Planning with elderly outpatients for contingencies of severe illness: a survey and clinical trial

Decision coaching for people making healthcare decisions

BACKGROUND

Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching.

OBJECTIVES

To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects.

SEARCH METHODS

We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence.

MAIN RESULTS

Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms.  For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low.  For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.

Advance Directives Affecting Medical Treatment Choices

Advance directives theoretically enhance individual autonomy and facilitate treatment decision making at the end of life. There is little empirical evidence to support this, however. Based on a national postal survey of 2172 randomly selected medical practitioners (response rate 73%), this paper examines the effect advance medical directives have on (a) treatment prescribing for terminally ill people and (b) the degree of difficulty practitioners experience in making treatment choices. A hypothetical patient with Alzheimer's disease and an acute life-threatening illness was presented with and without an advance directive. With a directive, respondents were more uniform in their choice of treatment, with 86% choosing as the patient had requested. Difficulty with decision making was also less with the directive, 31% vs 45% with no directive. The data indicate that advance directives do affect practitioners’ treatment choices in favor of patient wishes and reduce the difficulty practitioners may experience in making them.

Interventions in Physician-Elderly Patient Interactions

Currently, most research in the area of physician-elderly patient interactions relates to either outcome, context, or interaction styles. There are limited data in the area of intervention studies. The authors recognize five specific areas of interventional research to consider: communication during encounters, characteristics of older patients, physical impairments, physician attributes, and the team approach to health care. Also highlighted are recognition and evaluation of the special needs of elderly patients through geriatric assessment. The authors recognize the need for more intervention studies that attempt to change patient or physician behaviors and the applicability of the classic randomized controlled model of research. Overall, the authors contend that the formation of strong, meaningful relationships between elderly patients and their physicians is best achieved through effective medical communication and care, and thus should be the function of appropriate interventions.

Advance medical directives: a proposed new approach and terminology from an Islamic perspective

Advance directives are specific competent consumers' wishes about future medical plans in the event that they become incompetent. Awareness of a patient's autonomy particularly, in relation to their right to refuse or withdraw treatment, a right for the patient to die from natural causes and interest in end of life issues were among the main reasons for developing and legalizing advance medical directives in developed countries. However, in many circumstances cultural and religious aspects are among many factors that can hamper implementation of advance directives. Islam and Muslims in general have a good understanding of death and dying. Islam allows the withholding or withdrawal of treatments in some cases where the intervention is considered futile. However, there is lack of literature and debate about such issues from an Islamic point of view. This article provides the Islamic perspective with regards to advance medical directive with the hope that it will generate more thoughts and evoke further discussion on this important topic.

Cardiopulmonary resuscitation outcomes in hospitalized community-dwelling individuals and nursing home residents based on activities of daily living

OBJECTIVES

To determine whether poor functional status is associated with worse outcomes after attempted cardiopulmonary resuscitation (CPR).

DESIGN

Retrospective study of individuals who experienced cardiac arrest stratified according to dependence in activities of daily living (ADLs) and residential status (nursing home (NH) or community dwelling).

SETTING

Two hundred thirty-five hospitals throughout North America.

PARTICIPANTS

Adult inpatients aged 65 and older who had experienced a cardiac arrest as reported to the Get with the Guidelines-Resuscitation registry between 2000 and 2008.

MEASUREMENTS

Primary outcomes were return of spontaneous circulation (ROSC) and survival to discharge.

RESULTS

Twenty-six thousand three hundred twenty-nine individuals who experienced cardiac arrest met inclusion criteria. NH residents dependent in ADLs had a lower odds than community-dwelling independent participants of achieving ROSC (odds ratio (OR) = 0.73, 95% confidence interval (CI) = 0.63-0.85), whereas participants dependent in ADLs from either residential setting had lower odds of survival (community-dwelling: OR = 0.76, 95% CI = 0.63-0.92; NH: OR = 0.79, 95% CI = 0.64-0.96) after adjusting for participant and arrest characteristics. Duration of resuscitation and doses of epinephrine or vasopressin were similar between groups and had no significant effect on ROSC or survival, although participants dependent in ADLs were more likely to have a do-not-resuscitate (DNR) order placed after ROSC. Overall, median time to signing a DNR order after resuscitation was 10 hours (interquartile range 2-70).

CONCLUSION

Functional and residential status are important predictors of survival after in-hospital cardiac arrest. Contrary to the hypothesis but reassuring from a quality-of-care perspective, less-aggressive attempts at resuscitation do not appear to contribute to poorer outcomes in individuals dependent in ADL, regardless of residential status.

Discrepancies in End-of-life Decisions Between Elderly Patients and Their Named Surrogates

Introduction: This study aims to determine the attitudes of Asian elderly patients towards invasive life support measures, the degree of patient-surrogate concordance in end-of-life decision making, the extent to which patients desire autonomy over end-of-life medical decisions, the reasons behind patients’ and surrogates’ decisions, and the main factors influencing patients’ and surrogates’ decision-making processes. We hypothesize that there is significant patient-surrogate discordance in end-of-life decision making in our community. Materials and Methods: The patient and surrogate were presented with a hypothetical scenario in which the patient experienced gradual functional decline in the community before being admitted for life-threatening pneumonia. It was explained that the outcome was likely to be poor even with intensive care and each patient-surrogate pair was subsequently interviewed separately on their opinions of extraordinary life support using a standardised questionnaire. Both parties were blinded to each other’s replies. Results: In total, 30 patients and their surrogate decision-makers were interviewed. Twenty-eight (93.3%) patients and 20 (66.7%) surrogates rejected intensive care. Patient-surrogate concurrence was found in 20 pairs (66.7%). Twenty-four (80.0%) patients desired autonomy over their decision. The patients’ and surrogates’ top reasons for rejecting intensive treatment were treatment-related discomfort, poor prognosis and financial cost. Surrogates’ top reasons for selecting intensive treatment were the hope of recovery, the need to complete final tasks and the sanctity of life. Conclusion: The majority of patients desire autonomy over critical care issues. Relying on the surrogates’ decisions to initiate treatment may result in treatment against patients’ wishes in up to one-third of critically ill elderly patients. Key words: Advanced medical directive, Intensive care

