Predictors of advance directive restrictiveness and compliance with institutional policy in a long-term-care facility

OBJECTIVE

To ascertain factors influencing the level of advance directives selected by nursing home residents or surrogates and the time delay to documentation of these choices in the medical record after implementation of a facility-wide policy.

DESIGN

Longitudinal cohort study of nursing home residents followed from date of advance directive policy initiation or time of admission for a maximum of 21 months from study commencement.

SETTING

A 315-bed multilevel nursing home.

PARTICIPANTS

Four hundred twenty-four nursing home residents (mean age 85, 74.9% female, 96.1% white).

OUTCOME MEASURES

Level of advance directive status chosen--full code, do not resuscitate (DNR) or palliative care only--and date documented in the medical record.

RESULTS

Factors predictive of restricted advance directives (DNR or palliative care) included age greater than 85 years (P = 0.025), documented use of a surrogate decision maker (P = 0.001), low physical function (P less than 0.001), low cognitive function (P less than 0.001), and having a nursing home-employed physician (P = 0.001). These results were confirmed using logistic regression models. Median time to directive documentation decreased from 54 days for residents admitted in the first quarter to 1 day for residents admitted in the fourth quarter of the year following initiation of an advance directive policy.

CONCLUSION

In logistic models, nursing home-employed physicians were more likely to write restricted advance directive orders than community-based physicians even after controlling for resident age, cognitive status, and physical function. In addition, implementation of a formal nursing home advance directive policy can shorten time to physician documentation of resident advance directive status.

Senior women physicians: the question of retirement

Little is known about women physicians in their senior years. This paper describes a cross-sectional survey of 21 women physicians ranging in age from 59 to 95 years in eight different medical fields. The survey showed that 14 (66.7%) worked after age 65, including four who worked into their 70s and four who worked into their 80s. Although reasons for retirement varied, most retired due to personal illness or the wish to pursue other interests. Most respondents (76.2%) were married or had been married; 80% of these had children. This survey also explored initial practice styles and changes over time, and retirement planning and financing. Respondents also were asked to identify role models and to share their own mentoring activities. Traditionally, women professionals often have been thought to have shorter careers than men due to family constraints. Yet most of the women in this sample have had long-lived careers with simultaneous marital and family responsibilities.

Ventricular ectopy in totally symptom-free subjects with defined coronary artery anatomy

Ambulatory ECG recordings were obtained from 313 consecutive, totally symptom-free male subjects on whom cardiac catheterization was subsequently performed for occupational reasons. These recordings were examined for ventricular ectopy and the results were studied in relation to the findings on selective coronary angiography. Ventricular ectopy was a common finding, with 58% of those subjects with normal coronary artery anatomy having at least one ventricular premature beat during the period of monitoring (mean 16 1/2 hours), 22% having greater than one such complex per hour, and 10% having greater than 10 per hour. Complex ventricular ectopy was present in 21% of the normal subjects. No association between the extent or complexity of ventricular ectopy and the presence or grade of anatomic coronary artery disease was demonstrated, nor was ventricular ectopy overrepresented in those with both significant coronary artery disease on angiography and evidence of ischemia on provocative testing.

Reduced plasma half-life of radio-labelled 25-hydroxyvitamin D3 in subjects receiving a high-fibre diet

1. The plasma disappearance of 3H-labelled 25-hydroxyvitamin D3 (25(OH)D3) was studied in healthy volunteers on normal and high-fibre diets, using 3H-labelled tracer doses given intravenously. 2. The mean (+/- SEM) plasma half-life in the high-fibre-diet group was 19.2 +/- 1.7 d, which was significantly shorter than in the group on normal diets (27.5 +/- 2.1 d, P less than 0.01). 3. This finding suggests that a high-fibre diet leads to enhanced elimination of 25(OH)D3 by an action within the intestinal lumen. This may involve interference with an enterohepatic circulation of the metabolite, perhaps by binding of 25(OH)D3 to dietary fibre. 4. The reduced plasma half-life of 3H-labelled 25(OH)D3 associated with a high-fibre diet may explain the development of vitamin D deficiency in Asian immigrants with normal exposure to u.v. light.

Changes in plasma half-life and clearance of 3H-25-hydroxyvitamin D3 in patients with intestinal malabsorption

The plasma disappearance of intravenously administered tracer doses of tritium-labelled 25-hydroxyvitamin D3 (25OHD3) wa studied in six normal subjects and in 15 patients with intestinal malabsorption. The plasma half-life was significantly shorter and the clearance rate significantly greater in the group with malabsorption compared with the controls. One explanation for this increased elimination could be interruption of an enterohepatic circulation of 25OHD occurring in subjects with malabsorption and such a mechanism could account for the loss of endogenous vitamin D in these patients.

Controlled trial of maintenance cimetidine treatment in healed duodenal ulcer: short and long-term effects

Forty-two patients with endoscopically diagnosed duodenal ulcer were studied in a double-blind trial after their ulcers had been healed with cimetidine. Cimetidine was effective in preventing relapse, only five of the 20 patients allocated to cimetidine 400 mg twice daily relapsing during the six months' treatment, compared with 16 of the 22 on placebo treatment (P less than 0.01). Cimetidine was safe in the dosage and duration used, no symptomatic, haematological, or biochemical abnormalities occurring during the trial. Subsequent follow-up at the end of the trial when treatment had been stopped showed that relapse was frequent, particularly in the cimetidine group, making the cumulative relapse rate eight months after completion of the trial similar in the two groups (75% in the cimetidine group, 86% in the placebo group). It seems likely that maintenance cimetidine treatment has to be continued indefinitely in patients with duodenal ulcer, and, until such treatment is shown to be safe and effective, surgical treatment remains a logical option for many patients.