Older people's reasoning for resuscitation preferences and their role in the decision-making process

Perspective of geriatric patients on advance care planning in Denmark: a qualitative study

OBJECTIVE

Most previous studies on advance care planning (ACP) have focused on patients with specific diseases and only a few on frail ageing individuals. We therefore decided to examine the perspective of geriatric patients on ACP. Our research questions include if, when, with whom and with which content geriatric patients wish to have ACP conversations.

DESIGN

Participants were interviewed either in the hospital or in their own home. The interviewer followed a semistructured interview guide. Interviews were transcribed and analysed using the systemic text condensation method.

SETTING

Geriatric department in a regional hospital in a rural area in Region Zealand, Denmark.

PARTICIPANTS

We included 11 geriatric patients aged above 65 who had been referred for geriatric inpatient or outpatient assessment. Participants were clinically judged by experienced geriatricians to have sufficient physical and mental capacity to take part in an interview.

RESULTS

This study's main finding is that geriatric patients have varying preferences and feelings towards ACP. Some expressed concerns about ACP, especially regarding personal fear to talk about end-of-life (EOL) decisions, and whether a busy healthcare system has the resources to conduct ACP. Proper timing of ACP seemed unrelated to specific age but related to perception of health situation. The health professional involved should be well trained and a person the participant could trust. Most participants wanted family members to participate. Concerning content, participants mentioned quality of life, fear of losing their spouse, earlier experience with death, and practical concerns regarding funeral and will.

CONCLUSION

Among geriatric patients, feelings towards ACP are mixed. Even participants who were generally positive towards the concept uttered concerns about the circumstances when talking about EOL topics. Health professionals therefore should approach ACP discussions with caution. Further studies aiming to develop guidelines describing the proper way to introduce and perform ACP in this patient group are needed.

Goals of care discussions in acute hospital admissions - Qualitative description of perspectives from patients, family and their doctors

OBJECTIVE

Goals of care discussions guide care for hospital inpatients at risk of deterioration. We aimed to explore patient and family experience of goals of care during the first 72 h of admission along with their doctor's perspective.

METHODS

A qualitative descriptive study. Patients, family and doctors who participated in a goals of care discussion during an acute hospital admission at an Australian tertiary teaching hospital were interviewed in 2019.

RESULTS

Many participants found goals of care discussions appropriate and reported understanding. However, communication was commonly procedure-focused, with questioning about preferences for cardiopulmonary resuscitation and intubation. Some considered the discussion as inapplicable to their state of health, and occasionally surprising. Participants commonly related goals of care with death, and without context, this led to fear of abandonment. Previous experience with end of life care influenced decision-making. Preference for family presence was clear.

CONCLUSIONS

This study identifies deficiencies in goals of care communication in the acute hospital setting. Discussions are life-saving-procedure focused, leading to poor understanding and potentially distress, and jeopardising patient-centred care.

PRACTICE IMPLICATIONS

Assessment of patient values and clear communication on the aims of goals of care discussions is essential to optimise patient and institutional outcomes. Clinicians should consider environment and invite family participation.

Documentation of ethically relevant information in out-of-hospital resuscitation is rare: a Danish nationwide observational study of 16,495 out-of-hospital cardiac arrests

Background

Decision-making in out-of-hospital cardiac arrest should ideally include clinical and ethical factors. Little is known about the extent of ethical considerations and their influence on prehospital resuscitation. We aimed to determine the transparency in medical records regarding decision-making in prehospital resuscitation with a specific focus on ethically relevant information and consideration in resuscitation providers’ documentation.

Methods

This was a Danish nationwide retrospective observational study of out-of-hospital cardiac arrests from 2016 through 2018. After an initial screening using broadly defined inclusion criteria, two experienced philosophers performed a qualitative content analysis of the included medical records according to a preliminary codebook. We identified ethically relevant content in free-text fields and categorised the information according to Beauchamp and Childress’ four basic bioethical principles: autonomy, non-maleficence, beneficence, and justice.

Results

Of 16,495 medical records, we identified 759 (4.6%) with potentially relevant information; 710 records (4.3%) contained ethically relevant information, whereas 49 did not. In general, the documentation was vague and unclear. We identified four kinds of ethically relevant information: patients’ wishes and perspectives on life; relatives’ wishes and perspectives on patients’ life; healthcare professionals’ opinions and perspectives on resuscitation; and do-not-resuscitate orders. We identified some “best practice” examples that included all perspectives of decision-making.

