTS

Of the 466,792 patients admitted to hospital, more were women than men (57.0% v. 43.0% for all admissions, p < 0.001; 50.1% v. 49.9% for nonobstetric admissions, p < 0.001). However, fewer women than men were admitted to ICUs (39.9% v. 60.1%, p < 0.001); this difference was most pronounced among older patients (age > or = 50 years). After adjustment for admission diagnoses and comorbidities, older women were less likely than older men to receive care in an ICU setting (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.66-0.71). After adjustment for illness severity, older women were also less likely than older men to receive mechanical ventilation (OR 0.91, 95% CI 0.81-0.97) or pulmonary artery catheterization (OR 0.80, 95% CI 0.73-0.88). Despite older men and women having similar severity of illness on ICU admission, women received ICU care for a slightly shorter duration yet had a longer length of stay in hospital (mean 18.3 v. 16.9 days; p = 0.006). After adjustment for differences in comorbidities, source of admission, ICU admission diagnosis and illness severity, older women had a slightly greater risk of death in the ICU (hazard ratio 1.20, 95% CI 1.10-1.31) and in hospital (hazard ratio 1.08, 95% CI 1.00-1.16) than did older men.

INTERPRETATION

Among patients 50 years or older, women appear less likely than men to be admitted to an ICU and to receive selected life-supporting treatments and more likely than men to die after critical illness. Differences in presentation of critical illness, decision-making or unmeasured confounding factors may contribute to these findings.

Perceptions of "futile care" among caregivers in intensive care units

BACKGROUND

Many caregivers in intensive care units (ICUs) feel that they sometimes provide inappropriate or excessive care, but little is known about their definition of "futile care" or how they attempt to limit its impact. We sought to explore how ICU staff define medically futile care, why they provide it and what strategies might promote a more effective use of ICU resources.

METHODS

Using semi-structured interviews, we surveyed 14 physician directors, 16 nurse managers and 14 respiratory therapists from 16 ICUs across Ontario. We analyzed the transcripts using a modified grounded-theory approach.

RESULTS

From the interviews, we generated a working definition of medically futile care to mean the use of considerable resources without a reasonable hope that the patient would recover to a state of relative independence or be interactive with his or her environment. Respondents felt that futile care was provided because of family demands, a lack of timely or skilled communication, or a lack of consensus among the treating team. Respondents said they were able to resolve cases of futile care most effectively by improving communication and by allowing time for families to accept the reality of the situation. Respondents felt that further efforts to limit futile care should focus on educating the public and health care professionals about the role of the ICU and about alternatives such as palliative care; mandating early and skilled discussion of resuscitation status; establishing guidelines for admission to the ICU; and providing legal and ethical support for physicians who encounter difficulties. There was a broad consistency in responses among all disciplines.

INTERPRETATION

ICU physicians, nurses and respiratory therapists have similar and well-formed opinions about how to define and resolve medically futile care and where to focus future efforts to limit the impact of futile care in the ICU.

The association between treatment preferences and trajectories of care at the end-of-life

BACKGROUND

Honoring patients' treatment preferences is a key component of high-quality end-of-life care.

OBJECTIVE

To determine the association of preferences with end-of-life care.

DESIGN

Observational cohort study.

PARTICIPANTS

118 community-dwelling persons age > or = 65 years with advanced disease who died in a study which prospectively assessed treatment preferences.

MEASUREMENTS

End-of-life care was categorized according to four pathways: (1) relief of symptoms only, (2) limited attempt to reverse acute process with rapid change to symptomatic relief, (3) more intensive attempt to reverse acute process with eventual change to symptomatic relief, and (4) highly intensive attempt to reverse acute process with no change in goal.

RESULTS

Adjusting for diagnosis, those with greater willingness to undergo intensive treatment (defined as a desire for invasive therapies despite > or = 50% chance of death) were significantly more likely to receive care with an initial goal of life prolongation (pathways 2-4) [odds ratio 4.73 (95% confidence interval 1.39-16.08)] than those with lower willingness. Nonetheless, mismatches between preferences and pathways were frequent. Only 1 of 27 participants (4%) with lower willingness to undergo intensive treatment received highly intensive intervention (pathway 4); 53 of 91 participants (58%) with greater willingness to undergo intensive treatment received symptom control only (pathway 1).

CONCLUSIONS

The association between preferences and trajectories of end-of-life care suggests that preferences are used to guide treatment decision-making. In contrast to concerns that patients are receiving unwanted aggressive care, mismatches between preferences and trajectories were more frequently in the direction of patients receiving less aggressive care than they are willing to undergo.

Doctors' and patients' preferences for participation and treatment in curative prostate cancer radiotherapy

PURPOSE

Physicians hold opinions about unvoiced patient preferences, so-called substitute preferences. We studied whether doctors can predict preferences of patients supported with a decision aid.

METHODS

A total of 150 patients with prostate cancer facing radiotherapy were included. After the initial consultation, without discussing any treatment choice, physicians gave substitute judgments for patients' decision-making and radiation dose preferences. Physicians knew that several weeks later, patients would be empowered by a decision aid supporting a choice between two radiation doses involving a trade-off between disease-free survival and adverse effects. Subsequently, patient preferences for decision making (whether or not they wanted to choose a radiation dose) and for treatment (low or high dose) were obtained. The chosen radiation dose actually was administered.

RESULTS

Of the patients studied, 79% chose a treatment; physicians believed that 66% of the patients wanted to choose. Agreement was poor (64%; = 0.13; P = .11), and was better as patients became more hopeful (odds ratio [OR] = 4.4 per unit; P = .001) and as physicians' experience increased (OR = 1.09 per year; P = .02). Twenty percent of physicians' preferences, 51% of physicians' substitute preferences, and 71% of patients' preferences favored the lower dose; agreement was again poor (70%; = 0.2; P = .03).

CONCLUSION

Physicians had problems predicting the preferences of patients empowered with a decision aid. They slightly underestimated patients' decision-making preferences, and underestimated patients' preferences for the less toxic treatment. Counseling might be improved by first informing patients-possibly using a decision aid--before discussing patient preferences.

In-hospital resuscitation of the elderly: Characteristics and outcome

OBJECTIVES

To determine the characteristics of the geriatric patient population subjected to resuscitation attempts at a 1000-bed university hospital and to determine factors associated with mortality and outcome after in-hospital CPR.

METHODS

Retrospective chart review. The hospital records from all patients >75 years subjected to in-hospital resuscitation attempts during 2000-2001 were reviewed. Data regarding patient characteristics, mode of arrest and outcome details were extracted.

