AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults

A Care Paradox: The Relationship Between Older Adults' Caregiving Arrangements and Institutionalization and Mortality

We investigate how the type of caregiving arrangement is associated with older Americans' outcomes. We use the Health and Retirement Study (2004-2018) and discrete-time event history analysis to assess the odds of institutionalization or death over a 14-year period among older adults with limitations in Activities of Daily Living (ADLs; e.g., bathing). We consider caregiving arrangements as conventional (i.e., spouse or adult child), unconventional (e.g., extended family, employee, friend), or self-directed (i.e., no caregiver). We find a "care paradox" in that self-directing one's own care was associated with a lower risk of institutionalization or death compared with having conventional care (spouse/adult caregiver) and unconventional care (employee). Relative to conventional care, having an employee caregiver was associated with increased risk of institutionalization. Findings are still observed when controlling for level of impairment and various health-related factors. More research is needed to understand older adults who self-direct their own care.

Victimization in Unethical Unlicensed Small Residential Care Homes in the United States: The Case for Whole System Disruption

In the United States, small residential care homes provide affordable community-based care for disabled older adults. Also called adult foster care homes, residential care facilities, group homes, or board and care homes, small residential care homes are typically private, small businesses operating in single-family dwellings that provide round-the-clock care in a home-like setting in residential neighborhoods. While most states license small residential care homes they also exist, legally and illegally, as unlicensed and unregulated operations. The quality of care in some unlicensed and unregulated small residential care homes can be questionable. Disabled older adults are targeted and victimized by unethical small residential care home operators for financial gain. This commentary highlights the need for whole system disruption to end victimization in unethical unlicensed and unregulated small residential care homes through case studies of the abuse and neglect of residents living in unethical unlicensed operations and recommends ambitious goals centered on reducing secondary financial gains and medically neglectful practices. These recommendations are at federal, state, and local levels, and include creating a federal definition of small residential care homes, increasing and coupling government incomes with state registration and employee misconduct registry checks, increasing oversight and assessment, improving temporary guardianship processes, providing avenues for reporting abuse, and developing older adult fatality review teams.

Medical-Legal Partnerships and Prevention: Caring for Unrepresented Patients Through Early Identification and Intervention

Caring for unrepresented patients encompasses legal, ethical, and moral challenges regarding decision-making, consent, the patient's values, wishes, best interest, and the healthcare team's professional integrity and autonomy. In this article, I consider the impact of the aging population and the effects of the social determinants of health and suggest that without preventive intervention, the number of unrepresented patients will continue to increase. The health, social, and legal risk factors for becoming unrepresented require a multidisciplinary response. Medical-Legal Partnerships (MLPs) bring healthcare and legal professionals together to address risk factors and health-harming legal needs. The article discusses the role of MLPs in identifying at-risk individuals, providing preventive interventions, and providing support. I make recommendations and conclude that proactive MLPs offer a sustainable approach to the ethical challenges in caring for unrepresented patients by providing interventions to prevent individuals from becoming unrepresented.

The Sensitive Care of the Elder Orphan in Critical Care Environments

All patients within critical care units are vulnerable and many of them are unable to communicate their wishes and needs to the caregivers treating their acute critical illness. This inability to communicate is why interdisciplinary intensive care teams across the country heavily rely on spouses, children, siblings, parents, other next of kin, or other designated medical durable power of attorneys to advocate for those who cannot advocate for themselves. Unfortunately, there is a growing population of elder orphans who lack this support system when they need it the most.

Guardianship Before and Following Hospitalization

When ethics committees are consulted about patients who have or need court-appointed guardians, they lack empirical evidence about several common issues, including the relationship between guardianship and prolonged, potentially medically unnecessary hospitalizations for patients. To provide information about this issue, we conducted quantitative and qualitative analyses using a retrospective cohort from Veterans Healthcare Administration. To examine the relationship between guardianship appointment and hospital length of stay, we first compared 116 persons hospitalized prior to guardianship appointment to a comparison group (n = 348) 3:1 matched for age, diagnosis, date of admission, and comorbidity. We then compared 91 persons hospitalized in the year following guardianship appointment to a second matched comparison group (n = 273). Mean length of stay was 30.75 days (SD = 46.70) amongst those admitted prior to guardianship, which was higher than the comparison group (M = 7.74, SD = 9.71, F = 20.75, p < .001). Length of stay was lower following guardianship appointment (11.65, SD = 12.02, t = 15.16, p < .001); while higher than the comparison group (M = 7.60, SD = 8.46), differences were not associated with guardianship status. In a separate analysis involving 35 individuals who were hospitalized both prior to and following guardianship, length of stay was longer in the year prior (M = 23.00, SD = 37.55) versus after guardianship (M = 10.37, SD = 10.89, F = 4.35, p = .045). In qualitative analyses, four themes associated with lengths of stay exceeding 45 days prior to guardianship appointment were: administrative issues, family conflict, neuropsychiatric comorbidity, and medical complications. Our results suggest that persons who are admitted to hospitals, and subsequently require a guardian, experience extended lengths of stay for multiple complex reasons. Once a guardian has been appointed, however, differences in hospital lengths of stay between patients with and without guardians are reduced.