Conclusions

There is sparse and unclear evidence on ethically relevant information in the medical records documenting resuscitation after out-of-hospital cardiac arrests. However, the “best practice” examples show that providing sufficient documentation of decision-making is, in fact, feasible. To ensure transparency surrounding prehospital decisions in cardiac arrests, we believe that it is necessary to ensure more systematic documentation of decision-making in prehospital resuscitation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00654-y.

Nursing facility residents' cardiopulmonary resuscitation decisions

CONTEXT

As many as one-quarter of all residents in nursing facilities have cardiopulmonary resuscitation (CPR) as a documented choice in the medical record, despite the likelihood of limited medical benefit in this setting.

OBJECTIVES

The aim of this study was to understand the perspectives of healthcare providers and nursing facility residents regarding CPR decisions.

METHODS

We used qualitative interviews to examine the perspectives of residents with a documented decision for CPR in the medical record. We then compared residents' views with those of healthcare providers who routinely conduct advance care planning (ACP) conversations in the nursing facility setting.

RESULTS

Five themes emerged from the interviews: (a) Resident versus Provider Concerns, (b) Offering Information versus Avoidance, (c) Lack of Understanding of CPR, (d) Lack of Awareness, and (e) 'Don't Keep Me on Machines'. Residents held misconceptions about CPR and/or exhibited an overall poor understanding of the relationship between their own health status and the likelihood of a successful CPR attempt. Although healthcare providers offer information and health education in an attempt to address knowledge gaps, these efforts are not always successful or even accepted by residents. Resident viewpoints and priorities differed from healthcare providers in ways that affected communication about CPR.

CONCLUSIONS

Unrecognised differences in perceptions between providers and residents affect key aspects of ACP communication that can impact CPR decision-making. The concerns and priorities of institutionalized older adults may differ from those of healthcare providers, creating challenges for engaging some residents in ACP.

IMPLICATIONS FOR PRACTICE

ACP communication models and training should be designed not only to explore nursing facility residents' goals, values, and preferences, but also to elicit any underlying differences in perceptions that may affect communication. Healthcare providers can identifying the primary concerns of residents and assist them with integrating or reframing these issues as a part of ACP discussions.

What Matters at the End of Life: A Qualitative Study of Older Peoples Perspectives in Southern Denmark

What matters at the end of life (EOL) among the older population in Denmark is poorly investigated. We used focus groups and in-depth interviews, to identify perspectives within the EOL, along with what influences resuscitation, decision making, and other treatment preferences. We included eligible participants aged ≥65 years in the Region of Southern Denmark. Five focus groups and nine in-depth interviews were conducted, in total 31 participants. We found a general willingness to discuss EOL, and experiences of the process of dying were present among all participants. Three themes emerged during the analysis: (a) Being independent is crucial for the future, (b) Handling and talking about the EOL, and (c) Conditions in Everyday Life are Significant. Life experiences seemed to affect the degree of reflection of EOL and the decision-making process. Knowing your population of interest is crucial, when developing an approach or using an advance care plan from another setting.

Factors Predisposing Terminally Ill Cancer Patients' Preferences for Distinct Patterns/States of Life-Sustaining Treatments Over Their Last Six Months

CONTEXT

High-quality end-of-life (EOL) care depends on thoroughly assessing terminally ill patients' preferences for EOL care and tailoring care to individual needs. Studies on predictors of EOL-care preferences were primarily cross-sectional and assessed preferences for multiple life-sustaining treatments (LSTs), making clinical applications difficult.

OBJECTIVE/METHODS

We examined factors predisposing cancer patients (N = 303) to specific LST-preference states (life-sustaining preferring, comfort preferring, uncertain, and nutrition preferring) derived from six LSTs (cardiopulmonary resuscitation, intensive care unit care, chest compression, intubation with mechanical ventilation, intravenous nutrition, and tube feeding) in patients' last six months by multilevel multinomial logistic regression.