RESULTS

During the study period 151 resuscitation attempts were registered, and 53 (35%) of the patients were > or =75 years of age. The average age was 81 years; 29/53 (55%) patients were female. The admission diagnosis was "cardiac ischaemia" (angina pectoris, myocardial infarction) in 18/53 (34%) of the patients. PEA (pulseless electric activity) was the most common primary arrhythmia (17/53, 32%), and cardiac aetiology was the most common cause of arrest (41/53, 77%). The time of arrest was spread equally over the day. Most resuscitation attempts were performed at the general wards (28 patients, 53%). More then half-part of the patients died immediately (32/53, 60%); initially ROSC (return of spontaneous circulation) was established in 21/53 (40%) patients. A total of 9/53 (17%) patients were discharged home. 'Do not attempt resuscitation' (DNAR) orders or a statement that DNAR orders had been discussed with the patient was not documented in any of the patients resuscitated.

CONCLUSION

Selected patients among the geriatric hospitalised patients may benefit a from a short resuscitation attempt. This includes especially those admitted for cardiac ischemia suffering a cardiac arrest with VT or VF as a primary arrhythmia or patients suffering a primary respiratory/hypoxic arrest. Patients who are unlikely to benefit from CPR should be identified on or during hospital admission and the possibility of DNAR orders should be discussed to avoid inappropriate treatment and potential patient suffering. There is a need for implementing routines for discussing the existence of advance-directives or DNAR orders upon admission.

The end of life: a qualitative study of the perceptions of people over the age of 80 on issues surrounding death and dying

This study explored how elderly people living in the community perceive issues around death, dying, and the end of life using a qualitative grounded theory approach. Forty individuals aged between 80 and 89 years who were living alone in the community were interviewed and were identified through purposive and random sampling. The results revealed that issues associated with end of life included fear of how they would die, fear of becoming a burden to others, wanting to prepare for and have a choice with regard to where and when they die, and issues relating to assisted dying. The study demonstrated that issues relating to the end of life are a major concern for older people, but are seldom addressed by professionals. Listening to and understanding the views and experiences of the older age group regarding end-of-life care is needed if adequate person-centered care is to be delivered to this ever-growing population group.

The state of advance care planning: one decade after SUPPORT

The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) was a landmark study regarding end-of-life decision making and advance care planning. Phase I of the study looked at the state of end of life in various hospitals, and phase II implemented a nurse-facilitated intervention designed to improve advance care planning, patient-physician communication, and the dying process. The observational phase found poor quality of care at the end of life and the intervention failed to improve the targeted outcomes. The negative findings brought public attention to the need to improve care for the dying and spawned a wealth of additional research on decision-making at the end of life. In the decade since SUPPORT, researchers have defined the attributes of a "good death," addressed the role of advance directives in advance care planning, and studied the use of surrogate decision-making at the end of life. This rekindled the discussion on advance care planning and challenged health care providers to design more flexible approaches to end of life care.

Three methods of assessing values for advance care planning: comparing persons with and without dementia

Advance care planning ideally includes communication about values between patients, family members, and care providers. This study examined the utility of health care values assessment tools for older adults with and without dementia. Adults aged 60 and older, with and without dementia, completed three values assessment tools-open-ended, forced-choice, and rating scale questions-and named a preferred surrogate decision maker. Responses to forced-choice items were examined at 9-month retest. Adults with and without dementia appeared equally able to respond meaningfully to questions about values regarding quality of life and health care decisions. People with dementia were generally as able as controls to respond consistently after 9 months. Although values assessment methods show promise, further item and scale development work is needed. Older adults with dementia should be included in clarifying values for advance care planning to the extent that they desire and are able.

Palliation and supportive care in radiation medicine

The treatment of bone metastases represents a paradigm for evaluating palliative care in terms of symptom relief, toxicities of therapy, and the financial burden to the patient, caregivers, and society. Despite enormous expenditures to treat metastases, patients continue to sustain symptoms of the disease, and uninterrupted aggressive therapies are pursued until death that incur toxicity in approximately 25% of patients. This approach is inconsistent with the goals of palliative care, which should efficiently provide comfort using antineoplastic therapies or supportive care approaches to the patient with the fewest treatment-related side effects, recognizing that the patient will die of the disease.The development of therapies such as bisphosphonates is important in advancing options for palliative care; however, clinical trials demonstrating the efficacy of bisphosphonates have not addressed important issues for clinical practice. The primary study endpoints should primarily address pertinent patient outcomes such as pain relief rather than asymptomatic radiographic findings. These studies should define clear indications of when to start and stop the therapy, the appropriate patient populations to receive the therapy, and the cost effectiveness of the treatment relative to other available therapies such as radiation. Cost-utility analyses, which account for a broader domain of cost effectiveness, need to be performed as part of clinical trials, especially for palliative care endpoints. Clinical trials that include these criteria are critical to future practice guideline development. As health care resources continue to become more limited, the criteria for care must be better defined to avoid administration of therapy with limited benefit. Leadership must come from the specialty as clinical trials and clinical practice increasingly interface with health care policy. Goals of therapy must remain clear for the benefit of the individual and all patients.

Forgoing life sustaining treatments: differences and similarities between North America and Europe

BACKGROUND

As evidence exist that severe neurological damage or prolonged death after inappropriate CPR could occur, restraints and indications for CPR were perceived as necessary. The objective of this review is to examine policies and attitudes towards end-of-life decisions in Europe and North America and to outline differences and similarities.

METHODS

A bibliographic database search from 1990 to 2006 was performed using the following terms: do-not-resuscitate orders, end-of-life decisions, withholding/withdrawal of life-sustaining treatments, medical futility and advanced directives. Eighty-eight articles, out of 305 examined, were analyzed and their data systematically reported and compared where possible. They consisted of studies, questionnaires and surveys answering the following questions: percentage of deaths of critical patients preceded by do-not-resuscitate orders, factors affecting the decision for do-not-resuscitate orders, people involved in this decision (patient, surrogates and medical staff) and how it was performed.

RESULTS

There is an evident gap between the North American use of standard and formal procedures compared with Europe. Second, they diverge in the role acknowledged to surrogates in the decisional process, as in Europe, restraints and reserves to accept surrogates as decision makers seem still strong and a paternalistic approach at the end-of-life is still present.

CONCLUSION

Incidentally, despite the predictable differences between Europe and North America, concerns do exist about the actual extent of autonomy wished by patients and surrogates. It is important to highlight these findings, as the paternalistic attitude, too often negatively depicted, could be, according to the best medical practice, justified and more welcomed in some instances.

