Current health and preferences for life-prolonging treatments: an application of prospect theory to end-of-life decision making

Navigating Improper Care Settings: Nurses' Experiences Assisting Oncological Patients at the End of Life in Surgical Departments

BACKGROUND

Despite the growing preference for end-of-life care at home, numerous oncological patients continue to spend their final moments in surgical wards. This incongruity in settings may contribute to "dysthanasia," unnecessarily prolonging futile treatments and resulting in undue suffering. As frontline caregivers, nurses frequently bear the brunt of these challenging situations for patients and their families.

OBJECTIVE

To investigate the experiences of nurses providing care to terminally ill oncological patients inappropriately admitted to surgical departments.

METHODS

We adopted a phenomenological descriptive study. Nurses purposefully selected from 7 distinct surgical units at a University Hospital in Northeast Italy were recruited. Data collection took place through open-ended semistructured interviews. The interview content was analyzed using Colaizzi's framework.

RESULTS

The study with 26 participants revealed emotional challenges, especially for less-experienced nurses. Diverse perspectives among nurses emphasized the need for better palliative care knowledge. Despite the commitment to quality care, collaboration challenges and discordant goals with physicians impacted comprehensive care delivery.

CONCLUSIONS

Dysthanasia relates to participants' challenges in caring for oncological patients in inappropriate settings, hindering transparent communication and exacerbating discordance with doctors.

IMPLICATIONS FOR PRACTICE

Communication and collaboration among healthcare professionals, particularly nurses, and surgeons are crucial. Ongoing education in end-of-life care, coupled with advance care planning, empowers patients, aligns treatment choices, and prevents dysthanasia across diverse healthcare settings.

How age and health status impact attitudes towards aging and technologies in care: a quantitative analysis

BACKGROUND

Increasing proportions of geriatric patients pose tremendous challenges for our society. Developments in assistive technologies have the potential to support older and frail people in aging and care. To reach a sustainable adoption of these technologies, the perceptions and wishes of future users must be understood. In particular, the relationships between individual health-related factors, and the perceptions of aging and using assistive technologies in severe health situations must be empirically examined.

METHODS

Addressing this research gap, our quantitative study (N = 570) investigates the impact of diverse future users' age and health status on their a) perceptions of aging, b) perceptions and acceptance of using assistive technologies in aging and care, as well as c) end-of-life decisions regarding technology usage. For this, four groups were segmented for the comparison of younger (< 50 years) healthy, younger chronically ill, older (50 + years) healthy, and older chronically ill participants.

RESULTS

The results revealed that health status is more decisive for age-related perceptions compared to age. The technology-related perceptions were slightly impacted by either chronological age or health status. The end-of-life decisions showed the most striking differences in the willingness to use assistive technologies, revealing older chronically ill participants to have more restrained attitudes towards technology usage than older healthy as well as all younger participants.

CONCLUSIONS

The findings suggest that the benefits of assistive technologies in private or professional care contexts should be communicated and implemented tailored to the respective user group's needs. Moreover, the results allow us to derive practical implications within the geriatric care context.

Supportive care decision-making processes of persons with dementia and their caregivers

Little is known about the decision-making processes around seeking more supportive care for dementia. Persons with dementia are often left out of decision-making regarding seeking more supportive care as their dementia progresses. This paper provides a description of findings from the Decision-making in Alzheimer's Research project (DMAR) investigating the process of decision-making about transitions to more supportive care. We conducted 61 qualitative interviews with two stakeholder groups: 24 persons with dementia, and 37 informal caregivers to explore supportive care decisions and associated decision-making factors from the perspectives of persons with dementia and their caregivers. We identified four main decisions that persons with dementia and their informal caregivers played a role in: (1) sharing household responsibilities; (2) limiting routine daily activities; (3) bringing in formal support; and (4) moving to a care facility. Based on our findings we developed a schematized roadmap of decision-making that we used to guide the discussion of our findings. Four crosscutting themes emerged from our analysis: unknowns and uncertainties, maintaining life as you know it, there's no place like home and resource constraints. These results will be incorporated into the development of instruments whose goal is to identify preferences of persons with dementia and their caregivers, in order to include persons with dementia in care decisions even as their dementia progresses.

How Much Better is Faster? Value Adjustments for Health-Improvement Sequences

While the quality-adjusted life-year construct has advantages of simplicity and consistency, simplicity requires strong assumptions. In particular, standard assumptions result in health-state utility functions that are unrealistically linear and separable in risk and duration. Consequently, sequencing of a series of health improvements has no effect on the total value of the sequence because each increment is assessed independently of previous increments. Utility functions in nearly all other areas of applied economics are assumed to be nonlinear with diminishing marginal utility so it matters where an improvement occurs in a sequence. We construct a conceptual framework that that demonstrates how diminishing marginal utility for health improvements could affect preferences for different sequence patterns. Using this framework, we derive conditions for which the sum of conventional health-state utilities understates, overstates, or approximates the sequence-sensitive value of health improvements. These patterns suggest the direction and magnitude of possible adjustments to conventional value calculations. We provide numerical examples and identify recent studies whose results are consistent with the conceptual model.

No Time to Waste: An Appraisal of Value at the End of Life

OBJECTIVES

The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined.

METHODS

MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life.

RESULTS

A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed.

CONCLUSIONS

Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.

Cognitive and behavioural bias in advance care planning

Background:

We explore cognitive and behavioural biases that influence individual’s willingness to engage advance care planning (ACP). Because contexts for the initiation of ACP discussions can be so different, our objective in this study was to identify specific groups, particular preferences or uniform behaviours, that may be prone to cognitive bias in the ACP decision process.

Method:

We collected data from the Australian general public (n = 1253), as well as general practitioners (GPs) and nurses (n = 117) including demographics, stated preference for ACP decision-making; six cognitive bias tests commonly used in Behavioural Economics; and a framing experiment in the context of ACP.