RESULTS

Participants with accurate prognostic awareness and physician-patient EOL-care discussions were less likely to be in life-sustaining-preferring, uncertain, and nutrition-preferring states than in the comfort-preferring state. Better quality of life (QOL) and more depressive symptoms predisposed participants to be less likely to be in the uncertain than in the comfort-preferring state. Membership in the nutrition-preferring rather than the comfort-preferring state was significantly higher for participants in the state of moderate symptom distress with severe functional impairment than in the state of mild symptom distress with high functioning.

CONCLUSION

Accurate prognostic awareness, physician-patient EOL-care discussions, QOL, depressive symptoms, and symptom-functional states predisposed terminally ill cancer patients to distinct LST-preference states. Clinicians should cultivate patients' accurate prognostic awareness and facilitate EOL-care discussions to foster realistic expectations of LST efficacy at EOL. Clinicians should enhance patients' QOL to reduce uncertainty in EOL-care decision making and provide adequate psychological support to those with more depressive symptoms who prefer comfort care only.

End-of-life decisions in emergency patients: prevalence, outcome and physician effect

BACKGROUND

End-of-life decisions (EOLD) represent potentially highly consequential decisions often made in acute situations, such as 'do not attempt resuscitation' (DNAR) choices at emergency presentation.

AIM

We investigated DNAR decisions in an emergency department (ED) to assess prevalence, associated patient characteristics, potential medical and economic consequences and estimate contributions of patients and physicians to DNAR decisions.

DESIGN

Single-centre retrospective observation, including ED patients with subsequent hospitalization between 2012 and 2016. Primary outcome was a DNAR decision and associated patient characteristics. Secondary outcomes were mortality, admission to intensive care unit and use of resources.

METHODS

Associations between DNAR and patient characteristics were analysed using logistic mixed effects models, results were reported as odds ratios (OR). Median odds ratios (MOR) were used to estimate patient and physician contributions to variability in DNAR.

RESULTS

Patients of 10 458 were attended by 315 physicians. DNAR was the choice in 23.3% of patients. Patients' characteristics highly associated with DNAR were age (OR = 4.0, 95% CI = 3.6-4.3) and non-trauma presentation (OR = 2.3, 95% CI = 1.9-2.9). In-hospital mortality was significantly higher (OR = 5.4, CI = 4.0-7.3), and use of resources was significantly lower (OR = 0.7, CI = 0.6-0.8) in patients choosing DNAR. There was a significant effect on DNAR by both patient (MOR = 1.8) and physician (MOR = 2.0).

CONCLUSIONS

DNAR choices are common in emergency patients and closely associated with age and non-trauma presentation. Mortality was significantly higher, and use of resources significantly lower in DNAR patients. Evidence of a physician effect raises questions about the choice autonomy of emergency patients in the process of EOLD.

Advance directive: does the GP know and address what the patient wants? Advance directive in primary care

Background

Due to the rapid changes in the medical world and the aging population, the need for advanced care planning grows.

Despite efforts to make this topic discussed, only a minority of patients discusses the advance directive with their general practitioner (GP). This study aimed to map thresholds: What barriers are identified by GPs and patients in preparing and discussing an advance directive?

Methods

A cross section survey in patients and GP’s was performed. Citizens were recruited by multimedia and by street interviews. GP’s were recruited by mailing.

Results

Most of the 502 citizens already heard of an advance directive but only 17 had declared one while 21 never want one. Eighty percent wants to take the initiative themselves but half of the participants wants the GP to be actively involved. Thirty percent finds the document too difficult to understand. The need to draw an advance directive grew with increasing age. Of the 117 GP’s involved, 65% drafted five or less advance directives the past year. A lack of time, experience and a poor access to the correct administrative requirements were only a few of the barriers.

Conclusions

Preparing and drafting an advance directive is a time-consuming and difficult procedure.

Patients and GP’s have the right to be informed and instructed on how to prepare an advance directive.

Why do older people refuse resuscitation? A qualitative study examining retirement village residents' resuscitation decisions

BACKGROUND

There is a dearth of qualitative research on resuscitation preferences of older New Zealanders. The aim of this study was to investigate the resuscitation preferences of older New Zealanders in a retirement village or residential care setting, as well as the reasons for these preferences.

METHODS

This study had 37 participants from two retirement villages in Auckland, New Zealand. Participants were interviewed about a hypothetical case vignette about cardiopulmonary resuscitation, and then they completed a semi-structured interview. Interviews were subsequently transcribed and analyzed by two independent researchers using thematic qualitative methodology.