Augmenting advance care planning in poor prognosis cancer with a video decision aid: a preintervention-postintervention study

BACKGROUND

The authors tested whether an educational video on the goals of care in advanced cancer (life-prolonging care, basic care, or comfort care) helped patients understand these goals and had an impact on their preferences for resuscitation.

METHODS

A survey of 80 patients with advanced cancer was conducted before and after they viewed an educational video. The outcomes of interest included changes in goals of care preference and knowledge and consistency of preferences with code status.

RESULTS

Before viewing the video, 10 patients (13%) preferred life-prolonging care, 24 patients (30%) preferred basic care, 29 patients (36%) preferred comfort care, and 17 patients (21%) were unsure. Preferences did not change after the video, when 9 patients (11%) chose life-prolonging care, 28 patients (35%) chose basic care, 29 patients (36%) chose comfort care, and, 14 patients (18%) were unsure (P = .28). Compared with baseline, after the video presentation, more patients did not want cardiopulmonary resuscitation (CPR) (71% vs 62%; P = .03) or ventilation (80% vs 67%; P = .008). Knowledge about goals of care and likelihood of resuscitation increased after the video (P < .001). Of the patients who did not want CPR or ventilation after the video augmentation, only 4 patients (5%) had a documented do-not-resuscitate order in their medical record (kappa statistic, -0.01; 95% confidence interval, -0.06 to 0.04). Acceptability of the video was high.

CONCLUSIONS

Patients with advanced cancer did not change care preferences after viewing the video, but fewer wanted CPR or ventilation. Documented code status was inconsistent with patient preferences. Patients were more knowledgeable after the video, reported that the video was acceptable, and said they would recommend it to others. The current results indicated that this type of video may enable patients to visualize "goals of care," enriching patient understanding of worsening health states and better informing decision making.

Participation of Chronically Ill Older Adults in Their Life-Prolonging Treatment Decisions: Rights and Opportunity

The right of the individual to participate in her life-prolonging treatment decisions, either as a decision maker or by having her treatment wishes used as a decision-making criterion, is the result of an evolution in legal guidelines over the last two decades. Although necessary, these legal guidelines are however not sufficient to assure the individual's opportunity to participate. For the chronically ill older adult residing in a health care institution, the opportunity to participate in decisions concerning life-prolonging treatments implicitly depends on the effective communication among three key actors (the individual, her physician, and her proxy). The necessity of this communication has important implications for clinical practice and future empirical research.

"It helps me see with my heart": how video informs patients' rationale for decisions about future care in advanced dementia

OBJECTIVE

To explore how a video of a patient with advanced dementia impacts the rationale for patients' decisions about future care.

METHODS

Participants were read a verbal description of advanced dementia and asked their preferences for future care--either life-prolonging, limited, or comfort care--and the rationale for that choice. Participants then watched a video of a patient with advanced dementia and again stated their preferred level of care and the rationale. Thematic content analysis was utilized to develop common themes among the rationale of participants in each response category.

RESULTS

We interviewed 120 participants. The rationale of those who initially chose life-prolonging or limited care (47/120) emphasized lengthening life and cited an inherent good of medical treatment. Those who initially chose comfort care (60/120) focused on avoiding suffering and quality of life. Post-video, 107/120 participants chose comfort care and the rationale focused on the experience of the patient and family rather than treatment-centered considerations. Participants found great value in the video images.

CONCLUSIONS

While pre-video reasoning reflects general beliefs about extending life and the inherent good of treatment, the post-video reasoning reveals more focus on the experience of the actual patient and family.

PRACTICE IMPLICATIONS

Video may serve an important role in advanced care planning by enriching the understanding of the condition and allowing one to imagine a future health state.

Video decision support tool for advance care planning in dementia: randomised controlled trial

OBJECTIVE

To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks.

DESIGN

Randomised controlled trial conducted between 1 September 2007 and 30 May 2008. Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston.

PARTICIPANTS

Convenience sample of 200 older people (>or=65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women.

INTERVENTION

Verbal narrative alone (n=106) or with a video decision support tool (n=94).

MAIN OUTCOME MEASURES

Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care.

RESULTS

Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (chi(2)=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (kappa=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (kappa=0.79) (P<0.001 for difference).

CONCLUSION

Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00704886.