Current situation of the hospitalization of persons without family in Japan and related medical challenges

This study aims to determine the approximate number of hospitalizations of persons without family and the medical challenges they encounter in hospitals across Japan. Self-administered questionnaires were mailed to 4,000 randomly selected hospitals nationwide to investigate the actual conditions and problems, decision-making processes, and use of the government-recommended Guidelines for the hospitalization of, and decision-making support for, persons without family. To identify the characteristics of each region and role of hospitals, chi-square tests were used to make separate group comparisons by hospital location and type. Responses were received from 1,271 hospitals (31.2% response rate), of which 952 hospitals provided information regarding the number of admissions of persons without family. The mean (SD) and median number of hospitalizations (approximate number per year) of patients without family was 16 (79) and 5, respectively. Approximately 70% of the target hospitals had experienced the hospitalization of a person without family, and 30% of the hospitals did not. The most common difficulties encountered during the hospitalization were collecting emergency contact information, decision-making related to medical care, and discharge support. In the absence of family members and surrogates, the medical team undertook the decision-making process, which was commonly performed according to manuals and guidelines and by consulting an ethics committee. Regarding the use of the government-recommended Guidelines, approximately 70% of the hospitals that were aware of these Guidelines responded that they had never taken any action based on these Guidelines, with significant differences by region and hospital type. To solve the problems related to the hospitalization of persons without family, the public should be made aware of these Guidelines, and measures should be undertaken to make clinical ethics consultation a sustainable activity within hospitals.

Solo but Not Alone: An Examination of Social and Help Networks among Community-Dwelling Older Adults without Close Family

This study evaluates help sources for personal and health tasks of adults living in the community without a spouse or nearby children. Using data from the National Health and Aging Trends Study (NHATS), a nationally representative sample of Medicare beneficiaries ages 65 and over, we conducted a population-based study of 2998 community-dwelling adults who received assistance with personal, household, or medical tasks in the past month. Using ANOVA, we compared adults aging solo to those with spouses at home and/or children in the same state. Adults aging solo were significantly more likely to identify non-child/spouse family, friends, neighbors and paid aides as part of their social networks. Their sources of unpaid help included siblings (33%), friends (32%), and non-family (e.g., neighbors (23%)). Adults aging solo were more likely to use paid caregivers, despite having lower incomes than married peers. Interventions to support adults aging solo should incorporate diverse social/help networks.

Adults Without Advocates and the Unrepresented: A Narrative Review of Terminology and Settings

Socially isolated adults, including those with and without the ability to make medical decisions, are encountered in clinical practice and are at risk for adverse health outcomes. Consensus is lacking on appropriate terminology to describe subpopulations of these patients. In addition, little is known about the settings in which they present. These gaps prevent clinicians and policymakers from identifying and understanding these populations and deploying appropriate resources to meet their complex needs. We conducted a narrative review of literature on socially isolated adults aged 50 and older to assess and integrate the available evidence regarding the terminology used to describe unrepresented patients and adults without advocates to inform consensus on terminology. We also identified the settings in which unrepresented patients and adults without advocates are described in the literature, including both within and outside health care settings. Our results indicate that there is heterogeneity and inconsistency in the terminology used to describe socially isolated adults, as well as heterogeneity in the settings in which they are identified in the literature. Our findings suggest that future work should include achieving consensus on terminology and integrating proactive interdisciplinary interventions across health systems and communities to prevent adults without advocates from becoming unrepresented.

Using natural language processing to identify acute care patients who lack advance directives, decisional capacity, and surrogate decision makers