RESULTS

The majority of the participants (n = 25, 67.6%) decided against resuscitation, 10 (27.0%) wanted resuscitation, and 2 (5.4%) were ambivalent about their resuscitation preferences. Three main themes emerged during the data analysis regarding participants' reasons for deciding against resuscitation: (i) the wish for a natural death; (ii) advanced age; and (iii) a realistic awareness about the consequences of resuscitation. Responses related to the third these had three subthemes: (i) reduced quality of life; (ii) loss of personal integrity and sense of existence; and (iii) concern that resuscitation could result in unnecessary costs or a burden on others. Among participants who preferred resuscitation, two main themes emerged regarding their reasons for wanting resuscitation: (i) the wish to prolong a good quality of life; and (ii) unrealistic expectations of resuscitation.

CONCLUSIONS

Older people in this study were able to make reasoned decisions about resuscitation based on balancing their subjective estimations of quality of life and the presumed consequences of resuscitation. It is important therefore to educate older adults about the potential outcomes of resuscitation and explore (and document) their reasoning when discussing resuscitation preferences so their wishes can be respected.

[Elderly patients and intensive care: Systematic review and geriatrician's point of view]

The global population is aging and intensive care unit admission rate of elderly patients is dramatically increasing. The objective of this review is to provide an overview of the literature about the management of elderly patients in intensive care unit and more specifically about epidemiology, admission criteria, mortality, functional prognosis and ethical aspects. We also discuss the data on cardiorespiratory arrest, shock, acute respiratory failure and delirium. The mortality rate of patients over 80 years old in intensive care unit can reach up to 70% at 1year, but is dependent on many factors, such as comorbidities or frailty. Above all, more than half of elderly patients recover their long-term autonomy. Their quality of life is comparable to that of the same age population. Considering that the first 3months after an intensive care unit stay are the most decisive in terms of vital and functional prognosis, we will discuss strategies to improve care through the creation of dedicated intensive care-geriatrics networks.

Preferences for Aggressive End-of-life Care and Their Determinants Among Taiwanese Terminally Ill Cancer Patients

BACKGROUND

Studies on factors influencing preferences for aggressive end-of-life (EOL) care have focused predominantly on preferred goals of EOL and seldom comprehensively incorporate patients' predisposing, enabling, and need factors into their analyses.

OBJECTIVE

The aim of this study was to investigate the determinants of preferences for a wide range of aggressive EOL care from the aforementioned factors.

METHODS

A cross-sectional survey was conducted using a convenience sample of 2329 terminally ill cancer patients recruited from 23 hospitals throughout Taiwan.

RESULTS

Among these Taiwanese terminally ill cancer patients, 8.2% preferred prolonging life as their goal for EOL care. When combining those who wanted and those who were undecided as wanting that specific treatment, 27.9% preferred cardiopulmonary resuscitation when their life was in danger, and 36.0%, 27.3%, 24.3%, and 26.7% preferred to receive care at intensive care unit, cardiac massage, intubation, and mechanical ventilation support, respectively. Those at risk of preferring aggressive EOL care were men, younger than 45 years, married, diagnosed within 6 months, and with comorbidity and their physician had not accurately disclosed their prognosis or discussed EOL care issues to/with them.

CONCLUSIONS

Few Taiwanese terminally ill cancer patients preferred to prolong life as their goal for EOL care, cardiopulmonary resuscitation when their life was in danger, and life-sustaining treatments at EOL. Preferences for aggressive EOL care are determined by patients' predisposing, enabling, and need factors.

IMPLICATIONS FOR PRACTICE

Terminally ill cancer patients at risk of preferring aggressive EOL care should receive interventions to help them appropriately weigh the burdens and benefits of such aggressive treatments.

[Healthcare preferences of the very elderly: A review]

The preferences of the very elderly are not taken into account in healthcare planning. For this reason, a medical literature review was performed in order to fill the gap in appropriate information on this issue. The majority of them think that they receive good healthcare. They favour building a trusting relationship, with the physician handling their decision-making. They also maximise their quality of life at the expense of quantity, and give great importance to comfort and safety. Most of them express the wish to be cared for and die at home. But when an acute event occurs, they want to be transferred to hospital. More explicit communication must be encouraged between very elderly patients, providers, and families to meet their subjective needs, through on-going discussions, focused on expected outcomes and patient care goals. A healthcare system designed to look after them should be based on individual and flexible care, with coordination between healthcare services. Such a healthcare system could enable a growing number of them to die in their preferred conditions.