Results:

Compared to GPs (M = 57.6 years, SD = 17.2) and the general public (58.1 years, SD = 14.56), nurses on average recommend ACP discussions with patients occur approximately 15 years earlier (M = 42.9 years, SD = 23.1; p < 0.0001 in both cases). There is a positive correlation between the age of the general population and the preferred age for the initial ACP discussion (ρ = 0.368, p < 0.001). Our shared decision-making analysis shows the mean share of doctor’s ACP input is viewed to be approximately 40% by the general public, significantly higher than health professionals (GPs and nurses), who believe doctors should only contribute approximately 20% input. The general public show varying relationships (all p < 0.05) for both first ACP discussion, and shared decision-making for five of six cognitive tests. However, for health professionals, only those who exhibit confirmation bias show differences (8.4% higher; p = 0.035) of patient’s input. Our framing experiment results show that positive versus negative framing can result in as much as 4.9–7.0% shift in preference for factors most relevant to ACP uptake.

Conclusion:

Understanding how GPs, nurses and patients perceive, engage and choose to communicate ACP and how specific groups, particular preferences or uniform behaviours, may be prone to cognitive bias in the decision process is of critical importance for increasing future uptake and efficient future healthcare provision.

Perception Bias Effects on Healthcare Management in COVID-19 Pandemic: An Application of Cumulative Prospect Theory

Coronavirus disease 2019 (COVID-19) has posed severe threats to human safety in the healthcare sector, particularly in residents in long-term care facilities (LTCFs) at a higher risk of morbidity and mortality. This study aims to draw on cumulative prospect theory (CPT) to develop a decision model to explore LTCF administrators’ risk perceptions and management decisions toward this pandemic. This study employed the policy Delphi method and survey data to examine managers’ perceptions and attitudes and explore the effects of sociodemographic characteristics on healthcare decisions. The findings show that participants exhibited risk aversion for small losses but became risk-neutral when considering devastating damages. LTCF managers exhibited perception bias that led to over- and under-estimation of the occurrence of infection risk. The contextual determinants, including LTCF type, scale, and strategy, simultaneously affect leaders’ risk perception toward consequences and probabilities. Specifically, cost-leadership facilities behave in a loss-averse way, whereas hybrid-strategy LTCFs appear biased in measuring probabilities. This study is the first research that proposes a CPT model to predict administrators’ risk perception under varying mixed gain–loss circumstances involving considerations of healthcare and society in the pandemic context. This study extends the application of CPT into organizational-level decisions. The results highlight that managers counteract their perception bias and subjective estimation to avoid inappropriate decisions in healthcare operations and risk governance for a future health emergency.

Association between participation in sports club activities and decision-making preferences in end-of-life treatment among Japanese elderly people:a cross-sectional study

Introduction:

Decision-making regarding treatment at the end-of-life stage is an important issue for the elderly and their families. Such decision-making may be influenced by activities that promote communication and physical health. The purpose of this study was to examine the association between participation in sports club activities and decision-making regarding life-prolonging treatment among the general community-dwelling Japanese elderly.

Methods:

In this cross-sectional study, which used stratified random sampling, 1,603 elderly people aged 65 years or older as of January 2016, living in Fukushima prefecture, Japan were enrolled. Data was collected by a self-completed questionnaire (effective response rate: 53.4%). The association of sports club activity participation with a preference for accepting or declining life-prolonging treatment was analyzed by multinomial logistic regression analysis.

Results:

Of those participating in sports club activities, the results revealed an odds ratios of 1.812 for participants declining life-prolonging treatment (95% CI=1.325 to 2.477) and 1.948 for those who preferred life-prolonging treatment (95% CI=1.160 to 3.271).

Conclusions:

The present study suggests that participation in sports club activities is associated with articulating decisions about life-prolonging treatment in end-of-life care. Consideration of patient involvement in daily activities in non-medical settings may enhance decision-making for end-of-life care planning.

Age and Life-Sustaining Treatment Preferences in Parkinson Disease

Objective

Advance Care Planning (ACP) is one of 10 key elements in the American Academy of Neurology Parkinson disease (PD) clinical practice quality measures. We know little about how aging influences ACP views in people with PD.

Methods

We conducted a cross-sectional survey of 39 participants (mean age 70.3 years; range: 52-81) with PD to explore correlations between older age and life-sustaining treatment preferences while controlling for confounders including years of education, Montreal Cognitive Assessment score and Movement Disorders Society Unified Parkinson's disease Rating Scale motor score. Scenarios asked participants to choose their level of interest in pursuing life-sustaining measures in the setting of specific medical illnesses including stroke, metastatic cancer, severe heart attack, and dementia. All participants were men and were recruited from the Veterans Affairs Ann Arbor Healthcare System.

Results

In the hypothetical stroke, metastatic colon cancer, and dementia scenarios, older age correlated with more aggressive care goals related to the use cardiopulmonary resuscitation to treat cardiopulmonary arrest.

Conclusions

Advancing age in PD may correlate with paradoxically more aggressive goals as it relates to life-sustaining treatment preferences including cardiopulmonary resuscitation. This may reflect a response to heightened concern among older adults with PD about the potential for compromised autonomy in the setting of aging.

The impact of nursing home residents' characteristics on ratings of importance of autonomy preferences in daily care over time

Objective: Nursing home (NH) residents' preferences for everyday living are the foundation for delivering individualized care. Yet, work has not examined the impact of demographic and clinical characteristics of NH residents on the stability of their preferences over time.Method: This study examined the rate of change in reports of importance of 27 autonomy-related everyday preferences from the Preferences for Everyday Living Inventory over 3-months and the demographic and clinical characteristics associated with change for nursing home residents (N = 255). Descriptive frequencies and tests of mean difference were utilized to examine differences between individuals reporting change in importance over time compared to those that did not report change.Results: Autonomy preferences in daily care remained stable over 3-months for the majority of residents. For residents that did report change on autonomy preferences, no systematic associations of demographic or clinical characteristics were found to be associated with change. Rather, change was associated with differential characteristics based on the preference.Conclusion: This study indicates that knowing a person's demographic or clinical characteristics in care will not uniformly inform a caretaker's understanding of the individual's reports of importance for autonomy related preferences over time. Future work should explore the role of care environment on change in preference ratings over time.