The prevalence of patients who are Incapacitated with No Evident Advance Directives or Surrogates (INEADS) remains unknown because such data are not routinely captured in structured electronic health records. This study sought to develop and validate a natural language processing (NLP) algorithm to identify information related to being INEADS from clinical notes. We used a publicly available dataset of critical care patients from 2001 through 2012 at a United States academic medical center, which contained 418,393 relevant clinical notes for 23,904 adult admissions. We developed 17 subcategories indicating reduced or elevated potential for being INEADS, and created a vocabulary of terms and expressions within each. We used an NLP application to create a language model and expand these vocabularies. The NLP algorithm was validated against gold standard manual review of 300 notes and showed good performance overall (F-score = 0.83). More than 80% of admissions had notes containing information in at least one subcategory. Thirty percent (n = 7,134) contained at least one of five social subcategories indicating elevated potential for being INEADS, and <1% (n = 81) contained at least four, which we classified as high likelihood of being INEADS. Among these, n = 8 admissions had no subcategory indicating reduced likelihood of being INEADS, and appeared to meet the definition of INEADS following manual review. Among the remaining n = 73 who had at least one subcategory indicating reduced likelihood of being INEADS, manual review of a 10% sample showed that most did not appear to be INEADS. Compared with the full cohort, the high likelihood group was significantly more likely to die during hospitalization and within four years, to have Medicaid, to have an emergency admission, and to be male. This investigation demonstrates potential for NLP to identify INEADS patients, and may inform interventions to enhance advance care planning for patients who lack social support.

Inclusion of people living with Alzheimer's disease or related dementias who lack a study partner in social research: Ethical considerations from a qualitative evidence synthesis

BACKGROUND

Because use of a study partner (proxy decision-maker) to give informed consent on behalf of someone living with Alzheimer's disease or related dementias (ADRD) is common in nearly all clinical research, people living with ADRD who lack a study partner are regularly excluded from participation. Social research presents different opportunities and risks than clinical research. We argue that guidelines developed for the latter may be unduly restrictive for social research and, further, that the automatic exclusion of people living with ADRD presents separate ethical challenges by failing to support extant decision-making capacity and by contributing to underrepresentation in research.

PURPOSE

The study objective was to identify key components related to including cognitively vulnerable participants who lack a study partner in social research.

RESEARCH DESIGN/STUDY SAMPLE

We conducted an adaptive qualitative evidence synthesis (QES) and subsequent content analysis on 49 articles addressing capacity and research consent for potentially cognitively compromised individuals, to include people living with ADRD, who lack a study partner.

RESULTS

We identified four major topic areas: defining competency, capacity, and consent; aspects of informed consent; strategies to assess comprehension of risks associated with social research; and risks versus benefits.

CONCLUSIONS

Based on findings, we suggest new and ethically appropriate ways to determine capacity to consent to social research, make consent processes accessible to a population experiencing cognitive challenges, and consider the risks of excluding a growing population from research that could benefit millions.

The Cost of Medically Unnecessary Days Due to Waiting for Guardianship in a State Acute Hospital System

Hospitals must do more with less, making efficiency a priority. Discharge delays create challenges for acute care hospitals. Some delays are due to patients waiting for a guardian—a person appointed to assist an adult who lacks decision-making capacity. Previous studies examine the burden of excess days in a single academic medical center (AMC); however, these institutions do not represent the entire hospital system. This descriptive study expands upon previous analyses by calculating the financial implications of medically unnecessary days in a state’s hospitals to payers. Two models are presented: one calculates the gross patient service revenues required to support excess days; the other calculates the expense to hospitals. Results suggest that substantial funds are required to support excess days. Funds may be better allocated to support the health and well-being of people needing medical care or to address the cause of delays due to waiting for guardianship.

Family Members' Understanding of the End-of-Life Wishes of People Undergoing Maintenance Dialysis

BACKGROUND AND OBJECTIVES

People receiving maintenance dialysis must often rely on family members and other close persons to make critical treatment decisions toward the end of life. Contemporary data on family members' understanding of the end-of-life wishes of members of this population are lacking.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Among 172 family members of people undergoing maintenance dialysis, we ascertained their level of involvement in the patient's care and prior discussions about care preferences. We also compared patient and family member responses to questions about end-of-life care using percentage agreement and the κ-statistic.

RESULTS

The mean (SD) age of the 172 enrolled family members was 55 (±17) years, 136 (79%) were women, and 43 (25%) were Black individuals. Sixty-seven (39%) family members were spouses or partners of enrolled patients. A total of 137 (80%) family members had spoken with the patient about whom they would want to make medical decisions, 108 (63%) had spoken with the patient about their treatment preferences, 47 (27%) had spoken with the patient about stopping dialysis, and 56 (33%) had spoken with the patient about hospice. Agreement between patient and family member responses was highest for the question about whether the patient would want cardiopulmonary resuscitation (percentage agreement 83%, κ=0.31), and was substantially lower for questions about a range of other aspects of end-of-life care, including preference for mechanical ventilation (62%, 0.21), values around life prolongation versus comfort (45%, 0.13), preferred place of death (58%, 0.07), preferred decisional role (54%, 0.15), and prognostic expectations (38%, 0.15).

CONCLUSIONS

Most surveyed family members reported they had spoken with the patient about their end-of-life preferences but not about stopping dialysis or hospice. Although family members had a fair understanding of patients' cardiopulmonary resuscitation preferences, most lacked a detailed understanding of their perspectives on other aspects of end-of-life care.

