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Hughes MC, Vernon E, Egwuonwu C, Afolabi O. Measuring decision aid effectiveness for end-of-life care: A systematic review. PEC INNOVATION 2024; 4:100273. [PMID: 38525314 PMCID: PMC10957449 DOI: 10.1016/j.pecinn.2024.100273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/26/2024] [Accepted: 03/11/2024] [Indexed: 03/26/2024]
Abstract
Objective To systematically review research analyzing the effectiveness of decision aids for end-of-life care, including how researchers specifically measure decision aid success. Methods We conducted a systematic review synthesizing quantitative, qualitative, and mixed-methods study results using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Four databases were searched through February 18, 2023. Inclusion criteria required articles to evaluate end-of-life care decision aids. The review is registered under PROSPERO (#CRD42023408449). Results A total of 715 articles were initially identified, with 43 meeting the inclusion criteria. Outcome measures identified included decisional conflict, less aggressive care desired, knowledge improvements, communication improvements, tool satisfaction, patient anxiety and well-being, and less aggressive care action completed. The majority of studies reported positive outcomes especially when the decision aid development included International Patient Decision Aid Standards. Conclusion Research examining end of life care decision aid use consistently reports positive outcomes. Innovation This review presents data that can guide the next generation of decision aids for end-of-life care, namely using the International Patient Decision Aid Standards in developing tools and showing which tools are effective for helping to prevent the unnecessary suffering that can result when patients' dying preferences are unknown.
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Affiliation(s)
- M. Courtney Hughes
- School of Health Studies, Northern Illinois University, Wirtz Hall 209, DeKalb, IL 60115, USA
| | - Erin Vernon
- Department of Economics, Seattle University, Pigott 522, Seattle, WA 98122, USA
| | - Chinenye Egwuonwu
- School of Health Studies, Northern Illinois University, Wirtz Hall 209, DeKalb, IL 60115, USA
| | - Oluwatoyosi Afolabi
- School of Health Studies, Northern Illinois University, Wirtz Hall 209, DeKalb, IL 60115, USA
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Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, Pacheco-Brousseau L, Finderup J, Gunderson J, Barry MJ, Bennett CL, Bravo P, Steffensen K, Gogovor A, Graham ID, Kelly SE, Légaré F, Sondergaard H, Thomson R, Trenaman L, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2024; 1:CD001431. [PMID: 38284415 PMCID: PMC10823577 DOI: 10.1002/14651858.cd001431.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Meg Carley
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robert Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisa E Douglas
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J Barry
- Informed Medical Decisions Program, Massachusetts General Hospital, Boston, MA, USA
| | - Carol L Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paulina Bravo
- Education and Cancer Prevention, Fundación Arturo López Pérez, Santiago, Chile
| | - Karina Steffensen
- Center for Shared Decision Making, IRS - Lillebælt Hospital, Vejle, Denmark
| | - Amédé Gogovor
- VITAM - Centre de recherche en santé durable, Université Laval, Quebec, Canada
| | - Ian D Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | | | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Logan Trenaman
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Momiyama S, Kakeya K, Dannoue H, Yanagi H. A Survey of Emergency Nurses' Perceptions and Practices to Support Patients' Families as Surrogate Decision Makers. J Emerg Nurs 2023; 49:899-911. [PMID: 37690019 DOI: 10.1016/j.jen.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 06/21/2023] [Accepted: 08/01/2023] [Indexed: 09/11/2023]
Abstract
INTRODUCTION Family members acting as surrogate decision makers for severely ill patients in emergency and critical care centers face psychological burdens. This study aimed to investigate the actual situation of emergency nurses' perceptions and practices to support patients' families and its structural elements. METHODS We created an original 25-item questionnaire and surveyed 164 emergency nurses from 64 emergency and critical care centers regarding their perceptions of caring for people making surrogate decisions. Participants averaged 35.6 years old and 5.1 years as emergency nurses. RESULTS Cronbach's α coefficients for importance and practice on the original questionnaire were 0.936 and 0.933, respectively. We identified 4 elements of necessary support for patient families making surrogate decisions according to emergency nurses: "collaboration in understanding the condition of the patient as well as empathetic support," "care that addresses the needs of patient's family members," "confirming the role of nurses and surrogate decision making," and "participation in meeting with a doctor and patient families." In addition, we identified 5 elements that indicate the current state of practice: "support from specialists such as nurses and other professionals," "compassionate care for family members and those who are providing support to family members," "empathetic support for family members," "support for making arrangements that address the needs of family members," and "considerations for family members." DISCUSSION According to the findings of this study, emergency nurses should coordinate with other professionals and talk with family members and physicians to increase their understanding of the need to assist in surrogate decision making. In addition, emergency nurses also need to explain to patients' relatives how to support them in surrogate decision making.