The development of an individual differences end-of-life treatment preferences scale

The purpose of this study was to create an individual differences measure of end-of-life treatment preferences (EOLTPs). Young adults (n = 427) and older adults (n = 333) completed a survey. Results found that hope of recovery was an important factor in whether individuals preferred a given medical intervention. A single factor explained the majority of the variance in EOLTPs, and EOLTPs were distinct from more general attitudes about medical care. Older adults preferred less end-of-life medical intervention compared to younger adults. Overall, the results of the study support the use of an individual differences approach to measuring EOLTPs.

Assessment of Patient and Caregiver Attitudes and Approaches to Decision-Making Regarding Bone Marrow Transplant for Sickle Cell Disease: A Qualitative Study

IMPORTANCE

Bone marrow transplant (BMT) is a potentially curative treatment for sickle cell disease (SCD). Patient and caregiver attitudes toward BMT for SCD and the willingness to accept risks of BMT vary, but these attitudes are not well understood.

OBJECTIVE

To understand patient and caregiver perceptions of and attitudes toward BMT for SCD and decision-making about BMT.

DESIGN, SETTING, AND PARTICIPANTS

Qualitative study of interview transcripts from a convenience sample. Transcripts were from adults with SCD and caregivers of patients with SCD recruited from national and regional SCD conferences, symposia, and sickle cell clinics in 2 cities. Interview transcripts were used from the needs assessment phase to develop a patient-decision aid in 2013 to 2014 (group 1) and from the baseline point in 2015 to 2016 (group 2) of the parent trial, a randomized clinical trial of adults and caregivers of patients with SCD to evaluate the effectiveness of a patient decision aid.

MAIN OUTCOMES AND MEASURES

Participant perspectives on decision-making regarding BMT for SCD.

RESULTS

Fifty-seven transcripts from adults with SCD and 50 transcripts from caregivers of patients with SCD were included. Median (interquartile range [IQR]) age of adults with SCD was 34 (21-50) years in group 1 and 30 (23-38) years in group 2. The median (IQR) age of caregivers was 42.5 (31-52) years in group 1 and 41 (35-46.5) years in group 2. Most transcripts from adults with SCD (75.0% in group 1 and 72.4% in group 2) and caregivers of patients with SCD (76.7% in group 1 and 85.0% in group 2) were from female participants. Bone marrow transplant was perceived as a treatment option associated with serious risks. Reported attitudes toward BMT occurred on a continuum ranging from unfavorable to favorable. Participants reported serious decisional dilemma regarding BMT for SCD. Most participants expressed interest in learning about BMT or curative treatments.

CONCLUSIONS AND RELEVANCE

This qualitative study found a continuum in attitudes toward BMT for SCD and highlights the complexity of decision-making in BMT for SCD. Patients and families with SCD expressed an interest in learning about BMT. Future prospective studies of patient decision-making regarding BMT, especially in the context of emerging curative and novel disease-modifying therapies for SCD, are warranted.

Patient Treatment Preferences for Heart Failure Medications: A Mixed Methods Study

INTRODUCTION

Consideration of patient preferences for guideline-directed medical therapies (GDMT) for heart failure with reduced ejection fraction (HFrEF) may help improve major gaps in prescribing and adherence. This study aimed to identify the range and relative priority of factors influencing patients' decisions to take HFrEF medications.

MATERIALS AND METHODS

This was a convergent mixed methods study of patients with HFrEF. Focus groups were conducted to identify a list of factors followed by individuals rating and ranking the influence of each factor on their decision to take a medication. Using thematic analysis, we summarized preferences into categories.

RESULTS

Two focus groups with 13 participants reported 22 factors. Of the factors, "keeping you alive" was most commonly ranked in the top three (seven participants), followed by "communication and understanding" (six participants). Factors were summarized into six categories (listed in order of patient-reported influence): 1) demonstrated improvements in quality of life and longevity, 2) decreased risk of hospitalization, 3) opportunity for shared decision-making and trust in provider, 4) absence of adverse events, 5) affordability, and 6) convenience of taking and absence of interference with daily life.

CONCLUSION

Patients prioritize treatment benefits and being informed more than risks, cost and inconvenience of taking HFrEF medications.

Reconsidering the minimally important difference: evidence of instability over time and across groups

BACKGROUND CONTEXT

Underlying cognitive factors have been found to influence patients' symptom experience. Current evidence suggests that concomitant changes in appraisal must be taken into account to accurately interpret change as measured by standard spine patient-reported outcomes (PROs).

PURPOSE

To investigate changes in patients' minimally important differences (MID) over recovery from spinal surgery; whether and how cognitive appraisal processes are implicated in the change trajectories.

STUDY DESIGN/SETTING

Longitudinal cohort study with up to 12 months follow-up.

PATIENT SAMPLE

Surgical patients (n = 167) with a diagnosis of disc herniation or spinal stenosis.

OUTCOME MEASURES

Standard spine patient-reported PROs were used (Rand-36, Oswestry Disability Index, Numerical Rating Scale for pain, PROMIS Pain Impact).

METHODS

This study was funded by the Feldberg Chair in Spinal Research, Sunnybrook Health Sciences Centre and the authors have no conflicts of interest. MID used an anchor technique and was computed by global assessment of change (GAC) grouping. Participants were binned into groups based on their GAC response patterns at all time points: Consistently better post-surgery, consistently worse post-surgery, and bouncers, whose GAC ratings fluctuate (ie, better-then-worse-then-better; or vice versa). Individuals' longitudinal quality of life (QOL) and appraisal slope scores were computed. QOL-appraisal slopes' correlations were computed by GAC group. Fisher's Z transformation tested the hypothesis that GAC groups differed in the QOL-appraisal relationship over time.

RESULTS

Moderate to large changes are recognized as clinically important in the early stages of recovery (ie, 6 weeks post-surgery), and over time smaller and smaller changes become important. The three pattern groups emphasized and deemphasized different standards of comparison over time, with the Better group emphasizing personal goals and the Worse and Bouncers deemphasizing doctors' input. These group differences translated to differential relationships between PRO change and appraisal changes over time.