"I worry about this patient EVERY day": Geriatrics Clinicians' Challenges in Caring for Unrepresented Older Adults

Unrepresented older adults are at risk for adverse outcomes, and clinicians who care for them may face ethical dilemmas and unique challenges when making person-centered care recommendations. However, little is known about their perspectives on clinical challenges in caring for this population. An online survey was used to assess issues around providing care for unrepresented patients. Ninety-two American Geriatrics Society members working with older adults in inpatient and/or outpatient settings completed the survey. Descriptive qualitative analysis of narrative survey responses identified five broad themes: (a) health risk characteristics of patients, (b) care decisions facing the team, (c) psychosocial considerations by the team, (d) patient outcomes, and (e) burden of the provider and/or health system. These findings demonstrate that geriatrics clinicians face challenges in working with unrepresented adults in both inpatient and outpatient settings. We interpret these results in light of existing literature and propose collaborative approaches that may improve outcomes.

Medical Decision-Making Practices for Unrepresented Residents in Nursing Homes

OBJECTIVES

Unrepresented adults are individuals who lack decision-making capacity and have neither an available surrogate decision maker nor an applicable advance directive. Currently, the prevalence of unrepresented nursing home (NH) residents and how medical decisions are made is unknown. We examined (1) the prevalence of unrepresented NH residents, (2) NH policies and procedures to address medical decision making for those residents, and (3) NH staff's perceptions of medical decision making for unrepresented residents.

DESIGN

We reviewed resident medical records and NH policy and procedure documents. We also conducted a survey of NH staff using an investigator-developed questionnaire.

SETTING AND PARTICIPANTS

Sixty-six staff members recruited from 3 NHs (433 residents total) in 1 metropolitan area of Georgia, USA.

METHODS

Medical records and policy and procedure documents were reviewed using preset criteria. The survey included 31 structured and open-ended questions regarding medical decision-making practices for unrepresented residents (eg, awareness of medical decision-making processes, experiences in medical decision making, and suggestions to improve practice). We used descriptive statistics and conventional content analysis.

RESULTS

Four residents (1%) met the criteria of being unrepresented. We found no written statements that specifically addressed medical decision making for unrepresented residents in the participating NHs. Of 66 survey participants, 11 had been involved in medical decision making for unrepresented residents. The most common decisions involved do-not-resuscitate orders, major medical and surgical treatments, and life-sustaining treatments. These decisions were made primarily by relying on the resident's physician or through discussions within the facility's interdisciplinary team. Suggestions included adopting explicit mechanisms or protocols related to decision making for unrepresented residents, education/training, and resources for group-based decision making.

CONCLUSIONS AND IMPLICATIONS

Although prevalence in the 3 NHs was low, NH care providers, ethical and legal professionals, and other key stakeholders should discuss practical approaches and policies to systematically identify unrepresented residents and to improve NHs' medical decision-making practices for them.

End-of-Life Care for Persons Under Guardianship

CONTEXT

Guardians are surrogate decision makers appointed by a court when other health care decision-makers are unable, unwilling, or unavailable to make decisions. Prior studies suggest that persons under guardianship may experience delays in transitions of care.

OBJECTIVES

To compare quality of end-of-life care for persons under guardianship to a matched group on objective indicators and to identify narrative themes characterizing potential obstacles to quality end-of-life care.

METHODS

One hundred sixty-seven persons under guardianship who died between 2003 and 2019 within the Veterans Healthcare Administration in Massachusetts and Connecticut matched on a 1:1 basis to persons without guardians. The groups were compared on treatment specialty at death, days of hospice and intensive care unit care, and receipt of palliative care consultation. Additionally, patient narratives for those under guardianship with extended lengths in intensive care unit were subjected to qualitative analysis.

RESULTS

Overall, <1% were under guardianship. Within this sample of persons who died within the Veterans Health Administration, persons under guardianship were as likely as patients in the comparison group to receive palliative care consultation (odds ratio [CI] = 0.93 [.590-1.46], P = .359), but were more likely to have ethics consultation (odds ratio [CI] = 0.25 [0.66-0.92], P = .036) and have longer lengths of ICU admission (β = -.34, t = -2.70, P = .009). Qualitative findings suggest that issues related to family conflict, fluctuating medical course, and limitations in guardian authority may underlie extended lengths of stay.

CONCLUSION

Guardianship appears to be rare, and as a rule, those under guardianship have equal access to hospice and palliative care within Veterans Health Administration. Guardianship may be associated with health-care challenges in a small number of cases, and this may drive perceptions of adverse outcomes.