Interventions to Enhance Communication among Patients, Providers, and Families

Whether patient suffering is caused by physical symptoms, unwanted medical intervention, or spiritual crisis, the common pathway to relief is through a provider who is able to elicit these concerns and is equipped to help the patient and family address them. This paper reviews the current state of knowledge in communication at the end of life, organized according to a framework of information gathering, information giving, and relationship building; and then focuses on interventions to enhance communication among patients, providers, and families. Several observations emerge from the existing literature. Patients have highly individualized desires for information and we cannot predict patient preferences. Communication coding methodology has advanced significantly yet the current systems remain poorly understood and largely inaccessible. Physicians and other health care providers do not discuss sufficiently treatment options, quality of life or respond to emotional cues from patients, and there is plenty of room for improvement. On the positive side, we have also learned that physicians and other health care providers can be taught to communicate better through intensive communication courses, and that communication interventions can improve some patient outcomes. Finally, huge gaps remain in our current knowledge, particularly with regard to understanding the relationship between communication style and outcomes. These findings suggest several recommendations. We should create larger and more diverse datasets; improve upon the analysis of recorded communication data; increase our knowledge about patient preferences for information; establish a stronger link between specific communication behaviors and outcomes; and identify more efficient ways to teach providers communication skills.

End-of-life preferences in elderly patients admitted for heart failure

BACKGROUND

Heart failure is increasing in prevalence and incidence, with considerable mortality among the elderly.

AIM

To determine preferences concerning cardiopulmonary-resuscitation (CPR) and end-of-life care in elderly patients hospitalized for heart failure.

DESIGN

Prospective interview-based survey.

METHODS

Patients >64 years old admitted for acute heart failure were interviewed to address their preferences regarding end-of-life care and cardio-pulmonary resuscitation (CPR) when facing the last stages of their disease.

RESULTS

We interviewed 80 patients (mean age 79 years; 58% women). Thirty-two (40%) expressed a wish not to have CPR. Only two had previously discussed their CPR preferences with their physicians. When recovery from the illness was considered unlikely, 40 (50%) participants preferred to receive treatment at home, 32 (40%) preferred in-hospital management, and 8 (10%) were unsure. Thirty-three patients (41%) expressed a desire for spiritual support, 38 (48%) said not and the remaining 9 (11%) were indifferent.

DISCUSSION

Advance planning of end-of-life procedures and doctor-patient communication regarding these items remains poor and must be improved.

To be or not to be: assisted suicide revisited

Publicity accorded American physician-pathologist Jack Kevorkian and “physician-assisted suicide” bring a new, technological, twist to euthanasia. How and when we die and its meaning and how we live reflect cultural values within a historical context. High costs of medical care for the terminally ill when the cost of health care is the most rapidly rising portion of the consumer price index, Medicare expenses are the highest in the last year of life, and an estimated thirty-seven million people remain uninsured make euthanasia increasingly salient. Faced with great pain and the emotional and financial burden that often accompanies prolongation of life during terminal illness, the decision to die is not necessarily irrational, psychotic, or delusional but pragmatic. Yet inherent risks have often been overlooked in discussions of “the right to die.” This article reviews cultural values associated with beliefs about assisted suicide, the experience of other nations including the Nether; lands with assisted suicide, and the “slippery slopes” inherent in legitimization of physician-assisted suicide.

Physician orders for life-sustaining treatment (POLST): outcomes in a PACE program. Program of All-Inclusive Care for the Elderly

OBJECTIVES

To evaluate whether terminal care was consistent with Physician Orders for Life-Sustaining Treatment (POLST), a preprinted and signed doctor's order specifying treatment instructions in the event of serious illness for CPR, levels of medical intervention, antibiotics, IV fluids, and feeding tubes.

DESIGN

Retrospective chart review.

SETTING

ElderPlace, a Program of All-Inclusive Care for the Elderly (PACE) site in Portland, Oregon.

PARTICIPANTS

All ElderPlace participants who died in 1997 were eligible (n = 58). Reasons for exclusion were no POLST (1), missing POLST (1), and insufficient documentation of care (2).

MEASUREMENTS

POLST instructions for each participant and whether or not each of the treatments addressed by the POLST was administered in the final 2 weeks of life.

RESULTS

The POLST specified "do not resuscitate" for 50 participants (93%); CPR use was consistent with these instructions for 49 participants (91%). "Comfort care" was the designated level of medical intervention in 13 cases, "limited interventions" in 18, "advanced interventions" in 18, and "full interventions" in 5. Interventions administered were at the level specified in 25 cases (46%); at a less invasive level in 18 (33%), and at a more invasive level in 11 (20%). Antibiotic administration was consistent with POLST instructions for 86% of 28 subjects who had infections in the last 2 weeks of life, and less invasive for 14%. Care matched POLST instructions in 84% of cases for IV fluids and 94% for feeding tubes.

CONCLUSIONS

POLST completion in ElderPlace exceeds reported advance directive rates. Care matched POLST instructions for CPR, antibiotics, IV fluids, and feeding tubes more consistently than previously reported for advance directive instructions. Medical intervention level was consistent with POLST instructions for less than half the participants, however. We conclude that the POLST is effective for limiting the use of some life-sustaining interventions, but that the factors that lead physicians to deviate from patients' stated preferences merit further investigation.

Physician understanding of patient resuscitation preferences: insights and clinical implications

OBJECTIVE

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

DESIGN

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

PATIENTS/SETTING

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

CONCLUSIONS

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

Life-sustaining treatment decisions for nursing home residents: who discusses, who decides and what is decided?

OBJECTIVE

To evaluate whether nursing home residents and their families reported discussions about life-sustaining treatment with their physicians, the relationship between such discussions and orders to limit therapy, and predictors of physician-patient communication about life-sustaining treatment.

DESIGN

Cross-sectional interviews and retrospective chart abstraction.

SETTING

Three regions: West Coast, New England, Western.