CONCLUSIONS

The MID reflects increasingly subtle change over time in PROs. Appraisal may influence how patients experience the same (MID) change over time, with better outcomes associated with emphasizing long-term goals. PRO change seems to be driven by different standards of comparison. Potential avenues for clinical intervention are discussed.

Factors associated with requesting and receiving euthanasia: a nationwide mortality follow-back study with a focus on patients with psychiatric disorders, dementia, or an accumulation of health problems related to old age

BACKGROUND

Recently, euthanasia and assisted suicide (EAS) in patients with psychiatric disorders, dementia, or an accumulation of health problems has taken a prominent place in the public debate. However, limited is known about this practice. The purpose of this study was threefold: to estimate the frequency of requesting and receiving EAS among people with (also) a psychiatric disorder, dementia, or an accumulation of health problems; to explore reasons for physicians to grant or refuse a request; and to describe differences in characteristics, including the presence of psychiatric disorders, dementia, and accumulation of health problems, between patients who did and did not request EAS and between patients whose request was or was not granted.

METHODS

A nationwide cross-sectional survey study was performed. A stratified sample of death certificates of patients who died between 1 August and 1 December 2015 was drawn from the central death registry of Statistics Netherlands. Questionnaires were sent to the certifying physician (n = 9351, response 78%). Only deceased patients aged ≥ 17 years and who died a non-sudden death were included in the analyses (n = 5361).

RESULTS

The frequency of euthanasia requests among deceased people who died non-suddenly and with (also) a psychiatric disorder (11.4%), dementia (2.1%), or an accumulation of health problems (8.0%) varied. Factors positively associated with requesting euthanasia were age (< 80 years), ethnicity (Dutch/Western), cause of death (cancer), attending physician (general practitioner), and involvement of a pain specialist or psychiatrist. Cause of death (neurological disorders, another cause) and attending physician (general practitioner) were also positively associated with receiving euthanasia. Psychiatric disorders, dementia, and/or an accumulation of health problems were negatively associated with both requesting and receiving euthanasia.

CONCLUSIONS

EAS in deceased patients with psychiatric disorders, dementia, and/or an accumulation of health problems is relatively rare. Partly, this can be explained by the belief that the due care criteria cannot be met. Another explanation is that patients with these conditions are less likely to request EAS.

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.

Prospect Theory Concepts Applied to Family Members of Nursing Home Residents with Cancer: A Good Ending Is a Gain

Family members are often involved in medical decision-making on behalf of a nursing home resident. Prospect theory provides a framework for understanding how people weigh decisions. In the current study, prospect theory concepts are used to build understanding about how family members weigh medical decisions for an NH resident diagnosed with cancer. This is a secondary analysis of qualitative interview data from 24 family members of nursing home residents. Prospect theory concepts of gain, loss, risk, and reference point were used deductively in qualitative content analysis. Themes were developed by comparing content related to these four concepts, across the transcripts from the 24 participants. Three themes comprise the main findings, including "Don't prolong this," "A good ending is a gain," and "Experience can facilitate seeing the big picture." Prospect theory concepts applied to decisions faced by family members were useful in building an understanding of what participants considered as gains, losses, risks, and reference points. Many participants framed the medical decisions within the larger context of the resident's life and concluded that jeopardizing the chance for a peaceful dying process was too high a risk. Medical interventions were selected or avoided because of the impact on a comfortable dying process; considered a gain. Advance care planning discussions and goals of care discussions can benefit by directly addressing what residents/patients, families, and health practitioners consider outcomes worth pursuing and avoiding.

Patients' perceptions and ICU clinicians predictions of quality of life following critical illness

PURPOSE

To determine how patients perceive their quality of life (QOL) six months following critical illness and to measure clinicians' discriminative accuracy of predicting this outcome.

MATERIALS AND METHODS

This prospective cohort study of intensive care unit (ICU) survivors asked patients to report their QOL strictly at six months compared to one month before their critical illness as better, the same, or worse. ICU physicians and nurses made six-month QOL predictions for these patients.

RESULTS

Of 162 critical illness survivors, 33% (n = 53) of patients reported six-month QOL as better, 33% (n = 54) the same, and 34% (n = 55) worse. Abnormal cognition and inability to return to primary pastime or original place of residence (p < .05 for all) were associated with worse self-reported QOL at six months in multivariable regression. Predictions of patient perceptions of QOL at six months were pessimistic and had low discriminative accuracy for both physicians (sensitivity 56%, specificity 53%) and nurses (sensitivity 49%, specificity 57%).

CONCLUSIONS

Among survivors of critical illness, one-third each reported their six-month post-ICU QOL as better, the same, or worse. Self-reported six-month QOL was associated with six-month function. ICU clinicians should use caution in predicting self-reported QOL, as discriminative accuracy was poor in this cohort.

The Change in Nursing Home Residents' Preferences Over Time

OBJECTIVES

Nursing home (NH) residents' preferences for everyday living are the foundation for delivering individualized person-centered care. Yet, work has not examined what the most and least important preferences of nursing home residents are and if those preferences change over time.

DESIGN

This study examined the change in nursing home residents' (n = 255) preferences for everyday living over a 3-month period. Participants were recruited from 28 NHs in the suburbs of a major metropolitan East Coast area of the United States.

MEASURES

Residents were interviewed face-to-face using the Preferences for Everyday Living Inventory-Nursing Home version at baseline (T1) and 3 months later (T2). Change was analyzed in 2 ways: (1) percentage exact agreement (eg, respondent stated "very important" at both time points) and (2) percentage of preferences that remained either important or not important between T1 and T2.

RESULTS

Sixteen preferences were rated as very or somewhat important by 90% or more of NH residents. With regard to the stability of preference ratings, findings demonstrate an average exact agreement of 59%, and an average important versus not important agreement of 82%. In addition, 68 of the 72 preferences had 70% or higher stability over time. In other words, the preference either remained "important" or "not important" to the NH resident 3 months later. Preferences in the domain of enlisting others in care had the least amount of change.