Caring for Unbefriended Older Adults and Adult Orphans: A Clinician Survey

Objectives: Unbefriended older adults are those who lack the capacity to make medical decisions and do not have a completed advance directive that can guide treatment decisions or a surrogate decision maker. Adult orphans are those who retain medical decision-making capacity but are at risk of becoming unbefriended due to lack of a completed advance health care directive and lack of a surrogate decision maker. In a follow-up to the 2016 American Geriatrics Society (AGS) position statement on unbefriended older adults, we examined clinicians' experiences in caring for unbefriended older adults and adult orphans.Methods: Clinicians recruited through the AGS (N = 122) completed an online survey about their experiences with unbefriended older adults regarding the perceived frequency of contact, clinical concerns, practice strategies, and terminology; and also with adult orphans regarding the perceived frequency of contact, methods of identification, and terminology.Results: Almost all inpatient (95.9%) and outpatient (86.4%) clinicians in this sample encounter unbefriended older adults at least quarterly and 92.2% of outpatient clinicians encounter adult orphans at least quarterly. Concerns about safety (95.9%), medication self-management (90.4%), and advance care planning (86.3%) bring unbefriended older adults to outpatient clinicians' attention "sometimes" to "frequently." Prolonged hospital stays (87.7%) and delays in transitioning to end-of-life care (85.7%) bring unbefriended older adults to inpatient clinicians' attention "sometimes" to "frequently." Clinicians apply a wide range of practice strategies to these populations. Participants suggested alternative terminology to replace "unbefriended" and "adult orphan."Conclusions: This study suggests that unbefriended older adults are frequently encountered in geriatrics practice, both in the inpatient and outpatient settings, and that there is widespread awareness of adult orphans in the outpatient setting. Clinicians' awareness of both groups suggests avenues for intervention and prevention.Clinical Implications: Health care professionals in geriatric settings will likely encounter older adults in need of advocates. Clinicians, attorneys, and policymakers should collaborate to improve early detection and to meet the needs of this vulnerable population.

LGBT Seniors in the Pandemic: Silenced and Vulnerable

Lesbian, gay, bisexual, and transgender (LGBT) seniors face disparities in physical and mental health as well as high rates of social isolation and risk of discrimination in comparison to cisgender, heterosexual people. Having identities and experiences silenced by real or perceived risks of discrimination increases isolation and vulnerability for marginalized communities and individuals. This article presents the case of Janelle, a senior, transgender lesbian, and her experiences of isolation and intersecting disparities before and during the COVID-19 pandemic, and how those experiences shape her concerns about the future. Her experiences demonstrate the ways in which the health and social risks presented by the pandemic exacerbate preexisting vulnerabilities for older LGBT adults.

Unrepresented Adults Face Adverse Healthcare Consequences: The Role of Guardians, Public Guardianship Reform, and Alternative Policy Solutions

Persons without family or friends to serve as healthcare agents may become "unrepresented" in healthcare, with no one to serve as healthcare agents when decisional support is needed. Surveys of clinicians (N = 81) and attorneys/guardians (N = 23) in Massachusetts reveal that unrepresented adults experience prolonged hospital stays (66%), delays in receiving palliative care (52%), delays in treatment (49%), and other negative consequences. Clinicians say guardianship is most helpful in resolving issues related to care transitions, medical treatment, quality of life, housing, finances, and safety. However, experiences with guardianship are varied, with delays often/always in court appointments (43%) and actions after appointments (24%). Policy solutions include legal reform, education, and alternate models.

Challenges in Caring for Unbefriended Residents in Long-term Care Homes: A Qualitative Study

OBJECTIVES

This study examined challenges experienced by long-term care staff in caring for unbefriended residents who are incapacitated and alone. These residents often are estranged from or have no living family or live geographically distant from them and require a public guardian as their surrogate decision-maker. To date, research on unbefriended older adults has focused on those living in acute care and community settings. Little is known about those living in long-term care homes.

METHOD

We conducted semi-structured interviews with 39 long-term care staff (e.g., registered nurses, care aides, social workers) and 3 public guardians. Staff were sampled from seven long-term care homes in Alberta, Canada. We analyzed interview transcripts using content analysis and then using the theoretical framework of complex adaptive systems.

RESULTS

Long-term care staff experience challenges unique to unbefriended residents. Guardians' responsibilities did not fulfill unbefriended residents' needs, such as shopping for personal items or accompanying residents to appointments. Consequently, the guardians rely on long-term care staff, particularly care aides, to provide increased levels of care and support. These additional responsibilities, and organizational messages dissuading staff from providing preferential care, diminish quality of work life for staff.

DISCUSSION

Long-term care homes are complex adaptive systems. Within these systems, we found organizational barriers for long-term care staff providing care to unbefriended residents. These barriers may be modifiable and could improve the quality of care for unbefriended residents and quality of life of staff. Implications for practice include adjusting public guardian scope of work, improving team communication, and compensating staff for additional care.