Preferences for Life-Sustaining Treatments and Associations With Accurate Prognostic Awareness and Depressive Symptoms in Terminally Ill Cancer Patients' Last Year of Life

CONTEXT

The stability of life-sustaining treatment (LST) preferences at end of life (EOL) has been established. However, few studies have assessed preferences more than two times. Furthermore, associations of LST preferences with modifiable variables of accurate prognostic awareness, physician-patient EOL care discussions, and depressive symptoms have been investigated in cross-sectional studies only.

OBJECTIVES

To explore longitudinal changes in LST preferences and their associations with accurate prognostic awareness, physician-patient EOL care discussions, and depressive symptoms in terminally ill cancer patients' last year.

METHODS

LST preferences (cardiopulmonary resuscitation, intensive care unit [ICU] care, intubation, and mechanical ventilation) were measured approximately every two weeks. Changes in LST preferences and their associations with independent variables were examined by hierarchical generalized linear modeling with logistic regression.

RESULTS

Participants (n = 249) predominantly rejected cardiopulmonary resuscitation, ICU care, intubation, and mechanical ventilation at EOL without significant changes as death approached. Patients with inaccurate prognostic awareness were significantly more likely than those with accurate understanding to prefer ICU care, intubation, and mechanical ventilation than to reject these LSTs. Patients with more severe depressive symptoms were less likely to prefer ICU care and to be undecided about wanting ICU care and mechanical ventilation than to reject such LSTs. LST preferences were not associated with physician-patient EOL care discussions, which were rare in our sample.

CONCLUSION

LST preferences are stable in cancer patients' last year. Facilitating accurate prognostic awareness and providing adequate psychological support may counteract the increasing trend for aggressive EOL care and minimize emotional distress during EOL care decisions.

Knowledge and preferences regarding cardiopulmonary resuscitation: A survey among older patients

OBJECTIVE

Survival rates following cardiopulmonary resuscitation (CPR) are low for older people, and are associated with a high risk of neurological damage. This study investigated the relationship between the preferences, knowledge of survival chances, and characteristics among older people regarding CPR.

METHODS

A cross-sectional, self-administrated survey was distributed by researchers to 600 patients aged at least 50 years. The 14-question survey tool was used to collect basic demographic data, knowledge about CPR, and preference for CPR. We performed binary logistic regression analysis to predict whether patients wanted to receive CPR or not.

RESULTS

The response rate was 48%. Most respondents (84%) predicted the estimated survival rate to be higher than the actual rate. Patients were significantly less likely to want to receive CPR if they correctly estimated the survival rate, had ever contemplated CPR, were older, or female. Discussing CPR with a doctor had no influence on patient preference for CPR.

CONCLUSION

Older patients choose to receive CPR based on incorrect knowledge.

PRACTICE IMPLICATIONS

Doctors should be aware of the impact of knowing the true chances of survival on patient preference for CPR. Knowledge and skills need to be updated to provide this information to patients.

Do-not-resuscitate orders among trauma patients

BACKGROUND

Do-not-resuscitate (DNR) orders are an important means to communicate end-of-life wishes. Previous studies have demonstrated variable prevalence of DNR orders among hospitalized trauma patients.

OBJECTIVE

This study was conducted to identify the prevalence and type of DNR orders among trauma patients and to identify associations of DNR orders with injury severity, length of stay, and whether CPR was performed in cases of cardiac arrest.

METHODS

In this retrospective study, medical records were reviewed for 263 trauma patients at Miami Valley Hospital in Dayton, Ohio, in 2014 with a DNR order.

RESULTS

Among 3394 trauma patients in 2014, 263 (8%) patients had a DNR order. Participants were 43% male and 57% female. The mean age was 76 (range, 16-90+) years. The most common mechanisms of injury included fall (n = 214, 81.4%) and motor vehicle collision (n = 16, 6.1%). Most DNR orders in this patient population were instituted during the hospitalization (n = 176, 67%). The most common types of advance directives included DNR order (n = 224, 85.2%), living will (n = 124, 47.2%), and durable power of health care attorney (n = 126, 47.9%). A minority of patients died during hospitalization (n = 100, 38.0%). Among patients who were deceased, 14 (14.0%) had CPR performed.