Avoiding iatrogenic harm to patient and family while discussing goals of care near the end of life

BACKGROUND

Treatment of suffering is a core mission of medicine. Communication about treatment planning with the patient and family, called the goals of care discussion, offers the opportunity to provide effective relief. Such communication is particularly important near the end of life, because many medical decisions are determined then by emotional considerations and personal values.

OBJECTIVE

To define common unintended clinician behaviors, which impair discussion about goals of care near the end of life. To discuss the relationship between: (1) the medical decision-making responsibilities of patient and family, (2) clinician communication, (3) iatrogenic suffering, (4) the impact on medical decision-making, and (5) patient and family outcomes.

DESIGN

Thematic literature review.

RESULTS

The authors discuss how omission of the integral emotional and social elements of the goals of care discussion are reflected in five unintended clinician behaviors, each of which may impair medical decision-making and unknowingly induce patient and family suffering. We posit that such impaired decision-making and suffering may contribute to demands for ineffective, life-sustaining interventions made by the patient and family or, conversely, to requests for hastened death.

CONCLUSIONS

Understanding the challenges in the discussion about goals of care near the end of life will facilitate the development of more effective approaches to communication and shared decision-making. The authors hypothesize how decreased suffering through improved communication should diminish the occurrence of depression, anxiety disorders, and complicated grief in the patient and survivors, potentially improving medical outcomes. Proposed experiments to test this hypothesis will address important public health goals.

Challenges to end of life care in the acute hospital setting

BACKGROUND

Research exploring patients' care and treatment preferences at the end of life (EOL) suggests they prefer comfort more than life-extension, wish to participate in decision-making, and wish to die at home. Despite these preferences, the place of death for many patients is the acute hospital, where EOL interventions are reported to be inappropriately invasive and aggressive.

AIM

This paper discusses the challenges to appropriate EOL care in acute hospitals in the UK, highlighting how this setting contributes to the patients' and families' care and treatment requirements being excluded from decision-making.

METHODS

Twenty-nine cancer nurse specialists from five hospitals participated in a grounded theory study, using observation and semi-structured interviews. Data were collected and analysed concurrently using the constant comparative method.

RESULTS

EOL interventions in the acute setting were driven by a preoccupation with treatment, routine practice and negative perceptions of palliative care. All these factors shaped clinical decision-making and prevented patients and their families from fully participating in clinical decision-making at the EOL.

Understanding disparities in aggressive care preferences between patients with terminal illness and their family members

We examined the factors associated with the disparity in aggressive care preferences between patients with terminal cancer and their family members. Two hundred forty-four consecutive pairs recruited from three university hospitals participated in this study. Each pair completed questionnaires that measured two major aggressive care preferences-admission to the intensive care unit (ICU) and the use of cardiopulmonary resuscitation (CPR). Sixty-eight percent of patients and their family members were in agreement regarding admission to the ICU and 71% agreed regarding CPR. Regarding admission to the ICU, younger, unmarried patients and patients who preferred to die in an institution were more likely to have a different preference from their family caregivers. Regarding CPR, younger patients and patients from severely dysfunctional families were more likely to have a different preference from their family caregivers. Elucidation of the factors associated with such disparities should help reduce them.

High context illness and dying in a low context medical world

This article provides an introduction to the field of intercultural communication. Miscommunication among patients, families, and clinicians often results when participants are contextually "out-of-synch. " High context communication embeds more information in the contexts within which people communicate and is less dependent on language. Very sick and dying patients often use high context communication strategies. Low context communication stresses explicit verbal communication and is commonly used by clinicians. When clinicians use low context forms of communication with patients using high context styles, misunderstandings frequently arise. Suggestions are given for avoiding miscommunication and enhancing mutual understanding.

Is there no place like home? Caregivers recall reasons for and experience upon transfer from home hospice to inpatient facilities

OBJECTIVE

To describe caregivers' reasons for transfer from home hospice to inpatient facilities, preferences for site of care and death, and their experiences during these transfers.

DESIGN

Retrospective qualitative analysis of interviews with caregivers of deceased hospice patients who had undergone transfer.

SETTING

A university-affiliated community hospice provider.

SUBJECTS

Caregivers of deceased hospice patients who transferred to an acute care hospital, a freestanding inpatient hospice facility, or a nursing home while enrolled in hospice and died between January 2003 and February 2004.

MEASUREMENTS

A semistructured interview protocol was developed and used for all interviews. Interviews were coded for reasons for transfer, preferences for site of care and death, and experience upon transfer using a grounded theory approach.

RESULTS

Patients transferred because of an acute medical event, an uncontrolled symptom, imminent death, or inability to provide needed care safely at home. Although all caregivers expressed a strong preference for care at home, other concerns such as pain and symptom control, safety, and quality and quantity of life became more important with time. We found significant variation in specific preferences regarding care and site of death. Satisfaction with care at the transfer facilities was determined by clarifying goals of care, following treatment preferences, providing personalized care, and the patient's environment.

CONCLUSIONS

Hospice patients usually transfer to facilities to accomplish goals consistent with good end-of-life care. We can improve their experience by treating patients and their caregivers as unique individuals, exploring and respecting treatment preferences, and creating a pleasant physical environment.

End-of-life care: a retreat format for residents

BACKGROUND

The challenge of teaching end-of-life care involves finding ways to incorporate both the science and the art of medicine.

OBJECTIVES

To develop a curriculum so that internal medicine residents could more effectively (1) elicit patient's values, goals, and preferences for health care at the end of life, (2) communicate "bad news," (3) discuss patient preferences for nutrition and hydration, ventilator withdrawal, and cardiopulmonary resuscitation, (4) prescribe opioids using different routes of administration and, (5) recommend appropriate treatment of symptoms common at the end of life.

DESIGN

The daylong retreat utilized case presentations and problems for presenting scientific content and the film Wit to convey information related to communication, whole-patient assessment, and the palliative care approach. Materials from the Education for Physicians on End-of-Life Care (EPEC) project and the film Wit provided the main educational resources.

SETTING

All second-year internal medicine, and family medicine residents, and geriatric fellows from a community hospital in South Carolina attended.

RESULTS

The residents positively evaluated the seminar content and format. Pretests and posttests revealed that residents significantly improved their knowledge regarding pain management (p<0.001), symptom management (p<0.001) and whole-patient assessment (p<0.014). Scores on the pretest and posttest related to communication skills did not significantly change (p=0.092). Yet, qualitative postretreat evaluations showed that residents perceived that the retreat would affect their communication with patients and other less easily quantifiable factors.