CONCLUSION/IMPLICATIONS

This study highlights the most important everyday living preferences of NH residents and provides assurance to care providers that the majority of preferences assessed via the PELI are both important to NH residents and stable over time. Preference-based care plans can be designed and used over a 3-month period with confidence by providers.

Resuscitation status in psychogeriatric and general medical inpatients aged 65 years and older: a retrospective comparison study

Objective The aims of the present study were to establish rates of resuscitation order documentation of patients aged ≥65 years from both psychogeriatric and general medical units and to compare patients on predictors of resuscitation status, particularly examining the effect of depression. Methods A retrospective case note audit of psychogeriatric (n=162) and general medical (n=135) unit admissions within a tertiary teaching hospital was performed. Multivariate logistic regression was used to determine significant clinical and demographic predictors of resuscitation status. Results Resuscitation orders were documented in more psychogeriatric (94.4%) than general medical (48.1%) files. Depression did not significantly predict resuscitation status in either group. Having undergone competency assessment significantly predicted resuscitation status for the total sample and separately for psychogeriatric and medical patients. Older age (overall sample), poorer prognosis (overall sample), living in residential care (overall sample and medical group) and self-consenting to resuscitation status (overall sample and medical group) significantly predicted resuscitation status. Conclusions Resuscitation orders were more frequently documented on the psychogeriatric unit. Further prospective analysis is needed of how resuscitation orders are made before depression is discounted as a predictor of end-of-life decision-making. What is known about the topic? Despite increased community, media and research attention to end-of-life decision-making, resuscitation preferences of older patients are often poorly documented. Existing research into patient clinical and demographic factors that influence end-of-life decision-making have largely focused on general medical rather than psychogeriatric settings. There is a need to investigate rates of resuscitation documentation in psychogeriatric and general medical units and specific factors associated with having a 'do not attempt resuscitation' order in place, particularly the effect of current depression on decision-making. What does this paper add? Resuscitation orders were more frequently documented on the psychogeriatric than medical unit. Depression was not a significant predictor of resuscitation status in either group of patients. Although having undergone a competency assessment, older age and poorer prognosis predicted not being for resuscitation for the total sample, living in residential care and self-consenting to resuscitation status predicted not being for resuscitation for the overall sample and the medical group specifically. What are the implications for practitioners? This paper suggests that the need for clinicians to ensure documentation of preferences is a focus of day-to-day work with older patients. Clinicians should consider patient competency in end-of-life decision-making and how factors associated with depression, such as helplessness, may be more closely related to resuscitation decision-making in older patients.

Influences on Care Preferences of Older People with Advanced Illness: A Systematic Review and Thematic Synthesis

Objectives

To determine and explore the influences on care preferences of older people with advanced illness and integrate our results into a model to guide practice and research.

Design

Systematic review using Medline, Embase, PsychINFO, Web of Science, and OpenGrey databases from inception to February 2017 and reference and citation list searching. Included articles investigated influences on care preference using qualitative or quantitative methodology. Thematic synthesis of qualitative articles and narrative synthesis of quantitative articles were undertaken.

Setting

Hospital and community care settings.

Participants

Older adults with advanced illness, including people with specific illnesses and markers of advanced disease, populations identified as in the last year of life, or individuals receiving palliative care (N = 15,164).

Measurements

The QualSys criteria were used to assess study quality.

Results

Of 12,142 search results, 57 articles were included. Family and care context, illness, and individual factors interact to influence care preferences. Support from and burden on family and loved ones were prominent influences on care preferences. Mechanisms by which preferences are influenced include the process of trading‐off between competing priorities, making choices based on expected outcome, level of engagement, and individual ability to form and express preferences.

Conclusion

Family is particularly important as an influence on care preferences, which are influenced by complex interaction of family, individual, and illness factors. To support preferences, clinicians should consider older people with illnesses and their families together as a unit of care.

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.

Patient-reported Limitations to Surgical Buy-in: A Qualitative Study of Patients Facing High-risk Surgery

OBJECTIVE

To characterize how patients buy-in to treatments beyond the operating room and what limits they would place on additional life-supporting treatments.

BACKGROUND

During a high-risk operation, surgeons generally assume that patients buy-in to life-supporting interventions that might be necessary postoperatively. How patients understand this agreement and their willingness to participate in additional treatment is unknown.

METHODS

We purposively sampled surgeons in Toronto, Ontario, Boston, Massachusetts, and Madison, Wisconsin, who are good communicators and routinely perform high-risk operations. We audio-recorded their conversations with patients considering high-risk surgery. For patients who were then scheduled for surgery, we performed open-ended preoperative and postoperative interviews. We used directed qualitative content analysis to analyze the interviews and surgeon visits, specifically evaluating the content about the use of postoperative life support.

RESULTS

We recorded 43 patients' conversations with surgeons, 34 preoperative, and 27 postoperative interviews. Patients expressed trust in their surgeon to make decisions about additional treatments if a serious complication occurred, yet expressed a preference for significant treatment limitations that were not discussed with their surgeon preoperatively. Patients valued the existence or creation of an advance directive preoperatively, but they did not discuss this directive with their surgeon. Instead they assumed it would be effective if needed and that family members knew their wishes.

CONCLUSIONS

Patients implicitly trust their surgeons to treat postoperative complications as they arise. Although patients may buy-in to some additional postoperative interventions, they hold a broad range of preferences for treatment limitations that were not discussed with the surgeon preoperatively.

Sense of Control in End-of-Life Decision-Making

OBJECTIVES

To explore how older adults in the community with a limited life expectancy make healthcare decisions and the processes used when they are not in an acute crisis.

DESIGN

Grounded theory.

SETTING

Medical programs and geriatrics clinics at the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center.

PARTICIPANTS

Community-dwelling adults aged 67 to 98 with a life expectancy of less than 1 year (N = 20).

MEASUREMENTS

In-depth semistructured interviews in participants' homes. Constant comparative analysis was used to develop codes and identify themes.

RESULTS

Participants generally delegated decisions to others, expressing their wishes by describing desired end-of-life outcomes and highlighting meaningful aspects of their lives. They did this in the belief that the delegate would make appropriate decisions on their behalf. In this way, participants were able to achieve a sense of control without being in control of decisions. Four themes emerged from the analysis that reflect the various approaches participants used to articulate their goals and maintain a sense of control: direct communication, third-party analogies, adaptive denial, and engaged avoidance.