Older Adults without Desired Surrogates in a Nationally Representative Sample

BACKGROUND/OBJECTIVES

Little is known about older adults who have intact capacity but do not have a desired surrogate to make decisions if their capacity becomes impaired.

DESIGN

Cross-sectional study of a nationally representative sample.

SETTING

National Social Life, Health, and Aging Project (NSHAP), 2005-2006.

PARTICIPANTS

Community-dwelling older adults without known cognitive impairment, aged 57 to 85, interviewed as part of NSHAP (n = 2,767).

MEASUREMENTS

We examined demographic, medical, and social connectedness characteristics associated with answering "no" to this question: "Do you have someone who you would like to make medical decisions for you if you were unable, as for example if you were seriously injured or very sick?" Because many states permit nuclear family to make decisions for persons with no legally appointed health care agent, we used logistic regression to identify factors associated with individuals who were ill suited to this paradigm in the sense that they had nuclear family but did not have a desired surrogate.

RESULTS

Among NSHAP respondents, 7.5% (95% confidence interval = 6.4-8.7) did not have a desired surrogate. Nearly 90% of respondents without desired surrogates had nuclear family. Compared with respondents with desired surrogates, those without desired surrogates had lower indicators of social connectedness. On average, however, they had four confidants, approximately 70% socialized at least monthly, and more than 90% could discuss their health with a confidant. Among respondents who had nuclear family, few characteristics distinguished those with and without desired surrogates.

CONCLUSION

Nearly 8% of older adults did not have a desired surrogate. Most had nuclear family and were not socially disconnected. Older adults should be asked explicitly about a desired surrogate, and strategies are needed to identify surrogates for those who do not have family or would not choose family to make decisions for them.

Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement

Background and Rationale: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as “unrepresented.” There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice.

Purpose and Objectives: This multisociety statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting.

Methods: An interprofessional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law.

Main Results: The committee designed its policy recommendations to promote five ethical goals: 1) to protect highly vulnerable patients, 2) to demonstrate respect for persons, 3) to provide appropriate medical care, 4) to safeguard against unacceptable discrimination, and 5) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: 1) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; 2) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; 3) institutions should manage decision-making for unrepresented patients using input from a diverse interprofessional, multidisciplinary committee rather than ad hoc by treating clinicians; 4) institutions should use all available information on the patient’s preferences and values to guide treatment decisions; 5) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; 6) institutions should employ this fair process even when state law authorizes procedures with less oversight.

Conclusions: This multisociety statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.

Conceptualizing and Counting Discretionary Utilization in the Final 100 Days of Life: A Scoping Review

CONTEXT

There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care.

OBJECTIVE

The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice.

METHODS

We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored.

RESULTS

We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs.

CONCLUSION

Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care.

Views on the use of the term 'elder orphans': A qualitative study

Older adults living alone in the community with no immediate family network or support are referred in the literature as 'elder orphans'. The grey literature has a growing emphasis on the importance of supporting this vulnerable group, particularly with health and social care. However, there is a dearth of empirical research on 'elder orphans', and definitions remained semantically complicated and unknown to the public, healthcare professionals and those being referred as elder orphans. This research explored the views of older adults on the use of the terminology 'elder orphans', and the implications of using the terminology in health and social care systems. A descriptive qualitative approach through face-to-face interviews of 11 older adults was undertaken in Auckland, New Zealand in October 2018. Narratives were analysed using thematic analysis. Two themes were identified from the analysis of interview data. The first theme was 'realistic and practical term', which emphasised the participants' impression of the term 'elder orphan' resonating to themselves with great relevance to their current and future situations. The second theme is 'visibility and vulnerability', which highlighted participants' both positive and ambivalent views on the use of the terminology in healthcare settings. The participants viewed this terminology as beneficial to alerting care services, and in promoting awareness among healthcare providers. Older adults from the study, who are living alone without immediate family networks and support self-identified themselves as 'elder orphans' through a gradual realisation of their current and anticipated social situations. The use of the term within healthcare was considered and preferred by the participants to be used contextually, and targeted towards appropriate health and social care services within and outside hospital-care settings.

Feasibility of Advance Care Planning in Primary Care for Homeless Adults

Objectives: As the homeless population ages, it is imperative to improve access to advance care planning (ACP) and document preferences in case medical decision-making capacity is lost. Methods: We implemented an ACP Project to discuss and document advance care plans with all patients aged 45 and older who received primary care at our adult Homeless Program clinics. Results: Over 14 months, ACP was discussed with 48% ( n = 138) of the population and health care proxy (HCP) appointment with 91% ( n = 125) of these patients. Most (62%; n = 77) appointed a HCP from personal relationships, though a significant minority (38%; n = 48) could not and were considered “surrogateless.” End-of-life preferences varied. Approximately 20% of patients wanted to defer to a surrogate for each decision. Discussion: ACP is feasible in primary care for adults who have experienced homelessness and should be incorporated into routine care.