SAMPLE

A total of 413 nursing home residents, 363 family/surrogate interviews, and 192 resident interviews.

MAIN OUTCOME MEASURES

Measured were (1) physician-resident communication about life-sustaining treatment and (2) presence of an advance directive or do not resuscitate (DNR) order in resident's chart.

RESULTS

Seventy-four percent of residents had DNR orders, and 32% had advance directives; only 29% of residents reported discussions about life-sustaining treatment. Of residents with DNR orders who could have participated in discussions about life-sustaining treatment, nearly half reported they had not discussed CPR with their caregivers. Older age, longer duration of time living in nursing home, location in a New England nursing home, physician-family member discussion, and the presence of an advance directive in the medical chart were positively associated with having DNR orders. Physician-resident discussion was not associated with having a DNR order. For the subsample of interviewed residents, age and a diagnosis of cognitive impairment were negatively associated with a physician-resident discussion about life-sustaining treatment, whereas the likelihood of having a discussion increased with increasing numbers of medical diagnoses.

CONCLUSIONS

Chart orders to limit therapy are common, but physician-resident discussions about life-sustaining treatments are not. Far more family members than residents report such discussions with the resident's physicians.

Perceptions of do-not-resuscitate orders

Do-not-resuscitate (DNR) orders have differing meanings for persons depending on their age, training, and personal beliefs. In this paper we explore these meanings as expressed in the attitudes about do-not-resuscitate orders of three groups: university students in a health-related discipline of social work, university students in a non-health related discipline, and persons over the age of sixty. Findings from analysis of the three groups suggest a strong interest in issues surrounding resuscitation. Social and nonmedical factors are important in the decision to resuscitate and therefore should be given careful consideration. Next to their spouse, respondents named their physician as the person they most wanted to talk with about withholding resuscitation. Yet, studies of physicians cited earlier indicate many physicians are hesitant to discuss end of life decisions with their patients. With the added help and support of the family, concerned friends, and social workers, individuals can make the best possible DNR decision and avoid unnecessary pain and suffering.

Ethical issues of cardiopulmonary resuscitation: current practice among emergency physicians

OBJECTIVE

To determine current practice and attitudes among emergency physicians (EPs) regarding the initiation and termination of CPR.

METHODS

An anonymous survey was mailed to randomly selected EPs. Main outcome measures included respondents' answers to questions regarding outcome of resuscitation, and current practice regarding initiation, continuation, and termination of resuscitation for victims of cardiopulmonary arrest.

RESULTS

The 1,252 respondents were from all 50 states, a variety of practice settings, and varying board certification. Most (78%) respondents honor legal advance directives regarding resuscitation. Few (7%) follow unofficial documents, or verbal reports of advance directives (6%). Many (62%) make decisions regarding resuscitation because of fear of litigation or criticism. A majority (55%) have recently attempted numerous resuscitations despite expectations that such efforts would be futile. Most respondents indicated that ideally, legal concerns should not influence physician practice regarding resuscitation (78%), but that in the current environment, legal concerns do influence practice (94%).

CONCLUSIONS

Most EPs attempt to resuscitate patients in cardiopulmonary arrest, regardless of futility, except in cases where a legal advance directive is available. Many EPs' decisions regarding resuscitation are based on concerns of litigation and criticism, rather than their professional judgment of medical benefit or futility. Compliance with patients' wishes regarding resuscitation is low unless a legal advance directive is present. Possible solutions to these problems may include standardized guidelines for the initiation and termination of CPR, tort reform, and additional public education regarding resuscitation and advance directives.

Tube feeding preferences among nursing home residents

OBJECTIVE

To determine the preferences of nursing home residents regarding the use of tube feedings and to characterize the clinical, functional, and psychosocial factors that are associated with preferences.

DESIGN

In-person survey.

SETTING

Forty-nine randomly selected nursing homes.

PATIENTS/PARTICIPANTS

Three hundred seventy-nine randomly selected, decisionally capable, nursing home residents.

MAIN RESULTS

Thirty-three percent of participants would prefer tube feedings if no longer able to eat because of permanent brain damage. Factors positively associated with preferences for tube feedings include male gender. African-American race, never having discussed treatment preferences with family members or health care providers, never having signed an advance directive, and believing that tube feeding preferences will be respected by the nursing home staff. Twenty-five percent of the participants changed from preferring tube feedings to not preferring tube feedings on learning that physical restraints are sometimes applied during the tube feeding process.

CONCLUSIONS

Demographic and social factors are associated with preferences for tube feedings. The provision of information about the potential use of physical restraint altered a proportion of nursing home residents' treatment preferences.

The doctor's role in discussing advance preferences for end-of-life care: perceptions of physicians practicing in the VA

OBJECTIVES

Although previous studies have shown physicians support advance directives, little is known about how they actually participate in decision-making. This study investigate (1) how much experience physicians have had discussing and following advance preferences and (2) how physicians perceive their role in the advance decision-making process.

DESIGN

Mail survey conducted in 1993.

SETTING

The Department of Veterans Affairs.

PARTICIPANTS

A national probability sample of 1050 VA internists, family physicians, and generalists.