CONCLUSION

These findings challenge the prevailing view of personal autonomy. These older adults suggest a path to decision-making that focuses on priorities and goals, allowing them to take a more-passive approach to decision-making while still maintaining a sense of control.

A comparison of attitudes toward length and quality of life between community-dwelling older adults and patients with advanced cancer

OBJECTIVE

Applying prospect theory to end-of-life decision making, we hypothesize that community-dwelling older adults (CDOAs) will be relatively less inclined towards extending length over improving quality of life compared with patients. We also hypothesize that differences in relative inclination for length over quality of life between the 2 groups will decrease with advancing age.

METHODS

We tested these hypotheses by administering the quality-quantity questionnaire to 1067 CDOAs and 320 stage IV cancer patients and applying a linear regression model to assess whether relative inclination for length over quality of life, as estimated by the questionnaire, differed between CDOAs and patients after controlling for differences in sociodemographic characteristics. We also assessed the effect of interaction between age and participant status (CDOA compared to patient) on relative inclination for length over quality of life.

RESULTS

Consistent with prospect theory, a lower proportion of CDOAs (26%) than patients (42%) were relatively more inclined towards length over quality of life. Results were significant even after adjusting for differences in sociodemographics (P < .01). With increasing age, the difference in relative inclination between CDOAs and patients increased (P = .01).

CONCLUSIONS

Findings indicate that attitudes towards length and quality of life differ by life stage. This has implications for end-of-life care decisions made by CDOAs, such as purchasing health or disability insurance and signing advance directives or care plans.

Considering the CPR Decision Through the Lens of Prospect Theory in the Context of Advanced Chronic Illness

It is common for people with advanced chronic illness to have many health care providers and many health care-related visits. It is also common, during those visits, to be asked whether attempts at cardiopulmonary resuscitation (CPR) are desired, in the event of cardiac arrest. Although the question is common, the implications of a "yes" or a "no" may not be well understood. Although CPR can be a life-saving procedure, it is not always in the patient's best interest. This article discusses experiences with CPR of 2 older women (and their adult children) during their last years of life, and uses concepts from prospect theory to make suggestions for changes in the way health care providers and patients approach advance care planning including the CPR decision.

The Influence of Hypothetical Death Scenarios on Multidimensional End-of-Life Care Preferences

Background:

Differences in end-of-life (EOL) care preferences (eg, location of death, use of life-sustaining treatments, openness to hastening death, etc) based on hypothetical death scenarios and associated physical and/or cognitive losses have yet to be investigated within the palliative care literature.

Aim:

The purpose of this study was to explore the multidimensional EOL care preferences in relation to 3 different hypothetical death scenarios: pancreatic cancer (acute death), Alzheimer disease (gradual death), and congestive heart failure (intermittent death).

Design:

General linear mixed-effects regression models estimated whether multidimensional EOL preferences differed under each of the hypothetical death scenarios; all models controlled for personal experience and familiarity with the disease, presence of an advance directive, religiosity, health-related quality of life, and relevant demographic characteristics.

Setting/Participants:

A national sample of healthy adults aged 50 years and older (N = 517) completed electronic surveys detailing their multidimensional preferences for EOL care for each hypothetical death scenario.

Results:

The average age of the participants was 60.1 years (standard deviation = 7.6), 74.7% were female, and 66.1% had a college or postgraduate degree. Results revealed significant differences in multidimensional care preferences between hypothetical death scenarios related to preferences for location of death (ie, home vs medical facility) and preferences for life-prolonging treatment options. Significant covariates of participants’ multidimensional EOL care preferences included age, sex, health-related quality of life, and religiosity.

Conclusion:

Our hypothesis that multidimensional EOL care preferences would differ based on hypothetical death scenarios was partially supported and suggests the need for disease-specific EOL care discussions.

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.

Decision Making Among Older Adults at the End of Life: A Theoretical Perspective

Understanding changes in decision making among older adults across time is important for health care providers. We examined how older adults with a limited prognosis used their perception of prognosis and health in their decision-making processes and related these findings to prospect theory. The theme of decision making in the context of ambiguity emerged, reflecting how participants used both prognosis and health to value choices, a behavior not fully captured by prospect theory. We propose an extension of the theory that can be used to better visualize decision making at this unique time of life among older adults.

Care Consistency With Documented Care Preferences: Methodologic Considerations for Implementing the "Measuring What Matters" Quality Indicator

A basic tenet of palliative care is discerning patient treatment preferences and then honoring these preferences, reflected by the inclusion of "Care Consistency With Documented Care Preferences" as one of 10 "Measuring What Matters quality" indicators. Measuring What Matters indicators are intended to serve as a foundation for quality measurement in health care settings. However, there are a number of logistic and practical issues to be considered in the application of this quality indicator to clinical practice. In this brief methodologic report, we describe how care consistency with documented care preferences has been measured in research on patients near the end of life. Furthermore, we outline methodologic challenges in using this indicator in both research and practice, such as documentation, specificity and relevance, preference stability, and measuring nonevents. Recommendations to strengthen the accuracy of measurement of this important quality marker in health care settings include consistent recording of preferences in the medical record, considerations for selection of treatment preferences for tracking, establishing a protocol for review of preferences, and adoption of a consistent measurement approach.

Constructing High-stakes Surgical Decisions: It's Better to Die Trying

OBJECTIVE

To explore high-stakes surgical decision making from the perspective of seniors and surgeons.

BACKGROUND

A majority of older chronically ill patients would decline a low-risk procedure if the outcome was severe functional impairment. However, 25% of Medicare beneficiaries have surgery in their last 3 months of life, which may be inconsistent with their preferences. How patients make decisions to have surgery may contribute to this problem of unwanted care.

METHODS

We convened 4 focus groups at senior centers and 2 groups of surgeons in Madison and Milwaukee, Wisconsin, where we showed a video about a decision regarding a choice between surgery and palliative care. We used qualitative content analysis to identify themes about communication and explanatory models for end-of-life treatment decisions.