CONCLUSION

Quantitative methods that work well for documenting scientific principles and learning may not apply as well in assessing the art of medicine.

Family decision making at end of life

OBJECTIVE

To enhance understanding of the phenomenon of family surrogate decision-making at the end of life (EOL) by means of a systematic review and synthesis of published research reports that address this phenomenon.

METHODS

Garrard's (1999) methods for conducting a systematic review of the literature were followed. Fifty-one studies focusing on family decision-making experiences, needs, and processes when assisting a dying family member were selected following electronic database searches and ancestry searches.

RESULTS

In studies using hypothetical scenarios to compare patients' choices and surrogates' predictions of those choices, surrogates demonstrated low to moderate predictive accuracy. Increased accuracy occurred in more extreme scenarios, under conditions of forced choice, and when the surrogate was specifically directed to use substituted judgment. In qualitative explorations of their perspectives, family members voiced their desire to be involved and to accept the moral responsibility attendant to being a surrogate. Quality of communication available with providers significantly influenced family satisfaction with decision-making and EOL care. Group or consensual decision-making involving multiple family members was preferred over individual surrogate decision-making. Surrogates experienced long-term physical and psychological outcomes from being decision-makers.

SIGNIFICANCE OF RESULTS

Functioning as a surrogate decision-maker typically places great moral, emotional, and cognitive demands on the family surrogate. Clinicians can provide improved care to both patients and families with better understanding of surrogates' needs and experiences.

Impacto de los cuidados paliativos y perfil clínico del paciente con enfermedad terminal en un área de Medicina Interna

INTRODUCTION

The medical assistance to patients with terminal diseases has been structured with Primary Care and Palliative Care Units as protagonists, and with other specialties as secondary roles. Nevertheless the impact of this group of patients in Internal Medicine areas is unknown. Our objective was to evaluate these parameters in the area of Internal Medicine of a tertiary teaching Hospital.

MATERIAL AND METHODS

Prospective observational study of all patients attended in Internal Medicine areas during June 2003. Patients were stratified in three cohorts (palliative, pluripathologic, and general). Incidence of palliative patients, origin, clinical features, and burden of hospital care in the last 12 months were analyzed. Univariate analysis of the clinical differences between the palliative and the pluripathologic, and general cohorts was performed, using Chi-square, Fisher, ANOVA and post-hoc tests and Kruskal-Wallis test.

RESULTS

52 (53.8% women; mean age 66.5 +/- 15 years) were included from the global study cohort of 339 patients. Incidence of palliative patients was 15.4/100 admissions. The patients were admitted from other specialties (57.6%), Emergency department (27%), and Primary Care (10%). Mean hospital stay was 14.5 (1-150) days, and survival 63.5%. The 68.5% of deceases occurred at home. Patients of palliative cohort, with respect to general cohort had less functional ability at baseline (47.5 vs 95; p < 0.0001), admission (40 vs 75; p < 0.0001), and at discharge (20 vs 75; p < 0.0001), and more functional deterioration during hospital stay (mean fall in Barthel's values at baseline-discharge of 27.5 vs 20 points; p < 0.003). There were no differences in the burden of hospital care in the previous 12 months. With respect to the cohort of pluripathologic patients, palliative patients were younger (66.5 +/- 15 vs 75 +/- 11 years; p = 0.001) and had similar functional limitations at baseline (47.5 vs 45), admission (40 vs 20) and at discharge (20 vs 20).

DISCUSSION

Patients with terminal diseases are prevalent in the clinical setting in areas of internal medicine. These data support the role of the internist in palliative care proceedings, and prompt internists to acquire enough specific abilities to manage competitively these population.

Frequency and determinants of advance directives concerning end-of-life care in The Netherlands

In the USA, the use of advance directives (ADs) has been studied extensively, in order to identify opportunities to increase their use. We investigated the prevalence of ADs and the factors associated with formulation of an AD in The Netherlands, using samples of three groups: the general population up to 60 years of age, the general population over 60 years of age, and the relatives of patients who died after euthanasia or assisted suicide. The associated factors were grouped into three components: predisposing factors (e.g. age, gender), enabling factors (e.g. education) and need factors (e.g. health-related factors). We found that living wills had been formulated by 3% of younger people, 10% of older people, and 23% of the relatives of a person who died after euthanasia or assisted suicide. Most living wills concerned a request for euthanasia. In all groups, 26-29% had authorized someone to make decisions if they were no longer able to do so themselves. Talking to a physician about medical end-of-life treatment occurred less frequently, only 2% of the younger people and 7% of the older people had done so. Most people were quite confident that the physician would respect their end-of-life wishes, but older people more so than younger people. In a multivariate analysis, many predisposing factors were associated with the formulation of an AD: women, older people, non-religious people, especially those who lived in an urbanized area, and people with less confidence that the physician would respect their end-of-life wishes were more likely to have formulated an AD. Furthermore, the enabling factor of a higher level of education, the need factor of contact with a medical specialist in the past 6 months, and the death of a marital partner were associated with the formulation of an AD.

Patients' expectations of colorectal surgery for cancer

OBJECTIVE

The primary objectives of surgery for colorectal cancer are to achieve radical resection of the tumour and to ensure a satisfactory quality of life for the patient. But what is satisfactory quality of life for the patients? What do patients desire? The goal of our exploratory investigation was to evaluate prospectively the patient pre-operative expectations as objectively as possible and to analyse results in relation to age, gender and socio-economic status.

METHODS

In the period from 1998 to 2001, 167 patients were given a questionnaire consisting of 15 questions prior to surgery. The questionnaire included various aspects that were thought to influence the patient's quality of life. Moreover the patients were given the opportunity to rate the questions they considered most important.

RESULTS

The following five points were considered most important by the total group of patients: Complete cure of the disease was rated most important (95%); it was the prime expectation of the patients. This was followed by the avoidance of a stoma (81%), a reliable control of defaecation (52%), normal digestion (44%) and little pain (26%).

CONCLUSION

Age, gender and education influence the pre-operative expectations of patients undergoing surgery for colorectal cancer. In addition to the surgical standard, the care of the individual patient must be given due consideration in the treatment strategy.