MEASUREMENTS AND MAIN RESULTS

Questionnaires were returned by 67% of participants. In the last year, 79% stated they had discussed advance preference with at least one patient, and 19% had talked to more than 25. Seventy-three percent had used a written directive to make decisions for at least one incompetent patient. Younger age, board certification, spending less time in the outpatient setting, and personal experience with advance decision-making, were all associated independently with having advance preference discussions. Among physicians who had discussions, 59% said they often initiated the discussion, 55% said discussions often occurred in inpatient settings, and 31% said discussions often occurred in outpatient settings. Eighty-two percent of those responding thought physicians should be responsible for initiating discussions. Most would try to persuade a patient to change a decision that was not well informed (91%), not medically reasonable (88%), or not in the patient's best interest (88%); few would attempt to change decisions that conflicted with their own moral beliefs (14%).

CONCLUSIONS

Physicians report that they are actively involved with their patients in making decisions about end-of-life care. Most say they have had recent discussions with at least some of their patients and feel that as physicians they should play a large and important role in soliciting and shaping patient preferences.

Communication with the seriously ill: physicians' attitudes in Saudi Arabia

OBJECTIVES

To study some ethical problems created by accession of a previously nomadic and traditional society to modern invasive medicine, by assessment of physicians' attitudes towards sharing information and decision-making with patients in the setting of a serious illness.

DESIGN

Self-completion questionnaire administered in 1993.

SETTING

Riyadh, Jeddah, and Buraidah, three of the largest cities in Saudi Arabia.

SURVEY SAMPLE

Senior and junior physicians from departments of internal medicine and critical care in six hospitals in the above cities.

RESULTS

A total of 249 physicians participated in the study. Less than half (47%) indicated they provided information on diagnosis and prognosis of serious illnesses all the time. Physicians who were more senior and those who spoke Arabic fared better than other groups. The majority (75%) preferred to discuss information with close relatives rather than patients, even when the patients were mentally competent. Most of the physicians (72%) felt patients had the right to refuse a specific treatment modality, and 68% denied patients the right to demand such a treatment if considered futile. Further analysis showed that physicians' attitudes varied along a spectrum from passive (25%) to paternalistic (21%) with the largest group (47%) in a balanced position.

CONCLUSIONS

In traditional societies where physicians are regarded as figures of authority and family ties are important, there is a considerable shift of access to information and decision-making from patients to their physicians and relatives in a manner that threatens patients' autonomy. Ethical principles, wider availability of invasive medical technology and a rise in public awareness dictate an attitude change.

The importance of advance directives in primary care

The advance directive has been acknowledged widely by patients and physicians as a desirable tool to promote patient autonomy at the end of life. Rates of completion of advance directives, however, remain low among all segments of the population. Significant patient and physician barriers to completion of advance directives are considered. Legal and ethical principles of advance directives, as well as some practical means of overcoming barriers to these important discussions, are reviewed.

Preliminary validation of a measure of life support preferences

A rapid, easy to use instrument that provides illustrations of life support choices can enhance discussion of life support measures with patients. The goal of this preliminary study was to develop and validate an instrument, the Life Support Preferences Questionnaire (LSPQ). In a convenience sample of 116 healthy adults, the LSPQ showed a sturdy degree of internal consistency for a short measure. The 2-week stability evidence was supportive of respondents' consistent attitudes over time at both the item and scale level. Principal factor analyses give evidence there is one dominant theme underlying the items. Use of the LSPQ with hospitalized patients is being explored as a response to policy changes resulting from the 1991 Patient Self-Determination Act.

Advance care planning: eliciting patient preferences for life-sustaining treatment

Patient autonomy is a guiding principle in medical decision-making in America. This is challenging when patients become mentally incapacitated and cannot express their preferences. Advance care planning (ACP) addresses this challenge. ACP is a deliberative and communicative process that helps people formulate and communicate preferences for future medical care in the event of mental incapacity. Advance directives are mechanisms for communicating and/or documenting ACP, and are either instructional (e.g. statement of treatment preferences in living wills) or proxy types (e.g. appointment of another person to speak on the patient's behalf). ACP discussions between patients and health care providers and patient-orientated educational ACP materials often ignore insights from 2 related activities, health promotion and human information processing. More effective ACP should occur with greater attention to the concepts of stages of change and self-efficacy, the Health Belief Model, and the necessary requisites for cognitive integration.

Advance directives: a policy-capturing approach

Policy capturing was used to provide insight into those factors that people consider important in the decision of whether to accept life-sustaining medical treatment. First, open-ended interviews with community-dwelling elderly persons (n = 30) were conducted to determine the factors they would consider when drafting an advance directive. College students (n = 53) then made judgments as to whether they would accept life-sustaining treatment for each of 100 hypothetical vignettes comprising a similar set of factors. Results revealed that 1) students made consistent judgments, 2) there was considerable variability in their mean judgments, 3) the most influential factors were mental and physical functioning, 4) mental and physical functioning had an interactive effect on judgments, and 5) subjective estimates of importance were significantly related to policy-capturing weights. This approach for studying the relationship of individuals' values to their acceptance of life-sustaining therapy may be useful in future studies of patient and surrogate decision making.

Code status decision-making in a nursing home population: processes and outcomes

OBJECTIVES

To examine the clinical utility of prehospital code status discussions in a nursing home (NH) setting and the health care outcomes of the decisions made. Also to identify patient factors and other variables associated with these decisions.

DESIGN

Retrospective uncontrolled observational study carried out through record review.

SETTING

A single skilled-level teaching NH and its affiliated university hospital.

PATIENTS

All of the 350 individuals who resided at the NH during a 2-year period.