End-of-Life Decision Making and Treatment for Patients with Professional Guardians

OBJECTIVES

Concerns have repeatedly been raised about end-of-life decision making when a patient with diminished capacity is represented by a professional guardian, a paid official appointed by a judge. Such guardians are said to choose high-intensity treatment even when it is unlikely to be beneficial or to leave pivotal decisions to the court. End-of-life decision making by professional guardians has not been examined systematically, however.

DESIGN

Retrospective cohort study.

SETTING

Inpatient and outpatient facilities in the Department of Veterans Affairs (VA) Connecticut Healthcare System.

PARTICIPANTS

Decedent patients represented by professional guardians who received care at Connecticut VA facilities from 2003 to 2013 and whose care in the last month of life was documented in the VA record.

MEASUREMENTS

Through chart reviews, we collected data about the guardianship appointment, the patient's preferences, the guardian's decision-making process, and treatment outcomes.

RESULTS

There were 33 patients with professional guardians who died and had documentation of their end-of-life care. The guardian sought judicial review for 33%, and there were delays in decision making for 42%. In the last month of life, 29% of patients were admitted to the intensive care unit, intubated, or underwent cardiopulmonary resuscitation; 45% received hospice care. Judicial review and high-intensity treatment were less common when information about the patient's preferences was available.

CONCLUSION

Rates of high-intensity treatment and hospice care were similar to older adults overall. Because high-intensity treatment was less likely when the guardian had information about a patient's preferences, future work should focus on advance care planning for individuals without an appropriate surrogate. J Am Geriatr Soc 67:2161-2166, 2019.

Ethical Challenges in Caring for Unrepresented Adults: A Qualitative Study of Key Stakeholders

The decision-making process on behalf of unrepresented adults (ie, those who lack capacity to make medical decisions and have no identifiable surrogate) is at risk for not incorporating their interests, raising ethical concerns. We performed semistructured interviews with key stakeholders across multiple sectors in an urban county who participate in the care of or decision-making process for unrepresented adults. This included a safety net healthcare system, social services, and legal services. Participants were healthcare, social service, and legal professionals who worked with unrepresented adults (n = 25). Our interview questions explored the current process for proxy decision making in cases of unrepresented adults and potential alternatives. We recorded, transcribed, and analyzed interviews using the constant comparative method to identify major themes related to ethical challenges if they were raised. Participants grappled with multiple ethical challenges around the care of unrepresented adults. Themes described by participants were: (1) prioritizing autonomy; (2) varying safety thresholds; (3) distributing resources fairly; and (4) taking a moral toll on stakeholders. In conclusion, all stakeholders identified ethical challenges in caring for unrepresented adults. An applied ethical framework that takes these dilemmas into account could improve ethical practice for unrepresented adults and lessen the emotional toll on stakeholders. J Am Geriatr Soc 67:1724-1729, 2019.

Risk of Social Isolation among Older Patients: What Factors Affect the Availability of Family, Friends, and Neighbors upon Hospitalization?

OBJECTIVES

To examine the prevalence of social isolation among older patients admitted to a hospital, and the effects of sociodemographic and health-related factors on the availability of their family, friends, and neighbor networks.

METHODS

Analyses are based on interviews with a sample of 2,449 older patients admitted to an urban academic medical center in the United States. A nine-item version of Lubben's Social Network Scale was developed and used to assess the availability of different social networks.

RESULTS

About 47% of the sample was at risk of social isolation. The oldest old and non-White older adults showed greater risk. The availability of family networks was associated with age, sex, marital status, and prior hospitalization; friend networks with age, race, education, prior hospitalization, and functional limitations; neighbor networks with race, education, marital status, and functional limitations.

CONCLUSIONS

The risk of social isolation and the availability of social support for hospitalized older adults varies by both patient and network characteristics. Health professionals should attend to this risk and the factors associated with such risk.

CLINICAL IMPLICATIONS

By assessing the availability of various types and frequency of support among older patients, health professionals can better identify those who may need additional support after discharge. Such information should be used in discharge planning to help prevent unnecessary complications and potential readmission.

Racial and Ethnic Differences in Advance Care Planning: Results of a Statewide Population-Based Survey

BACKGROUND

Few studies have focused on racial and ethnic differences in advance care planning other than advance directives among population-based samples of adults across the lifespan.

METHODS

Using data from a statewide random-digit dial telephone survey of adults 18 years or older (n = 1851), we investigated racial and ethnic differences in (1) designation of a healthcare agent (HCA); and (2) communication of goals, values, and preferences for end-of-life care with healthcare providers, a HCA, or other family members and friends.