“Nobody Understands”: On a Cardinal Phenomenon of Palliative Care

In the clinical practice of palliative medicine, recommended communication models fail to approximate the truth of suffering associated with an impending death. I provide evidence from patients' stories and empiric research alike to support this observation. Rather than attributing this deficiency to inadequate training or communication skills, I examine the epistemological premises of the biomedical language governing the patient-physician communication. I demonstrate that the contemporary biomedicine faces a fundamental aporetic occlusion in attempting to examine death. This review asserts that the occlusion defines, rather than simply complicating, palliative care. Given the defining place of aporia in the care for the dying, I suggest that this finding shape the clinicians' responses to the needs of patients in clinical care and in designing palliative research. Lastly, I briefly signal that a genuinely apophatic voice construing the occlusion as a mystery rather than an aporia may be superior to the present communication and empathy models.

Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes

Even though good communication among clinicians, patients, and family members is identified as the most important factor in end-of-life care in ICUs, it is the least accomplished. According to accumulated evidence, communication about end-of-life decisions in ICUs is difficult and flawed. Poor communication leaves clinicians and family members stressed and dissatisfied, as well as patients' wishes neglected. Conflict and anger both among clinicians and between clinicians and family members also result. Physicians and nurses lack communication skills, an essential element to achieve better outcomes at end of life. There is an emerging evidence base that proactive, multidisciplinary strategies such as formal and informal family meetings, daily team consensus procedures, palliative care team case finding, and ethics consultation improve communication about end-of-life decisions. Evidence suggests that improving end-of-life communication in ICUs can improve the quality of care by resulting in earlier transition to palliative care for patients who ultimately do not survive and by increasing family and clinician satisfaction. Both larger, randomized controlled trials and mixed methods designs are needed in future work. In addition, research to improve clinician communication skills and to assess the effects of organizational and unit context and culture on end-of-life outcomes is essential.

Correspondence between patients' preferences and surrogates' understandings for dying and death

We examined the agreement between hospice patients' preferences for desired experiences during the last week of life and their surrogates' understandings of those preferences (n=92 pairs). Analyses included percent agreement, intraclass correlation coefficients, and Bland-Altman plots. Demographic characteristics and communication measures associated with better agreement were identified using t-tests and analysis of variance. The median number of items on which patients and family members agreed was 14 of 30 (interquartile range, IQR 10, 16). Preferences with good agreement included both observable and non-observable experiences. Patients who reported having had conversations about treatment preferences and who reported that their surrogates knew their preferences reported higher agreement. Surrogates display a better understanding of what is important to patients at the end of life if they have had discussions about patient preferences. These discussions may enable surrogates and clinicians to more accurately follow patient preferences.

Attitudes toward advance directives and the impact of prognostic information on the preference for cardiopulmonary resuscitation in medical inpatients in Chiang Mai University Hospital, Thailand

Our previous study revealed that cardiopulmonary resuscitation (CPR) was performed in 65.7% of 411 terminally ill patients who died in a tertiary-care university hospital in northern Thailand. Advance directives (ADs) are needed to ensure that life-sustaining therapies are used more appropriately. To investigate inpatients' attitudes regarding ADs for CPR and the impact of providing prognostic information on treatment preferences for CPR, we interviewed a randomly selected group of 200 ambulatory medical inpatients in multiple sessions. The results showed that most subjects had a positive attitude towards ADs for CPR. The majority preferred to have CPR when no information was provided on the chance of survival. However, this proportion decreased depending on the prognostic scenarios. Our investigation suggested that the preference of patients for CPR should be assessed individually and gradually, with adequate information given on the chance of survival.

Medical decision-making for seriously ill non-elderly and elderly patients

OBJECTIVES

Age of patients by itself is no longer a contra-indication for most medical interventions. The increase of possible interventions for elderly patients has contributed to a sharp age-specific increase of health care costs. Our study aimed to increase the insight in medical decision-making about life-prolonging interventions for patients from non-elderly and elderly age groups.

DESIGN

Case-control study.

SETTING

Clinical practices in three settings: oncology, nursing home and cardiology.

SUBJECTS

Eighty-one physicians, representing a response of 60%.

METHODS

Face-to-face interviews using a structured questionnaire addressing decision-making about the application of taxoid treatment for breast cancer patients, the application of bypass surgery for patients with angina pectoris under or over 70 years of age, and referral to specialist treatment because of a suspected malignancy of nursing home patients under or over 75 years of age.

RESULTS

The chance of having been treated was in all settings lower for patients with a relatively poor quality of life and for patients who had no (known) preference to be treated. No differences were found for chance of having been treated between non-elderly and elderly patients with similar patient characteristics. The only exception to this is the patient preference concerning treatment: elderly patients were more likely to have been treated against their will than non-elderly patients were.

CONCLUSIONS

A relatively high frequency of non-treatment decisions for elderly patients may be predominantly explained by the fact that patient characteristics that determine non-treatment decision-making are more prevalent in elderly age groups, and not by the effect of age per se.

Concordance of preferences for end-of-life care between terminally ill cancer patients and their family caregivers in Taiwan

There is a dearth of information in the literature about the concordance of preferences for end-of-life care between terminally ill patients and their family surrogates outside the Western countries. The purpose of this study was to examine the extent of concordance in preferences for end-of-life care goals and life-sustaining treatments between Taiwanese terminally ill cancer patients and their primary family caregivers. A total of 617 dyads of patients-family caregivers across 21 hospitals throughout Taiwan were surveyed. Overall agreements on the goals for end-of-life care and preferences for initiating life-sustaining treatments ranged from 62.4% to 96.9% (average: 71.0%). Kappa values for the extent of concordance ranged from 0.13 to 0.46 (average: 0.29), indicating poor to moderate consistency in personal preferences. Family caregivers had a significantly more aggressive attitude toward each examined life-sustaining treatment for their ill family members than the patients' own stated preferences. In societies, such as in Asian countries, where physicians' respect for patient autonomy is frequently subordinate to the power of family, disagreements between a patient and family about end-of-life care may result in the patient's preferences being overridden at the end of life. To effect real change and to gain increased agreement on preferences for end-of-life care, an open dialogue between patients and their primary family caregivers should become standard.

Striving for quality or length at the end-of-life: attitudes of the Dutch general public

Questionnaires were mailed to 1777 members of the Dutch public (response: 78%), measuring to what extent respondents appreciate life-prolonging treatment, even if it would seriously impair their quality of life. The association between these attitudes and personal characteristics and initiatives to engage in advance care planning was analyzed. About one third of the respondents prefers quality of life at the expense of survival, another third prefers length of life regardless of impaired quality, whereas the remaining third did not express a clear attitude towards quality or length of life. People who were younger, male, having children, having religious beliefs, and without a history of serious illness were more likely to strive for length, whereas the reverse associations were found for striving for quality. The latter was related to undertaking initiatives to engage in advance care planning. Awareness of differences in attitudes towards life-prolonging treatment within the public may improve communication about appropriate end-of-life care.