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Kunzler BR, Smith TJ, Levi BH, Green MJ, Badzek L, Katsaros MG, Van Scoy LJ. The Value of Advance Care Planning for Spokespersons of Patients With Advanced Illness. J Pain Symptom Manage 2023; 65:471-478.e4. [PMID: 36690164 DOI: 10.1016/j.jpainsymman.2022.12.143] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/22/2022] [Accepted: 12/27/2022] [Indexed: 01/21/2023]
Abstract
CONTEXT Advance Care Planning (ACP) has fallen under scrutiny primarily because research has not consistently demonstrated patient-focused benefits. OBJECTIVES To better understand how spokespersons regard, engage with, and find value in ACP during decision-making for their loved ones. METHODS This qualitative analysis was part of a randomized controlled trial involving spokespersons of patients with advanced illness who had completed ACP. After making a medical decision on behalf of their loved one (or that loved one's death), semi-structured interviews explored spokespersons' experience of decision-making and if (and how) ACP played a role. Thematic analysis was conducted on interview transcripts. RESULTS From 120 interviews, five themes emerged: 1) Written advance directives (ADs) helped increase spokespersons' confidence that decisions were aligned with patient wishes (serving as a physical reminder of previous discussions and increasing clarity during decision-making and family conflict); 2) Iterative discussions involving ACP facilitated "In the moment" decision-making; 3) ADs and ACP conversations helped spokespersons feel more prepared for future decisions; 4) Spokespersons sometimes felt there was "no choice" regarding their loved one's medical care; and 5) Regrets and second-guessing were the most common negative emotions experienced by spokespersons. CONCLUSION Considering the recent debate about the utility of ACP and ADs, this analysis highlights the value of ACP for spokespersons involved in surrogate decision-making. Reframing the goals of ACP in terms of their benefit for spokespersons (and identifying appropriate outcome measures) may provide additional perspective on the utility of ACP.
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Affiliation(s)
| | - Theresa J Smith
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA
| | - Benjamin H Levi
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Pediatrics, Penn State College of Medicine (B.H.L.), Hershey, PA, USA
| | - Michael J Green
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Medicine, Penn State College of Medicine (M.J.G, L.J.V.S.), Hershey, PA, USA
| | - Laurie Badzek
- Penn State Ross and Carol Nese College of Nursing (L.B.), University Park, PA, USA
| | - Maria G Katsaros
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA
| | - Lauren J Van Scoy
- Department of Humanities, Penn State College of Medicine (T.J.S., B.H.L, M.J.G., M.G.K., L.J.V.S), Hershey, PA, USA; Department of Medicine, Penn State College of Medicine (M.J.G, L.J.V.S.), Hershey, PA, USA; Department of Public Health Sciences, Penn State College of Medicine (L.J.V.S.), Hershey, PA, USA.