MAIN RESULTS

Code status decisions were routinely sought through discussion involving primary care physician/social worker teams and residents or surrogates of demented patients. Choices were made for 80% of the NH residents, most (73%) by surrogates and most (80%) for do-not-resuscitate (DNR) orders, usually within 10 weeks of NH admission. Neither short-term measures of NH care intensity nor hospital use changed after a DNR decision. Most (80%) hospital transfer records included code status documentation. At the NH, both the likelihood of decisions and their directions were associated with involvement by specific physician/social worker teams. Additionally, a dementia diagnosis, white race, and older age were associated with a nursing home DNR decision. At the hospital, a DNR order was associated with white race, the presence of nursing home DNR documentation in the transfer records, hospital attending care by certain NH physicians, and a terminal hospital stay. Hospital inpatient medical and surgical therapy use, except for intensive care procedures, was similar for DNR and non-DNR inpatients. Residents with DNR orders had a higher mortality rate, yet most survived at least 1 year after the order. In the short term, a DNR order had no impact on measured health care resource consumption, but, for those in the final months of life, in-patient hospital use was less for the DNR group, and most of these died at the nursing home.

CONCLUSIONS

Prehospital code status decisions can be made effectively within the NH setting. Outside of medical intensive care, DNR orders have no impact on NH and hospital care intensity in the short term. In the final 6 months of life, however, hospital use is less for the DNR subgroup.

Prior capacity of patients lacking decision making ability early in hospitalization: implications for advance directive administration. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

OBJECTIVE

To investigate the appropriateness of hospitalization as the time to elicit patients' medical care preferences, the authors evaluated the capability of seriously ill patients to participate in decision making early in hospitalization and their decision making capacity two weeks before hospital entry.

DESIGN

Cross-sectional study with retrospective evaluation of preadmission decision making capacity.

SETTING

Five acute care teaching hospitals.

PATIENTS

Four thousand three hundred one acutely ill hospitalized adults meeting predetermined severity of illness criteria in nine specific disease categories.

MEASUREMENTS

Surrogate decision makers' estimates of the prior mental capacities of patients unable to be interviewed early in hospitalization about care preferences due to intubation, coma, or cognitive impairment. Comparison of the demographics, degrees of sickness at admission, and outcomes of interviewable vs noninterviewable patients.

MAIN RESULTS

Forty percent of the patients were not interviewable concerning preferences. Of these, 83% could have participated in treatment decisions two weeks prior to hospitalization. The patients who were not interviewable were more acutely ill, had less chronic disease, and were more likely to die during hospitalization than the interviewable patients.

CONCLUSIONS

Many acutely ill patients likely to die in the hospital lost their ability to make medical care decisions around the time of hospital admission. Preferences for care and advance directives should be discussed in the outpatient setting or very early in hospital admission.

Impact of patient incompetence on decisions to use or withhold life-sustaining treatment

PURPOSE

To study the relationship of patient incompetence to decisions to withhold life-sustaining treatments.

DESIGN AND PATIENTS

This prospective cohort study consisted of 311 inpatients with end-stage congestive heart failure, chronic obstructive pulmonary disease, cancer, and cirrhosis.

METHODS

Daily assessments were used to classify patients as incompetent if they had depressed consciousness, major psychiatric disease, or cognitive impairment throughout their hospital stay. Treatment decisions were assessed by observation and medical record review.

RESULTS

Forty-eight (15%) patients were incompetent: 33 had depressed consciousness, 11 failed cognitive screens, and 4 had major psychoses. Incompetent patients were more severely ill (APACHE II score 14.9 versus 12.6, P < or = 0.05) and more commonly had cancer (73% versus 44%, P < or = 0.05). Decisions were made to withhold cardiopulmonary resuscitation (CPR) for 71% of incompetent patients, but for only 21% of competent patients (P < or = 0.001). Decisions to withhold other treatments were also more common for incompetent patients (42% versus 16%, P < or = 0.001). After controlling for differences in severity of illness, diagnosis, race, and insurance status, patient incompetence remained strongly associated with a decision to withhold CPR (odds ratio 4.0, 95% confidence interval 1.8 to 8.9) and with decisions to withhold other treatments (odds ratio 2.4, 95% confidence interval 1.1 to 5.3). Decisions for incompetent patients were made by physicians with family surrogates 79% of the time. No decision was based on a written advanced directive. Patient preference was the rationale for 41% of decisions to withhold CPR from incompetent patients. Major conflict occurred in only 1% of all cases where a decision was made to withhold treatment.

CONCLUSIONS

Despite current legal and ethical debate, incompetent patients are far more likely than competent patients to have life-sustaining treatment withheld. Most decisions are made by a consensus of physicians and family surrogates, and major conflicts rarely occur.

The influence of the probability of survival on patients' preferences regarding cardiopulmonary resuscitation

BACKGROUND

Studies suggest that a majority of elderly patients would want to undergo cardiopulmonary resuscitation (CPR) if they had a cardiac arrest. Yet few studies have examined their preferences after clinicians have informed them about the outcomes of CPR.

METHODS

To study older patients' preferences regarding CPR, we interviewed as many ambulatory patients as possible in one geriatrics practice in Denver from August 1, 1991, through July 31, 1992.

RESULTS

A total of 371 patients at least 60 years of age were eligible; 287 completed the interview (mean age, 77 years; range, 60 to 99). When asked about their wishes if they had cardiac arrest during an acute illness, 41 percent opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (10 to 17 percent), 22 percent opted for CPR. Only 6 percent of patients 86 years of age or older opted for CPR under these conditions. When asked about a chronic illness in which the life expectancy was less than one year, 11 percent of the 287 patients opted for CPR before learning the probability of survival to discharge. After learning the probability of survival (0 to 5 percent), 5 percent said they would want CPR.