Factors associated with difficulties encountered by nurses in the care of terminally ill cancer patients in hospitals in Japan

Objective:To identify the factors associated with difficulties encountered by nurses working in general wards in hospitals in Japan.

Methods:Questionnaires including items regarding difficulties in providing care to terminally ill cancer patients, the existence of a mentor regarding end-of-life issues, awareness of end-of-life issues, and demographic factors were administered to 375 staff nurses working in general in-patient wards. Multivariate regression analyses were employed to investigate correlations between factors.

Results:Multivariate regression analysis revealed that the existence of a mentor for end-of-life issues was associated with fewer difficulties in all areas other than “Knowledge and skill of nurses.” Clinical experience was inversely related to difficulties in “Communication with patients and families” and “Personal issues.” Greater awareness of end-of-life issues was related to higher difficulties in most areas.

Significance of results:The existence of a mentor was correlated with fewer difficulties in most areas. Support by a palliative care team might be effective in reducing difficulties experienced by nurses and in improving care for terminally ill cancer patients. Basic communication training undertaken sooner after registration might be also useful.

A Chart Review of Seven Hundred Eighty-Two Deaths in Hospitals, Nursing Homes, and Hospice/Home Care

BACKGROUND

While most people die in the hospital or a nursing home, surveys indicate that more than 70% of people would prefer to die at home. Expert panel recommendations have called for epidemiologic studies to document the nature of dying in America.

OBJECTIVE

To determine if the experience of dying differed among settings in New Hampshire.

DESIGN

A voluntary, statewide medical record audit of adult deaths in hospitals, nursing homes and home care/hospice agencies was conducted for February and March 2002.

MEASUREMENTS

Records were examined for place of death, patient decision-making capacity and advance directives (ADs). Information was collected on demographic characteristics, primary and secondary diagnoses, presence of a "values history" (documented discussion with patient about their values and end-of-life care) and whether emotional and spiritual support was provided to patients and their families. Medical chart notes for the 48 hours preceding death were reviewed for "pain" and "other symptoms routinely assessed, treated and documented," and for whether the patient had undergone any of the following "treatments": surgery, ventilator, cardiopulmonary resuscitation, or extubation.

RESULTS

Nearly one third (32%) of health care organizations in the state reported on 782 deaths (424 hospital, 148 nursing home, and 210 home care/hospice) representing 44% of the adult deaths during this period. Significant differences among settings (p < 0.001) were found for mean age, gender, marital status, primary insurance, diagnosis, ADs, symptom assessment, and provision of emotional and spiritual support for patients and families. Among hospital decedents, 56% were in acute care beds, 30% were in intensive care units, and 4% were in palliative care beds. Nineteen percent of decedents received interventions such as extubation, placed on a ventilator or surgery in the 48 hours preceding death. Over 80% had a do-not-resuscitate (DNR) order, 45% had a Durable Power of Attorney for Health Care, and 37% had a Living Will. Age and setting were significant factors in the presence of ADs.

CONCLUSIONS

This information provides a benchmark for different care systems to identify areas for improvements in end-of-life care.

End-of-Life Decision Making in Nursing Home Residents with Dementia and Pneumonia: Dutch Physicians?? Intentions Regarding Hastening Death

When patients with severe dementia become acutely ill, little is known about the extent to which physicians take actions intended to hasten death. For 143 nursing home patients with dementia who died of pneumonia after a decision not to treat with antibiotics, we asked Dutch facility-employed physicians whether they intended to hasten death and any estimated life shortening. In 53% of cases, the physicians reported an explicit intention to hasten death; in another 41% of cases they reported taking into account a probability or certainty that the withholding of antibiotics or other palliative treatments would hasten death. Opiates were frequently used for symptom control (43%), but the administration of medications specifically intended to induce death was rare (2%). Considering all treatments, physicians estimated that life was shortened by 24 hours or less in 46% of patients and 1 month or longer in 24% of patients. The frequent withholding of antibiotics with an intention to hasten death may reflect a willingness to abandon a cure-oriented approach in dying patients for whom prolongation of life is not an aim. The results reflect the importance of explicit goals for medical interventions in patients with end-stage dementia where life-prolonging treatments may be seen as prolonging suffering.

Medical Care at the End of Life: Views of African American Patients in an Urban Hospital

BACKGROUND

Although one goal of end-of-life care is to honor the wishes and needs of patients, little research has been done to characterize what is important to seriously ill African American patients at the end of life.

OBJECTIVE

To characterize the views of seriously ill African American patients toward end-of- life care.

DESIGN

A qualitative study using semistructured, in-depth interviews.

SETTING AND PARTICIPANTS

Patients in a large, urban, public hospital who are facing a serious illness.

RESULTS

Twenty-three African American patients were interviewed. Although most acknowledged a point at which they would want to cease aggressive care, some equated this with giving up. Most subjects expressed that the end of life was in God's hands. Many expressed a concern to be free of pain and suffering. Few saw a significant role for the physician at the end of life. Some had expressed their wishes for care to a family member. Others thought such discussions were unnecessary because a family member would make decisions or because death was not imminent. Subjects raised concerns about trust in the physician and the burden of end-of-life discussions.

CONCLUSIONS

African Americans in an urban, public hospital who are facing a severe illness have clear desires for care at the end of life and are willing to discuss their views at length. Such discussions should explore patients' desire for aggressive care, consider spiritual views and the importance of family in end-of-life decisions, and consider that some patients will not believe such discussions are necessary.

ACare: A communication training program for shared decision making along a life-limiting illness

Objective: This article describes an innovative 8-h training program that provides clinicians with the competencies necessary to conduct efficient, effective, and compassionate advance care planning discussions throughout the trajectory of life-limiting illnesses.

Method: The Advance Care Training Program (ACare) includes 6 h of group workshops and 2 h of one-on-one faculty–learner interaction. In this article, we describe the (1) objectives of ACare; (2) structure, training procedures, and educational rationale of ACare training; and (3) educational outcome studies in progress.

Results: ACare training in various forms has already been provided to over 100 medical professionals (medical students, medical residents, oncology and geriatric fellows, medical attendings, social workers, and nurses). Formative outcome data indicate considerable trainee satisfaction. Emerging summative outcome data indicate improved skills.

Significance of results: Widespread adoption of the program could increase the frequency and quality of advance care planning discussions between patients with life-limiting illnesses, their health care providers, and families.