RESULTS

Seniors (n = 37) and surgeons (n = 17) agreed that maximizing quality of life should guide treatment decisions for older patients. However, when faced with an acute choice between surgery and palliative care, seniors viewed this either as a choice between life and death or a decision about how to die. Although surgeons agreed that very frail patients should not have surgery, they held conflicting views about presenting treatment options.

CONCLUSIONS

Seniors and surgeons highly value quality of life, but this notion is difficult to incorporate in acute surgical decisions. Some seniors use these values to consider a choice between surgery and palliative care, whereas others view this as a simple choice between life and death. Surgeons acknowledge challenges framing decisions and describe a clinical momentum that promotes surgical intervention.

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.

Depression of Family Caregivers Is Associated with Disagreements on Life-Sustaining Preferences for Treating Patients with Dementia

Background

Family caregivers may not agree with patients with dementia regarding attitudes toward end-of-life preferences, and the effects of this type of disagreement are not well understood. This study sought to identify such a disagreement and its predictors.

Methods

A cross-sectional sample of 84 family caregivers and patients with dementia was recruited from memory clinics. We used the Mini-Mental State Examination, Neuropsychiatric Inventory, Clinical Dementia Rating, and Katz index of independence in activities of daily living to assess patient symptoms, functions, and severity of dementia. Caregivers completed questionnaires on perceived patient end-of-life care preferences, caregiver end-of-life care preferences for patients, Zarit Burden Interview (ZBI), Center for Epidemiological Studies–Depression Scale (CES-D), and knowledge of clinical complications of advanced dementia.

Results

The self-disclosure rates of patient preferences were 34.5% for tube feeding, 39.3% for cardiopulmonary resuscitation, and 45.2% for mechanical ventilation. For patients who had disclosed preferences, the disagreement rate between them and their caregivers was 48.3% for tube feeding, 48.5% for cardiopulmonary resuscitation, and 60.3% for mechanical ventilation. Caregiver depression (i.e., CES-D ≥16) was associated with disagreements on cardiopulmonary resuscitation (adjusted odds ratio (aOR) = 6.6, 95% CI = 1.4–31.1, P = 0.01) and mechanical ventilation (aOR = 14, 95% CI = 2.2–87.2, P = 0.005) preferences.

Conclusion

The preferences of end-of-life issues differed greatly between dementia patients and their caregivers. Depression in caregivers is associated with such discrepancy.

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.

Framing Effects on End-of-Life Preferences Among Latino Elders

This study compared how the presentation of end-of-life (EOL) choices influences responses by Latino and White older adults relative to resuscitation preferences. The authors apply prospect theory, which deals with decision making based on how choices are framed. Participants were presented with differently ordered questions framing a resuscitation scenario and asked to rate their preferences. Results show that Latino participants were significantly influenced by the framing order of treatment options with regard to resuscitation while Whites were not. Health professionals need to be aware that the ways they present EOL options are likely to affect the choices of Latino older adults. Further research is needed with Latino subgroups.

The consistency of self-reported preferences for everyday living: implications for person-centered care delivery

Preferences are the expression of an individual's basic psychosocial needs and are related to care outcomes. The current study tested the consistency of 87 individuals' everyday preferences over 1 week, comparing responses of nursing home residents (n = 37; mean age = 82) and university students (n = 50; mean age = 20). Participants completed the Preferences for Everyday Living Inventory at baseline and 5 to 7 days later. Preference consistency was calculated three ways: (a) correlations (range = 0.11 to 0.90); (b) overall percent of exact agreement (e.g., response was "very important" at both time points) (66.1%); and (c) responses collapsed as "important" or "not important" (increase in percent agreement to 86.6%). Personal care preferences were more stable, whereas leisure activities were less stable. The groups did not have significant differences in consistency. Some preferences are more consistent than others; age and frailty do not appear to be related to preference instability.

"It Depends": Reasons Why Nursing Home Residents Change Their Minds About Care Preferences

PURPOSE OF THE STUDY

Understanding and honoring preferences are fundamental in the promotion of well-being for frail elders. This study aims to understand and describe nursing home residents' perspectives on why the importance of their preferences may change in daily care.

DESIGN AND METHODS

Secondary data analyses of cognitive interviews with 39 cognitively capable nursing home residents regarding their importance of preferences for everyday living were completed. Interviews were coded by 5 team members for reasons why residents may change their minds about the importance of their preferences or why their preferences may be restricted; discrepancies were reconciled through consensus.

RESULTS

Content analysis revealed 4 major domains: within person (e.g., functional ability, personal schedule), facility environment (e.g., facility schedule, facility policy), social environment (e.g., quality and type of interactions), and global environment (e.g., weather, current events, special occasions). Residents reflected that the importance of their preferences fluctuated "depending upon" the circumstances related to these factors or their ability to perform the preference (i.e., barriers they encountered). A total of 27 themes for dependencies and barriers were identified.

IMPLICATIONS

Findings indicate that nursing home residents' preferences may change in importance or fulfillment in relation to personal or environmental circumstances. In order to develop formal care that matches older adults' preferences, regular assessment of both elders' preferences and the contextual factors affecting preferences is needed. However, given the changing nature of preference importance, there is also a need to determine how to best balance older adults' changing preferences within care delivery environments.

Decision-making styles of seriously ill male Veterans for end-of-life care: Autonomists, Altruists, Authorizers, Absolute Trusters, and Avoiders

OBJECTIVE

To describe self-reported decision-making styles and associated pathways through end-of-life (EOL) decision-making for African-American, Caucasian, and Hispanic seriously ill male Veterans, and to examine potential relationships of race/ethnicity on these styles.

METHODS

Forty-four African American, White, and Hispanic male Veterans with advanced serious illnesses participated in 8 racially/ethnically homogenous focus groups. Transcripts were qualitatively analyzed to identify major themes, with particular attention to themes that might be unique to each of the racial/ethnic groups.