CONCLUSIONS

Among trauma patients with DNR orders, most DNR orders were instituted during the hospital admission. Most deceased patients with DNR orders did not have CPR performed during the hospital stay.

Viewing Hospice Decision Making as a Process

Research focused on understanding that the nature of hospice decision making has both described the characteristics of those who do and do not utilize hospice and identified many factors related to choosing hospice. However, this literature has not explored the underlying decision-making processes, limiting our understanding. We examine the extant literature and propose a framework that views hospice decisions as an evolving process, identify key factors that bear directly on this process, and discuss the contextual environment, including the idea of a decision maker triad. We end with a discussion of how this framework can be used to support clinical practice and future research. Our goal is to provide a framework from which to understand the end-of-life needs of all patients, no matter where they receive care.

Cancer in the elderly: is it time for palliative care in geriatric oncology?

BACKGROUND

Persons aged 65 and over are the fastest growing segment of the population in most Western countries. Although cancer-related death occurs far more commonly in older people than in any age group, studies on palliative care in older adults are lacking.

OBJECTIVE

This paper aims at evaluating the needs in elderly patients affected by cancer and the state of the art of the research in palliative care in this setting.

MATERIALS AND METHODS

A literature search was performed (PubMed) to identify relevant studies. Papers were reviewed for relevance to palliative care in the elderly.

RESULTS

Elderly who need palliative care are frequently disregarded as individuals and may experience discrimination because of their age. Palliative care for older patients relates particularly to multiple treatments for various conditions. This causes extra complexities for the researchers.

CONCLUSIONS

The aim of the study was not fully achieved due to the paucity of literature focusing upon these issues. The areas of investigation that need to be addressed comprise: establishing the prevailing symptoms in elderly patients, understanding patients' psychological/spiritual well-being and quality of life and elucidating the sources of caregiver burden, adapting research methodologies specifically for palliative care and comparing the needs and the outcomes of this age group to younger patients.

Attitude of elderly patients towards cardiopulmonary resuscitation in Greece

AIM

Although researchers in several countries have investigated patients' points of view regarding cardiopulmonary resuscitation, there has been no research investigating this issue in Greece. The present study aimed at identifying the attitude of older Greek patients regarding cardiopulmonary resuscitation.

METHODS

One basic questionnaire consisting of 34 questions was used in order to identify patients' opinions regarding cardiopulmonary resuscitation in five different hospitals from June to November 2011.

RESULTS

In total, 300 questionnaires were collected. Although patients' knowledge regarding cardiopulmonary resuscitation was poor, most of them would like to be resuscitated in case they suffered an in-hospital cardiac arrest. Also, they believe that they should have the right to accept or refuse treatment. However, the legal and sociocultural norms in Greece do not support patients' choice for the decision to refuse resuscitation. The influence of several factors, such as their general health status or the underlying pathology, could lead patients to give a "do not attempt resuscitation" order.

CONCLUSIONS

The attitudes of older Greek patients regarding resuscitation are not different from others', whereas the legal and sociocultural norms in Greece do not support patient choice in end-of-life decisions, namely the decision to refuse resuscitation. We advocate the introduction of advanced directives, as well as the establishment and implementation of specific legislation regarding the ethics of resuscitation in Greece.

How to ask: older adults' preferred tools in health outcome prioritization

OBJECTIVE

To assess older adults' attitudes toward eliciting health outcome priorities.

METHODS

This observational cohort study of 356 community-living adults age ≥65 included three tools: (1) Health Outcomes: ranking four outcomes (survival, function, freedom from pain, and freedom from other symptoms); (2) Now vs. Later: rating importance of current versus future quality of life; (3) Attitude Scale: agreement with statements about health outcomes and current versus future health.

RESULTS

Whereas 41% preferred Health Outcomes, 40% preferred the Attitude Scale. Only 7-12% rated any tool as very hard or hard. In bivariate analysis, participants of non-white race and with lower education, health literacy, and functional status were significantly more likely to rate at least one of the tools as easy (p < .05). Across all tools, 17% of participants believed tools would change care. The main reason for thinking there would be no change was satisfaction with existing care (62%).