CONCLUSIONS

Older patients readily understand prognostic information, which influences their preferences with respect to CPR. Most do not want to undergo CPR once a clinician explains the probability of survival after the procedure.

The discussion of end-of-life medical care by primary care patients and physicians: a multicenter study using structured qualitative interviews. The EOL Study Group

OBJECTIVES

To identify primary care patients' and physicians' beliefs, attitudes, preferences, and expectations regarding discussions of end-of-life medical care, and to identify factors limiting the quality and frequency of these discussions.

DESIGN

Descriptive study using audiotaped, structured, qualitative interviews.

SETTING

Ambulatory care clinics and offices at eight medical centers in six states.

PARTICIPANTS

Forty-three primary care physicians and 47 ambulatory outpatients.

RESULTS

The patients expressed strong feelings about having end-of-life discussions early in their medical courses while they were competent. They desired straightforward and honest discussions and were less concerned than the physicians about damaging hope. The patients wanted their physicians to play central roles in discussions and both the patients and the physicians noted the impact of the patient-physician relationship on these discussions. The patients desired information focusing more on expected outcomes than on medical processes. The physicians expressed feelings of ambiguity when their desire to save lives clashed with their belief that aggressive life-sustaining treatments were futile. The physicians described their roles in end-of-life discussions in five major categories; lifesaver, neutral scientist, guide, counselor, and intimate confidant. The physicians considered living wills excellent "icebreakers" for starting discussions but of limited utility otherwise.

CONCLUSIONS

Patients prefer end-of-life discussions earlier and with greater honesty than physicians may perceive. These discussions are inseparably linked with the patient-physician relationship. Physicians can better address patients' desires in end-of-life discussions by altering their timing, content, and delivery.

Effect of an educational program on medical students' conversations with patients about advance directives: a randomized trial

Advance directives, such as the durable power of attorney for health care (DPAHC), help patients and physicians make end-of-life health care decisions. Medical education should prepare student physicians to be knowledgeable about and comfortable with discussing advance directives. The authors developed an educational module for the third-year medical school curriculum and conducted a randomized trial to evaluate in students its effect on various outcome measures regarding the DPAHC. Over a six-week period, students who received written material about the DPAHC and a two-hour seminar significantly increased knowledge about and reported increased skill, comfort, and experience with the DPAHC.

How well is the Patient Self-Determination Act working?: an early assessment

OBJECTIVES

To assess the association between implementation of the Patient Self-Determination Act (PSDA) and (1) the use of formal, written advance directives, (2) the use of informal advance care arrangements, and (3) discussions between patients and their physicians and proxies an advance care planning and end-of-life treatment preferences.

DESIGN

A time-sequence study in which patients discharged from acute care hospitals 1 month before the implementation of the PSDA and 5 months after implementation of the PSDA were interviewed.

SETTING

Two medical school-affiliated, major teaching hospitals with more than 500 beds and 3 nonteaching community hospitals with fewer than 400 beds in eastern Massachusetts.

PATIENTS

A total of 579 adult patients were interviewed: 258 patients discharged before the implementation of the PSDA (pre-PSDA) and 321 patients discharged 5 months after implementation of the PSDA (post-PSDA).

MEASUREMENTS

Patients were asked about their formal, written or informal advance care planning arrangements, about the frequency of inquiries and information provided on advance care planning by the hospitals, and about their discussions of advance care planning and end-of-life treatment preferences with physicians and their proxies.

RESULTS

In the pre-PSDA cohort, 60.9% of the patients had some kind of advance care planning, whereas in the post-PSDA cohort, 72.6% did (p = 0.01). However, there was not a significant increase in the proportion of patients who had advance care planning "in a written document" (19.8% of the pre-PSDA cohort compared with 25.5% of the post-PSDA cohort, p = 0.11). The increase in written advance care planning was concentrated in the community, nonteaching hospitals (10.7% pre-PSDA versus 23.7% post-PSDA). Overall, 41.4% of patients recalled inquiries or information about advance care planning during their hospitalization. Implementation of the PSDA was not associated with a significant change in the proportion of patients who discussed advance care planning or end-of-life issues with their physicians (13.6% pre-PSDA versus 17.1% post-PSDA, p = 0.25). However, there was an increase in the proportion of patients with poorer health who spoke with their physicians (15.4% pre-PSDA versus 24.8% post-PSDA). Implementation of the PSDA was associated with an increase in the proportion of patients who had general discussions with proxies about end-of-life issues (61.8% pre-PSDA versus 73.0% post-PSDA, p = 0.024). However, 33.6% of pre-PSDA and 33.2% of post-PSDA patients had detailed discussions with their proxy about specific interventions such as mechanical ventilation or artificial nutrition. Patients with formal proxies had detailed discussions significantly more frequently than other patients (50.0% versus 26.8%, p < 0.0001).

CONCLUSIONS

The PSDA was associated with significant effects on general advance care planning issues, increasing the proportion of patients who had (1) some kind of advance care arrangements and (2) general discussions of end-of-life issues with their proxies. However, the PSDA did not appear associated with significant increases (1) in the use of formal, written advance care documents, (2) in the frequency of discussions between patients and their physicians on advance care documents or end-of-life issues, or (3) in the frequency of discussions about specific treatment preferences between patients and their proxies.