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Van Scoy LJ, Bliton CF, Smith T, Badzek L, Green MJ, Levi BH, Foy AJ. Intrinsic Traits Such as Personality and Decision-Making Style are Predictive of Stress in Surrogate Decision-Makers. Am J Hosp Palliat Care 2022:10499091221135594. [PMID: 36266775 DOI: 10.1177/10499091221135594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Despite its prominence in psychology, little is known about how personality traits play a role in the stress experiences of surrogate decision-makers. We tested the hypothesis that intrinsic traits (personality and decision-making styles) would be related to surrogates' stress in order to learn whether screening or tailoring interventions based on personality traits could help support surrogate decision-makers. Methods: This pre-specified secondary analysis evaluated data from an interventional study with dyads of patients with advanced chronic illness and their spokespersons. Measures included stress after decision-making or patient death (Impact of Events-Revised), personality (Big Five Index; BFI) and decision-making style (maximization and regret scales). Multivariate linear regressions explored the impact of personality on the stress experience; linear regressions independently modeled the impact of maximization and regret on the stress experience. Results: Of 38 spokespersons, 89.5% were women, 97.4% non-Hispanic, and 29.0% had a college degree or higher. In univariate analyses, total stress was correlated with neuroticism (r = .56, P < .01), higher scores on the regret (r = .55, P < .01) and maximization (r = .48, P < .05). In adjusted models, BFI was significantly associated with total stress (R2 = 27.08, P = .02). However, only neuroticism was independently associated with total stress. Conclusions: Personality traits, particularly neuroticism, and decision-making styles predicted heightened stress in spokespersons of patients with advanced chronic illness. If ACP interventions are intended to reduce spokesperson stress, personality and decision-making style scales may help identify spokespersons most likely to benefit from ACP interventions.
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Affiliation(s)
- Lauren J Van Scoy
- Departments of Medicine, 12310Penn State College of Medicine, Hershey, PA, USA.,Department of Humanities, 12310Penn State College of Medicine, Hershey, PA, USA.,Department of Public Health Sciences, 12310Penn State College of Medicine, Hershey, PA, USA
| | - Chloe F Bliton
- Department of Psychology, Pennsylvania State University, State College, PA, USA
| | - Theresa Smith
- Department of Humanities, 12310Penn State College of Medicine, Hershey, PA, USA
| | - Laurie Badzek
- 15965Penn State Ross and Carol Nese College of Nursing, University Park, PA, USA
| | - Michael J Green
- Departments of Medicine, 12310Penn State College of Medicine, Hershey, PA, USA.,Department of Humanities, 12310Penn State College of Medicine, Hershey, PA, USA
| | - Benjamin H Levi
- Department of Humanities, 12310Penn State College of Medicine, Hershey, PA, USA.,Department of Pediatrics, 12310Penn State College of Medicine, Hershey, PA, USA
| | - Andrew J Foy
- Departments of Medicine, 12310Penn State College of Medicine, Hershey, PA, USA
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Martins CS, Sousa I, Barros C, Pires A, Castro L, da Costa Santos C, Nunes R. Do surrogates predict patient preferences more accurately after a physician-led discussion about advance directives? A randomized controlled trial. BMC Palliat Care 2022; 21:122. [PMID: 35820845 PMCID: PMC9277787 DOI: 10.1186/s12904-022-01013-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/28/2022] [Indexed: 12/03/2022] Open
Abstract
Background Caregivers frequently assume the role of surrogate decision-makers but often are unable to accurately predict patients’ preferences. This trial aims to find if the use of the Advance Directives documents as a communication tool, improves the agreement between patients and caregivers. Methods This trial occurred in a palliative care service of a Portuguese hospital center. A prospective, single-blinded, controlled, randomized trial, enrolling patients and caregivers as a dyad was conducted. Participants individually fulfilled an Advance Directive document, in which patients reported their end-of-life preferences and caregivers reported their decisions as patients’ health surrogates. Dyads were randomly assigned to the Intervention or the Control group, in which the physician respectively promoted an open discussion about patients’ Advance Directives or evaluated patients’ clinical condition. Caregivers’ Advance Directives as surrogates were collected one month later. Proportions of agreement and Cohen’s κ were used to access agreement and reliability, respectively, between the dyads. Results Results from 58 dyads were analyzed. We observed an improvement in agreement between the caregivers’ answers and the patients’ wishes on two-thirds (8/12) of the answers, in the Intervention group, contrasting to one-quarter (3/12) of the answers, in the Control group, despite statistical significance in differences wasn´t obtained. Conclusions Although not reaching statistical significance, the results suggest that discussions of advance directives with physicians may lead to better prepared surrogates. Trial registration ClinicalTrials.gov ID NCT05090072. Retrospectively registered on 22/10/2021.