RESULTS

Less than half (44%, 95% confidence interval [CI] = 41.3%-47.0%) of all participants had named a HCA. In multivariable analyses, participants who identified as Hispanic (adjusted odds ratio [aOR] = 0.4, 95% CI = 0.2-0.7) or non-Hispanic other (aOR = 0.6, 95% CI = 0.4-0.9) were less likely than non-Hispanic whites to have named a HCA. Only 14.5% (95% CI = 12.6%-16.5%) of all participants had ever had a conversation with a healthcare provider about their end-of-life care wishes, with no differences by race/ethnicity. Over half (53.9%, 95% CI = 51.0%-56.8%) of all participants reported having had conversations with someone other than a healthcare provider about their end-of-life wishes. In multivariable analyses, non-Hispanic whites were more likely than Hispanics (aOR = 0.5, 95% CI = 0.3-0.7), black/African Americans (aOR = 0.5, 95% CI = 0.3-0.9), and non-Hispanic others (aOR = 0.7, 95% CI = 0.5-1.0) to report having had such conversations.

CONCLUSIONS

Racial and ethnic minorities may be disadvantaged in the quality of care they receive if they have a serious illness and are unable to make decisions for themselves because most have not talked to anyone about their goals, values, or preferences for care.

Medical Decision-Making for Adults Who Lack Decision-Making Capacity and a Surrogate: State of the Science

Background:

Adults who lack decision-making capacity and a surrogate (“unbefriended” adults) are a vulnerable, voiceless population in health care. But little is known about this population, including how medical decisions are made for these individuals.

Objective:

This integrative review was to examine what is known about unbefriended adults and identify gaps in the literature.

Methods:

Six electronic databases were searched using 4 keywords: “unbefriended,” “unrepresented patients,” “adult orphans,” and “incapacitated patients without surrogates.” After screening, the final sample included 10 data-based articles for synthesis.

Results:

Main findings include the following: (1) various terms were used to refer to adults who lack decision-making capacity and a surrogate; (2) the number of unbefriended adults was sizable and likely to grow; (3) approaches to medical decision-making for this population in health-care settings varied; and (4) professional guidelines and laws to address the issues related to this population were inconsistent. There have been no studies regarding the quality of medical decision-making and its outcomes for this population or societal impact.

Conclusion:

Extremely limited empirical data exist on unbefriended adults to develop strategies to improve how medical decisions are made for this population. There is an urgent need for research to examine the quality of medical decision-making and its outcomes for this vulnerable population.

Going it Alone: A Scoping Review of Unbefriended Older Adults

Older adults who have reduced decision-making capacity and no family or friends to compensate for these deficiencies are known as unbefriended and require a public guardian. The purpose of this study was to review the peer-reviewed and grey literature to determine the scope of available research on unbefriended older adults in Canada and the United States. We found limited research examining unbefriended older adults. No Canadian studies or reports were located. Unbefriended older adults were childless or had fewer children, were more cognitively impaired, and were older than older adults who were not unbefriended. These findings demonstrate a stark scarcity of studies on unbefriended older adults. Research is urgently needed using standardized data collection of guardianship status in order to enable studies of the prevalence of public guardianship in Canada.

"Maybe They Don't Even Know That I Exist": Challenges Faced by Family Members and Friends of Patients with Advanced Kidney Disease

BACKGROUND AND OBJECTIVES

Family members and friends of patients with advanced chronic illness are increasingly called on to assist with ever more complex medical care and treatment decisions arising late in the course of illness. Our goal was to learn about the experiences of family members and friends of patients with advanced kidney disease.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

As part of a study intended to identify opportunities to enhance advance care planning, we conducted semistructured interviews at the Veterans Affairs Puget Sound Health Care System with 17 family members and friends of patients with advanced kidney disease. Interviews were conducted between April of 2014 and May of 2016 and were audiotaped, transcribed, and analyzed inductively using grounded theory to identify emergent themes.

RESULTS

The following three themes emerged from interviews with patients' family members and friends: (1) their roles in care and planning were fluid over the course of the patient's illness, shaped by the patients' changing needs and their readiness to involve those close to them; (2) their involvement in patients' care was strongly shaped by health care system needs. Family and friends described filling gaps left by the health care system and how their involvement in care and decision-making was at times constrained and at other times expected by providers, depending on system needs; and (3) they described multiple sources of tension and conflict in their interactions with patients and the health care system, including instances of being pitted against the patient.

CONCLUSIONS

Interviews with family members and friends of patients with advanced kidney disease provide a window on the complex dynamics shaping their engagement in patients' care, and highlight the potential value of offering opportunities for engagement throughout the course of illness.