Three principles to improve clinician communication for advance care planning: overcoming emotional, cognitive, and skill barriers

BACKGROUND

Medical care of patients with life limiting illness remains fraught with serious deficiencies, including inadequate advance care planning, delayed hospice referral, and continued delivery of aggressive treatment that is overtly counter to patients' preferences.

OBJECTIVE

This paper describes clinicians' emotional, cognitive, and skill barriers to shared decision-making with seriously ill patients and their loved ones.

DESIGN

Thematic literature review.

RESULTS

Based on a literature review, as well as clinical and educational experience, we articulate three principles to address these barriers and guide future professional communication training for advance care planning.

CONCLUSIONS

We argue that these barriers must be overcome before deficiencies in end-of-life care can be fully ameliorated.

Futility in evolution

Must health care professionals provide treatments or interventions that they consider futile? Although much of the past and current debate about futility has centered on how to best define futility, it is the application of the concept in clinical decision making that is of central concern. Most physicians feel confident that they know futile treatment when they see it, but despite years of debate in scholarly journals, professional meetings, and popular media, consensus on a precise definition eludes us still. This article reviews numerous definitions of futility to illustrate the general lack of consensus over this concept. It also provides a flexible definition of futility that is patient centered and reliant on goals of care as the morally preferable definition. In short, the concept of futility as a means to resolve disputes over treatment decisions may, itself, be futile.

When Race Matters

Several widely held assumptions shape end-of-life discussion in the United States. They are embedded in mainstream bioethics and biomedical discourse, debate, and discussion, as well as in the popular media. We have come to regard them as the conventional wisdom. Despite their apparent reasonableness, the assumptions are not held universally by all US citizens, particularly those of color. They hold contradictions that partially explain why fewer African Americans than whites complete advance directives, and why African Americans tend to desire aggressive care at the end of life. This article considers some of these assumptions. It then considers a case and an approach to care that seeks to resolve potential conflicts proactively.

Preferences in end-of-life care of older persons: after-death interviews with proxy respondents

This population-based study employing after-death interviews with proxies describes older persons' preferences regarding medical care at the end of life. Interviews were held with 270 proxy respondents of 342 deceased persons (age range 59-91) in the Netherlands, The deceased were respondents to the Longitudinal Aging Study Amsterdam. The prevalence of advance directives (ADs), preferences for medical decisions at the end of life (i.e. withholding treatment, physician-assisted suicide euthanasia) and preferences about the focus of treatment in the last week of life (i.e. comfort care versus extending life) were examined. Written ADs were present in 14% of the sample. A quarter had designated a surrogate decision-maker. Co-morbidity and perceived self-efficacy (PSE) were positively associated with ADs. About half the sample had expressed a preference in favour or against one or more medical decisions at the end of life. Predictors positively associated with expressing a preference were co-morbidity, dying from cancer, and PSE. Being religious was negatively associated with expressing a preference. The knowledge of the proxy regarding the older person's preference for the focus of treatment was dependent on the patient's symptom burden as perceived by the proxy. The majority of older persons had died without either an AD, or having expressed preferences for end-of-life care. Stimulating the formulation of ADs may help professionals who work with older people to understand these preferences better, especially in the case of non-cancer patients and those with low PSE.

Admission to intensive care unit at the end-of-life: is it an informed decision?

There is a major deficiency in the end-of-life care offered to patients dying in the intensive care unit (ICU).

HYPOTHESIS

Hospitalized dying patients had informed discussions on end-of-life and palliative care options before admission to ICU.

PATIENTS AND METHODS

A descriptive non-interventional study was performed at a teaching hospital to examine if patients who died in hospital had informed discussions on end-of-life care before admission to ICU. The impact of these discussions on subsequent patient care: aggressive therapy in the ICU, the quality of palliation, use of hospice care services and utilization of hospital resources were examined. Data were collected from medical records for all hospital deaths over 24 months.

RESULTS

Of 252 hospital deaths, 196 (78%) were treated and subsequently 165 (65%) died in the ICU. Patients treated either in the ICU or general hospital wards had similar frequency of ultimately or rapidly fatal pre-existing disease (47% versus 62%, P: ns) and readmission to hospital within one year before death (43% versus 57%, P, ns). The median age (10-90% percentile) was slightly younger for the ICU than hospital wards patients: 73 (45-85) versus 76 (55-91) years, P < 0.01. Of the 156 patients who were transferred to ICU from hospital wards: 136 (87%) were managed by house staff on teaching services and 20 (13%) were managed by attending staff hospitalists, P < 0.01. None of those transferred to the ICU who subsequently died had discussion of palliation or end-of-life care as an alternative treatment. Of those who died who were treated on general wards, 14 (25%) patients had discussion of palliation as an alternative treatment option before death. Do-not-resuscitate decisions were made in 48% of cases two days before death. Patients who were treated in the ICU had more invasive tests performed on them and were less likely to have adequate pain control or referral to hospice care services than on a general ward. Median hospital charge was much higher for patients who received ICU versus general ward care (33,252 dollars versus 8549 dollars, P < 0.001).

CONCLUSIONS

Patients who died in the ICU did not have informed discussions of end-of-life or palliative care as an alternative treatment option before admission. The quality of end-of-life care was disrupted for patients with fatal pre-existing chronic disease who were admitted to the ICU before death. Lack of clinical experience, knowledge and competency with end-of-life care influenced admission of patients to ICU regardless of poor prognosis. Decisions regarding the pursuit of aggressive therapy versus palliative care must be addressed with patients by physicians who are competent and experienced in end-of-life care as this will have a profound impact on both the quality of care delivered and effective use of limited hospital resources.

Using a Values Discussion Guide to facilitate communication in advance care planning

The utility of values clarification tools for advance care planning needs further study. This descriptive, qualitative study aimed to describe patients' and surrogates' experiences using a Values Discussion Guide (VDG), both with and without a professional facilitator. Ten male Veterans Health Administration outpatients over age 50 and their health care agents completed audio-taped discussions, both without and with a facilitator, and responded to structured feedback interviews. Most participants found a discussion using the VDG to be helpful and reassuring. Discussions varied in quantity and quality, and participants varied in preferring self-guided versus professionally facilitated discussions. The best interchanges were elicited by questions about prior experience with medical decisions, for oneself or others, and trusted versus non-trusted others to help with decision-making. A VDG appears a useful tool in a repertoire of advance care planning tools, which need to be geared towards the needs and abilities of particular patients and families.