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Affiliation(s)
- Catarina Sampaio Martins
- Palliative Medicine Service of Centro Hospitalar de Tràs-Os-Montes E Alto Douro, 5000-508, Vila Real, Portugal.
| | - Iva Sousa
- Palliative Medicine Service of Centro Hospitalar de Tràs-Os-Montes E Alto Douro, 5000-508, Vila Real, Portugal
| | - Cláudia Barros
- Palliative Medicine Service of Centro Hospitalar de Tràs-Os-Montes E Alto Douro, 5000-508, Vila Real, Portugal
| | - Alexandra Pires
- Palliative Medicine Service of Centro Hospitalar de Tràs-Os-Montes E Alto Douro, 5000-508, Vila Real, Portugal
| | - Luisa Castro
- MEDCIDS-Department of Community Medicine, Information and Decision in Health, University of Porto, 4200-450, Porto, Portugal.,CINTESIS-Center for Health Technology and Services Research, 4200-450, Porto, Portugal.,School of Health of the Polytechnic of Porto, 4200-450, Porto, Portugal
| | - Cristina da Costa Santos
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, MEDCIDS, University of Porto, Rua Dr. Plácido da Costa, 4200-319, Porto, Portugal.,Faculty of Medicine, CINTESIS, Centre for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Rui Nunes
- Faculty of Medicine, MEDCIDS-Department of Community Medicine, Information and Decision in Health, University of Porto, 4200-450, Porto, Portugal
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Liu X, Chen H, Zhang L, Zhang Q, Feng T, Liu D. Advance Care Planning Engagement Among Family Members of Community-Dwelling Elderly Patients With Chronic Diseases in China: A Mixed-Methods Study. J Hosp Palliat Nurs 2022; 24:E26-E34. [PMID: 35045050 DOI: 10.1097/njh.0000000000000829] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In China, traditional culture advocates family consensus, and the advance care planning (ACP) engagement of family members is crucial to the implementation of ACP. However, there is still a lack of research on family members' engagement in ACP in mainland China. This study investigated the ACP engagement of family members of community-dwelling elderly patients with chronic diseases and provided evidence for further ACP intervention research. We conducted a mixed-methods sequential explanatory study, 273 family members were surveyed, and semistructured interviews were conducted. Following that, 12 family members were selected after statistical analysis to supplement the quantitative results. The results showed that the ACP engagement of family members of elderly patients with chronic diseases in the community was low, but the self-efficacy was higher. The age of family members, severity, and duration of patients' diseases were the main influencing factors for family members' ACP engagement. Traditional cultural, clinical decision-making mode, lack of understanding of ACP, and factors within the family may impede family members' engagement. This study showed that family-centered ACP practice has significant advantages in China and that future research should focus on the Chinese culture and medical system and highlight the role of families.
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Bakke BM, Feuz MA, McMahan RD, Barnes DE, Li B, Volow AM, Powell J, Sudore RL. Surrogate Decision Makers Need Better Preparation for Their Role: Advice from Experienced Surrogates. J Palliat Med 2022; 25:857-863. [DOI: 10.1089/jpm.2021.0283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Brian M. Bakke
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Mariko A. Feuz
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
- Des Moines University College of Osteopathic Medicine, Des Moines, Iowa, USA
| | - Ryan D. McMahan
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
| | - Deborah E. Barnes
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Brookelle Li
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Aiesha M. Volow
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jana Powell
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Rebecca L. Sudore
- Division of Geriatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Health Care System, San Francisco, California, USA
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