RESULTS

Patients described two main decision-making styles, deciding for oneself and letting others decide, leading to five variants that we labeled Autonomists, Altruists, Authorizers, Absolute Trusters, and Avoiders. These variants, with exception of avoiders (not found among White patients), were found across all racial/ethnic groups. The variants suggested different 'implementation strategies', i.e., how clear patients made decisions and whether or not they then effectively communicated them.

CONCLUSION

These identified decision-making styles and variants generate strategies for clinicians to better address individualized advance care planning.

PRACTICE IMPLICATIONS

Physicians should elicit seriously ill patients' decision-making styles and consider potential implementation strategies these styles may generate, thus tailoring individualized recommendations to assist patients in their advance care planning. Patient-centered EOL decision-making can ensure that patient preferences are upheld.

Vouchers versus Lotteries: What works best in promoting Chlamydia screening? A cluster randomised controlled trial

In this cluster randomised trial (N=1060), we tested the impact of financial incentives (£5 voucher vs. £200 lottery) framed as a gain or loss to promote Chlamydia screening in students aged 18-24 years, mimicking the standard outreach approach to student in halls of residence. Compared to the control group (1.5%), the lottery increased screening to 2.8% and the voucher increased screening to 22.8%. Incentives framed as gains were marginally more effective (10.5%) that loss-framed incentives (7.1%). This work fundamentally contributes to the literature by testing the predictive validity of Prospect Theory to change health behaviour in the field.

Long-term health investment when people underestimate their adaptation to old age-related health problems

This paper explores in a two-period model the economic implications of people's tendency to underestimate their ability to adapt to age-related health problems. We model this misperception by assuming that the individual underestimates his future subjective health. Under standard assumptions, we show that, when people allocate their resources during their youth between present consumption, savings, and health investment, they invest more in health as long as the magnitude of the cross-marginal utility of health and consumption is not too negative.

Factors that affect decisions to receive (or not receive) life-sustaining treatment in advance care planning

This study identifies factors that affect decisions people make regarding whether they want to receive life-sustaining treatment. It is an interpretive-descriptive study based on qualitative data from three focus groups (N = 23), representing a diverse population in central Pennsylvania. Study sites included a suburban senior center serving a primarily White, middle-class population; an urban senior center serving a frail, underserved, African American population; and a breast cancer support group. The most important factors affecting whether participants wished to receive life-sustaining medical treatment were prognosis, expected quality of life, burden to others, burden to oneself in terms of the medical condition and treatment, and effect on mental functioning and independence. Our findings contribute to the knowledge of the complex factors that influence how people make decisions about advance care planning and life-sustaining treatments. This understanding is critical if nurses are to translate the patient's goals, values, and preferences into an actionable medical plan.

Patient values and preferences for end-of-life treatments: are values better predictors than a living will?

BACKGROUND

Advance care planning is widely considered important for good treatment decision making. Patient values have been proposed as superior to standard living wills as guides to end-of-life (EOL) care decisions on behalf of decisionally incapacitated patients. Little research has examined whether values outperform living wills as predictors of treatment preferences.

OBJECTIVE

The study aimed to test whether patient values are associated with treatment preferences, compare values and preferences to responses from a standard living will, and determine whether some values are better predictors than others.

DESIGN

Community-dwelling elderly men and women (n=304) were interviewed in their homes by telephone. The interview consisted of an eight-item EOL values scale, a standard living will question, preferences for four life-prolonging treatments in each of six scenarios, and sociodemographic questions.

RESULTS

Principal components analysis of the EOL values revealed two factors: (1) dignity, pain management, and reluctance to burden others; and (2) religiosity and desire for longevity and following family wishes. In regression analyses, stronger preferences for life-prolonging treatments were correlated with higher scores on factor 1 and lower scores on factor 2. But when living will responses were also entered into the regression model, only religiosity, longevity, and following family wishes predicted treatment preferences independently of the living will responses.

CONCLUSIONS

Providing better guidance than a living will in determining a patient's EOL treatment preferences are (1) knowledge about a patient's religiosity, (2) patient's wishes for longevity, and (3) patient's wishes for following family preferences. Wishes for dignity and pain management and reluctance to burden others do not offer better guidance than a living will.

Persistent problems in end-of-life planning among young- and middle-aged American couples

OBJECTIVES

Guided by the transtheoretical model of health behavior change, this study sought to explain why (a) rates of advance care planning remain low in the general population and (b) surrogate decision makers are often inaccurate about patients' end-of-life preferences.

METHODS

The study used quantitative data from a cross-sectional internet survey conducted between July and October 2010. The 2,150 participants aged 18-64 belonged to 1,075 married or cohabiting heterosexual couples. Participants included members of a nationally representative internet panel and a convenience sample from online advertisements.

RESULTS

Older age was associated with a greater likelihood of having executed a living will and/or appointed a durable power of attorney for health care. Both older age and poorer health were independently associated with a greater likelihood of having discussed end-of-life health care treatment preferences. Completion of one's own end-of-life planning was unrelated to one's ability to accurately report one's partner's treatment preferences.

DISCUSSION

Readiness to plan for end of life appears to differ across planning behaviors. Age and health are related to aspects of one's own advance care planning, but none of these factors are related to accuracy as a partner's surrogate.

Elders' preferences for life-prolonging treatment and their proxies' substituted judgment: influence of the elders' current health

OBJECTIVE

People in poor health tend to view life-prolonging treatments (e.g., tube feeding) as more acceptable than do healthier people. Do proxies' substituted judgments reveal a similar tendency, showing greater acceptance when the elder is in worse health?

METHOD

In a cross-sectional telephone-based survey of 202 elderly individuals and their proxies, preferences for 4 life-prolonging treatments in 7 health prospects were examined in relation to the elder's current health status, operationalized as number of deficits in activities of daily living.

RESULTS

Stronger preferences for life-prolonging treatments in worse-health prospects were expressed by both elders and proxies when the elders' current health was relatively poor. The interaction effect was at least as pronounced for proxies' substituted judgment as for elders' own preferences.

DISCUSSION

Findings provide important insight into proxy decision making and have particular implications for proxy decision making on behalf of elders with dementia or other causes of decisional incapacity.