Critical care use during the course of serious illness

Despite its expense and importance, it is unknown how common critical care use is. We describe longitudinal patterns of critical care use among a nationally representative cohort of elderly patients monitored from the onset of common serious illnesses. A retrospective population-based cohort study of elderly patients in fee-for-service Medicare is used, with 1,108,060 Medicare beneficiaries at least 68 years of age and newly diagnosed with serious illnesses: 1 of 9 malignancies, stroke, congestive heart failure, hip fracture, or myocardial infarction. Medicare inpatient hospital claims from diagnosis until death (65.1%) or fixed-right censoring (more than 4 years) were reviewed. Distinct hospitalizations involving critical care use (intensive care unit or critical care unit) were counted and associated reimbursements were assessed; repeated use was defined as five or more such hospitalizations. Of the cohort, 54.9% used critical care at some time after diagnosis. Older patients were much less likely to ever use critical care (odds ratio, 0.31; comparing patients more than 90 years old with those 68-70 years old), even after adjustment. A total of 31,348 patients (2.8%) were repeated users of critical care; they accounted for 3.6 billion dollars in hospital charges and 1.4 billion dollars in Medicare reimbursement. We conclude that critical care use is common in serious chronic illness and is not associated solely with preterminal hospitalizations. Use is uneven, and a minority of patients who repeatedly use critical care account for disproportionate costs.

A content analysis of forms, guidelines, and other materials documenting end-of-life care in intensive care units

OBJECTIVE

The purpose of this study was to determine the extent to which data entry forms, guidelines, and other materials used for documentation in intensive care units (ICUs) attend to 6 key end-of-life care (EOLC) domains: 1) patient and family-centered decision making, 2) communication, 3) continuity of care, 4) emotional and practical support, 5) symptom management and comfort care, and 6) spiritual support. A second purpose was to determine how these materials might be modified to include more EOLC content and used to trigger clinical behaviors that might improve the quality of EOLC.

PARTICIPANTS

Fifteen adult ICUs-8 medical, 2 surgical, and 4 mixed ICUs from the United States, and 1 mixed ICU in Canada, all affiliated with the Critical Care End-of-Life Peer Workgroup

METHODS

Physician-nurse teams in each ICU received detailed checklists to facilitate and standardize collection of requested documentation materials. Content analysis was performed on the collected documents, aimed at characterizing the types of materials in use and the extent to which EOLC content was incorporated.

MEASUREMENTS AND MAIN RESULTS

The domain of symptom management and comfort care was integrated most consistently on forms and other materials across the 15 ICUs, particularly pain assessment and management. The 5 other EOLC domains of patient and family centered decision-making, communication, emotional and practical support, continuity of care, and spiritual support were not well-represented on documentation. None of the 15 ICUs supplied a comprehensive EOLC policy or EOLC critical pathway that outlined an overall, interdisciplinary, sequenced approach for the care of dying patients and their families. Nursing materials included more cues for attending to EOLC domains and were more consistently preprinted and computerized than materials used by physicians. Computerized forms concerning EOLC were uncommon. Across the 15 ICUs, there were opportunities to make EOLC- related materials more capable of triggering and documenting specific EOLC clinical behaviors.

CONCLUSIONS

Inclusion of EOLC items on ICU formatted data entry forms and other materials capable of triggering and documenting clinician behaviors is limited, particularly for physicians. Standardized scales, protocols, and guidelines exist for many of the EOLC domains and should be evaluated for possible use in ICUs. Whether such materials can improve EOLC has yet to be determined.

Effects of religiosity on patients' perceptions of do-not-resuscitate status

Forty-eight oncology inpatients participated in a survey designed to characterize their understanding of and beliefs about do-not-resuscitate (DNR) decisions and to identify dimensions of religiosity associated with moral beliefs about DNR decisions. Seventy-five percent of the patients believed they understood the meaning of "DNR," but only 32% were able to provide an accurate definition. Seventeen percent believed that DNR decisions are morally wrong, and 23% believed that they are equivalent to suicide. Those who lacked an accurate understanding of DNR status were significantly more likely to perceive them as morally wrong. Gender, but not religious denomination, was significantly related to patients' attitudes about the morality of DNR decisions. The belief that DNR decisions are morally wrong was predicted by certain religious practices, including near-daily meditation, near-daily thinking about God, and the current practice of meditation, and by endorsement of the statement, "My faith sometimes restricts my action."

Tube feeding in advanced Alzheimer's disease: when language misleads

For much of the late 20th century, feeding tubes were often considered essential in the treatment of people with advanced Alzheimer's disease (AD) who developed swallowing or eating problems. Increasingly, the use of feeding tubes (i.e., percutaneous endoscopic gastrostomy or PEG tubes), has been challenged by empirical research, which has not supported the rationales provided for this intervention. The purpose of this commentary is to explain why healthcare providers, in light of empirical evidence, should refrain from using the terms "life-sustaining" or "life-prolonging" when discussing tube feeding with older adults, their family members, or other surrogate decision-makers.

Improving care for patients dying in the intensive care unit

It is impossible for ICU clinicians to avoid caring for dying patients and their families. For many, this is an extremely rewarding aspect of their clinical practice. There is ample evidence that there is room to improve the care of patients who are near death in the ICU. Despite the considerable holes in our knowledge about optimal care of dying critically ill patients, there is considerable agreement on the general principles of caring for these patients and about how to measure the outcomes of palliative care in the ICU. Practical approaches to improving the quality of end-of-life care exist and should be implemented.

L’annonce d’un diagnostic grave par le pneumologue : un acte thérapeutique

INTRODUCTION

The profession of respiratory medicine is often involved in communicating bad news, dealing with handicapping chronic disease or a poor prognosis.

STATE OF THE ART

Particularly when dealing with a cancer diagnosis, the "bad news" process is poorly described in the literature. The communication techniques that are used are specific to this highly charged encountered and they are neither innate nor widely taught. Yet the performance of the doctor at this crucial stage has a bearing on the patient throughout their clinical course and later complications. Ethical values, in particular respect of the patient's right to autonomy, as well as psychological and practical issues, govern the decision of giving the diagnosis to the patient or their next of kin.

PERSPECTIVES

From the patient's point of view, the breaking of bad news will be language, delivered with therapeutic intentions, which describes a significant loss. This language has the potential to unleash a mourning process, a calling into question and readjustment of direction and future plans. This process and its stages, if recognised by the doctor, can be harnessed so thatthe patient can by assisted into making correct therapeutic decisions whilst reinforcing their sense of autonomy. A study, which looks closely at the mechanisms of this process, and the benefits delivered, as well as the necessary training required by doctors, remains to be done.

CONCLUSION

Breaking bad news to a patient is therefore as much a therapeutic process as the sharing of information.