The effects of providing chronic hemodialysis patients written material on advance directives

Because little is known about the stability of knowledge, attitudes, and behavior toward advance directives in chronic hemodialysis patients, we chose to determine whether providing written information on advance directives affects chronic hemodialysis patients' knowledge, attitudes, and behavior toward advance directives over time. Various patient demographic factors were also assessed for association with the above parameters. Thirty-one chronic in-center hemodialysis patients (55% women, 48% African-Americans, 81% on dialysis for more than 3 years) completed a questionnaire consisting of patient demographic features and agreement or disagreement with statements concerning knowledge, attitudes, and behavior toward advance directives. The responses were scored from 1 (strongly agree) to 5 (strongly disagree). Patients completed the questionnaire before, shortly after (1 to 3 months), and distant to (6 to 7 months) receiving written information on advance directives. Receiving written information on advance directives did not improve patients' understanding of living wills (58% understood before, 77% shortly after, and 58% distant to receiving the information) and only transiently improved understanding of a health care proxy (32% before, 67% shortly after [P < 0.006], 55% distant [P = not significant]) and the hospital policy on advance directives (35% before, 61% shortly after [P < 0.02], 48% distant [P = not significant]). Patients' attitudes about advance directives and perceived barriers to their use were not different before, shortly after, or distant to receiving information. After receiving information on advance directives, more patients (13% before, 48% shortly after, 37% distant; P < 0.002) and their family members (10% before, 30% shortly after, 20% distant; P < 0.02) completed advance directives.(ABSTRACT TRUNCATED AT 250 WORDS)

Discussions about limiting treatment in a geriatric clinic

OBJECTIVE

Obtain detailed information about the frequency and content of discussions about withholding treatment between doctors and elderly outpatients.

DESIGN

Survey.

SETTING

Primary care geriatric clinic at an urban university.

PARTICIPANTS

Twelve physicians and one nurse practitioner completed questionnaires for 185/198 (93.4%) patient visits.

MEASUREMENTS

Questionnaires were completed by physicians after each patient visit during August 1989. Interviews were conducted with physicians who had discussed limiting life-sustaining treatment with patients.

RESULTS

Ten percent (n = 19) of patients seen had had discussions with their physicians about life-sustaining treatment. These patients were older and had worse prognoses as estimated by their physicians. Physicians usually raised the issue with the families of demented patients and mentioned dementia, quality of life, prognosis, and the need to make other clinical decisions as motivation for initiating discussions. The majority of patients with poor prognoses, however, had not had discussions about life support.

CONCLUSIONS

Despite increasing attention given to end-of-life decisions in the medical and lay press, discussions with elderly outpatients about limiting treatment occur rarely. They are more likely when patients are older or have worse prognoses, but age, prognosis, and poor quality of life do not consistently lead physicians to raise the issue.

Decisions about enteral tube feeding among the elderly

OBJECTIVE

To determine choices about enteral tube feeding and factors associated with deciding to accept or forego this intervention in a group of ambulatory non-demented older individuals.

DESIGN

Descriptive survey.

SETTING AND PARTICIPANTS

Thirty four volunteers from a senior adult day center and 34 volunteers from the residential care section of a multilevel long-term care institution, mean age 77.8.

INTERVENTION

Structured interview using a hypothetical clinical vignette in simplified language, story-book format depicting an irreversibly and severely impaired state of health.

MEASUREMENT

Choice of whether to accept or forego enteral tube feeding based on the clinical vignette.

RESULTS

Thirty four (50%) decided to accept and 34 (50%) chose to forego enteral tube feeding in the situation presented in the vignette. No demographic, cognitive, or affective factors were associated with the decision. Presentation of the vignette and associated questions were not anxiety-provoking or upsetting to the vast majority of participants.

CONCLUSION

A hypothetical clinical vignette depicting a state of severely impaired health resulted in 34 (50%) of 68 ambulatory non-demented older individuals deciding to accept enteral tube feeding. No factors we examined were strongly associated with the decision. The vignette and discussion were not anxiety-provoking when presented in the format used in this study. Advance-directive discussions about enteral tube feeding and other health care decisions, using understandable hypothetical clinical vignettes that describe risks and benefits that might influence decisions, should be encouraged in the practice of geriatric medicine.

Empowerment of the older patient? A randomized, controlled trial to increase discussion and use of advance directives

OBJECTIVE

To see if an educational intervention directed at older outpatients would lead to increased use or discussion of advance directives and to characterize patients' reasons for not obtaining advance directives.

DESIGN

Randomized, controlled trial of an educational intervention versus usual care.

SETTING

Outpatient geriatrics clinic of a university hospital.

PATIENTS

One hundred and thirty-one non-demented patients over the age of 65 who did not have an advance directive documented in their record at the start of the study. Forty-eight patients were in the trial arm and 83 in the control.

MAIN OUTCOME MEASURES

All patients had their charts reexamined 6 months after enrollment to look for the presence of a living will, a durable power of attorney for health care, or a physician's note describing a discussion of advance directives. Trial patients were also re-interviewed to examine their reasons for not executing an advance directive.

MAIN RESULTS

Six months after the intervention, only seven of the 48 trial subjects (15%) had an advance directive or note describing discussion of advance directives in their charts compared to eight of the 83 controls (10%) (P greater than 0.05). When asked to give reasons for not obtaining an advance directive, many patients' responses pointed to procrastination as a significant barrier.

CONCLUSIONS

Promoting advance directive use is a complicated task. Barriers other than information and access to documents appear to be involved and need to be addressed in future efforts.