CONCLUSIONS

There is variability in how older persons wish to be asked about health outcome priorities. Few find this task difficult, and difficulty was not greater among participants with lower health literacy, education, or health status.

PRACTICE IMPLICATIONS

By offering different tools, healthcare providers can help patients clarify their health outcome priorities.

Advance Care Planning in terminally ill and frail older persons

OBJECTIVE

Advance Care Planning (ACP) - the communication process by which patients establish goals and preferences for future care - is encouraged to improve the quality of end-of-life care. Gaining insight into the views of elderly on ACP was the aim of this study, as most studies concern younger patients.

METHODS

We conducted and analysed 38 semi-structured interviews in elderly patients with limited prognosis.

RESULTS

The majority of participants were willing to talk about dying. In some elderly, however, non-acceptance of their nearing death made ACP conversations impossible. Most of the participants wanted to plan those issues of end-of-life care related to personal experiences and fears. They were less interested in planning other end-of-life situations being outside of their power of imagination. Other factors determining if patients proceed to ACP were trust in family and/or physician and the need for control.

CONCLUSIONS

ACP is considered important by most elderly. However, there is a risk of pseudo-participation in case of non-acceptance of the nearing death or planning end-of-life situations outside the patient's power of imagination. This may result in end-of-life decisions not reflecting the patient's true wishes.

PRACTICE IMPLICATIONS

Before engaging in ACP conversations, physicians should explore if the patient accepts dying as a likely outcome. Also the experiences and fears concerning death and dying, trust and the need for control should be assessed.

The effects of socioeconomic status on participation in care among middle-aged and older adults

OBJECTIVE

This study assesses the effects of socioeconomic status (education and poverty) on seeking health information and subsequent use of this information during the medical encounter.

METHOD

Data on 19,944 adults (aged 45 and older) were drawn from the 2000-2001 Household Component of the Community Tracking Study, a nationally representative survey of non-institutionalized individuals.

RESULTS

Higher levels of education were associated with a greater likelihood of seeking health information and mentioning information to physicians. The poor and near poor were less likely to seek health information, but only the near poor were significantly less likely to mention information to the physician.

DISCUSSION

These findings underscore the importance of education in the acquisition and use of health information among middle-aged and older adults.

A pilot study exploring the factors that influence the decision to have PEG feeding in patients with progressive conditions

This original pilot study was conducted to explore and understand the factors that influence a patient's decision-making when considering percutaneous endoscopic gastrostomy placement for nonoral nutrition and hydration supplementation. Seven patients living with progressive dysphagic symptoms who had made a decision about percutaneous endoscopic gastrostomy placement were interviewed and their responses analyzed using the constant comparison method. All participants felt they had no option other than to accept the percutaneous endoscopic gastrostomy. The impact of visible physical deterioration and medical opinion were the most powerful influences on patients' decisions. Patients' perception of their involvement in the decision varied. This was linked to the amount and timing of information supplied and support they felt they received. Few patients have prior knowledge of tube feeding and rely heavily on medical advice. Effective communication by healthcare professionals can promote an environment that is supportive of patients' involvement in decisions. Adequate preparation time is vital if patients are to stop feeling uninvolved or peripheral to the decision-making process. Multidisciplinary teams need to address their working practices so that they do not intimidate patients, but rather empower patients in their decision-making.

Food for Thought: How Do Patients With ALS Decide About Having a PEG?

Dysphagia is a distressing problem in amyotrophic lateral sclerosis. Patients and caregivers must decide whether to use supplementary non-oral feeding. The deliberations and timing of this decision may be haphazard. The optimum time for this choice, in terms of residual (quality) life expectancy and decision competency, is unknown. Health-care workers may fear that even the offer of enteral feeding might be construed as an unwelcome landmark on the disease deterioration. This paper provides a qualitative report on the subjective experiences of 2 patients deciding whether to have a PEG or not. Semi-structured interviews were conducted with each patient and transcripts are provided for the reader to review.

Canadian Cardiovascular Society Consensus Conference guidelines on heart failure--2008 update: best practices for the transition of care of heart failure patients, and the recognition, investigation and treatment of cardiomyopathies

Heart failure is a clinical syndrome that normally requires health care to be provided by both specialists and nonspecialists. This is advantageous because patients benefit from complementary skill sets and experience, but can present challenges in the development of a common, shared treatment plan. The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006, and on the prevention, management during intercurrent illness or acute decompensation, and use of biomarkers in January 2007. The present update builds on those core recommendations. Based on feedback obtained through a national program of heart failure workshops during 2006 and 2007, several topics were identified as priorities because of the challenges they pose to health care professionals. New evidence-based recommendations were developed using the structured approach for the review and assessment of evidence that was adopted and previously described by the Society. Specific recommendations and practical tips were written for best practices during the transition of care of heart failure patients, and the recognition, investigation and treatment of some specific cardiomyopathies. Specific clinical questions that are addressed include: What information should a referring physician provide for a specialist consultation? What instructions should a consultant provide to the referring physician? What processes should be in place to ensure that the expectations and needs of each physician are met? When a cardiomyopathy is suspected, how can it be recognized, how should it be investigated and diagnosed, how should it be treated, when should the patient be referred, and what special tests are available to assist in the diagnosis and treatment? The goals of the present update are to translate best evidence into practice, apply clinical wisdom where evidence for specific strategies is weaker, and aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.

The perceptions of do-not-resuscitate policies of dying patients with cancer

Patients in hospitals must authorize do-not-resuscitate (DNR) orders or the default cardiopulmonary resuscitation (CPR) occurs. Using discursive analysis, we examined the speech of 28 cancer patients, judged as within 3 months of death, to determine how they justified preferences for DNR orders. Most saw these as a positive outcome of not interfering with a natural death with the decision being personal and the legal right of a competent autonomous person. If surrogates were required, they needed knowledge of the medical facts and the patient's wishes. The doctor was crucial, while family although likely to be supportive may be burdened by the responsibility. Some favored an early DNR discussion, but the majority favored a later discussion when it was applicable. At interview, 58% patients had a DNR order, rising to 82% by the time of death. Written orders were favored, yet 9 of 21 who did not want CPR had no DNR order. Hope was mentioned spontaneously by 25 patients, both as a thing over which patients had little control and as the desire of a positive future outcome. If doctors' and patients' assessments of eligibility for DNR orders do not coincide, the process and documentation of decision-making needs revision.

The Turning Point: Clinical Identification of Dying and Reorientation of Care

Palliative care is increasingly organized within the setting of formal health care systems but the demarcation has become unclear between, on the one hand, care directed at cure and rehabilitation and palliative care aimed at relief of suffering on the other. With the purpose to increase the understanding about the turning point reflecting identification of dying and reorientation of care, this study explores this phenomenon as determined from health care records of a representative sample (n = 229). A turning point was identified in 160 records. Presence of circulatory diseases, sporadic confinement to bed, and deterioration of condition had a significant impact upon the incidence of such turning point. The time interval between the turning point and actual death ranged between one and 210 days. Thirty percent of these turning points were documented within the last day of life, 33% during the last 2-7 days, 19.5% during the last 8-30 days, 13% during the last 31-90 days, and 4.5% during the last 91-210 days of life. The time interval between the turning point and actual death was significantly longer among individuals with neoplasm(s) and significantly shorter among individuals suffering from musculoskeletal diseases. Perhaps this reflects a discrepancy between the ideals of palliative care, and a misinterpretation of the meaning of palliative care in everyday clinical practice. The findings underscore that improvement in timing of clinical identification of dying and reorientation of care will likely favour a shift from life-extending care to palliative care.

A middle range theory for generative quality of life for the elderly

Decades of quality of life (QOL) research has failed to produce widely recognized QOL definitions or measurements. The inconsistency may be due to an ontological error in the perspective of researchers. Most researchers portray QOL as a given or inherent condition that declines in the face of challenges. We believe QOL is a cumulative process that results from a series of connections and disconnections that elders experience in their daily lives. The Register theory of Generative Quality of Life for the Elderly offers an alternative ontological perspective by placing elder QOL in a generative context.

Cardiopulmonary resuscitation in continuing care settings: time for a rethink?

Cardiopulmonary resuscitation is rarely successful in people who are old or frail, but current policy guidance fails to take this into account