Goals of care and end-of-life decision making for hospitalized patients at a canadian tertiary care cancer center.

Limited information is available regarding the quality of end-of-life care at cancer centers. We sought to characterize the end-of-life decision-making process for advanced cancer patients admitted to our tertiary cancer center, and to examine the association between goals of care and practice patterns. Information on patient characteristics, investigations, cancer treatments, and goals of care was collected retrospectively for consecutive patients who died at the inpatient unit of the Vancouver Cancer Center between January 1, 2005 and December 31, 2006. One hundred eighteen advanced cancer patients had a median admission duration of 10 days (range 1-64 days). A median of two tests per day was performed, with a decreasing trend over time (P<0.001). Forty percent received cancer treatments during hospitalization, with 75% terminated prematurely. Do-not-resuscitate orders, supportive care plans, and diagnosis of dying were documented for 96%, 86%, and 76% of the patients, respectively. Early establishment of supportive care plan and diagnosis of dying were associated with timely discontinuation of cancer treatments (Spearman coefficients 0.47 and 0.60, respectively). Multivariate analysis revealed that timely diagnosis of dying was associated with early establishment of code status (P=0.042), supportive care plans (P<0.001), and discontinuation of cancer therapy (P=0.005). Cancer patients who died at our oncology center were investigated and treated intensively during their short hospitalization. Early establishment of goals of care may be associated with changes in practice consistent with improved quality of care.

Combined effect of the metabolic syndrome and hostility on the incidence of myocardial infarction (the Normative Aging Study).

A growing body of evidence suggests that the metabolic syndrome and hostility are independent risk factors for the development of coronary heart disease. However, few studies have examined the combined effect of the metabolic syndrome and hostility on the incidence of myocardial infarction (MI). We examined prospectively the relation among the metabolic syndrome, hostility, and the incidence of MI in healthy, older men (mean +/- SD 59.7 +/- 7.2 years) who participated in the Normative Aging Study. Seven hundred fifty-four men who were diagnosed as not having coronary heart disease and diabetes mellitus were included in the present study. Men were assigned to 1 of 4 risk-factor groups based on the presence or absence of the metabolic syndrome and low or high hostility. Hierarchical logistic regression was used to assess the multivariate risk of developing a MI. The incidence of MI was 11.3% (n = 85) over an average follow-up period of 13.8 years. After adjusting for potential covariates, risk-factor group significantly predicted the incidence of MI (odds ratio 1.59, 95% confidence interval 1.29 to 1.96, p <0.0001). The effect was strongest among patients who had the metabolic syndrome and high levels of hostility, with this subgroup showing a fourfold increase in the odds of developing a MI (odds ratio 4.21, 95% confidence interval 2.21 to 8.04, p = 0.0001). In conclusion, it appears that hostility may provide additional prognostic information to the assessment of coronary heart disease risk in patients with the metabolic syndrome and should routinely be evaluated as part of a comprehensive risk factor assessment.

The context of health care communication in chronic illness.

Patient-professional communication is a critically important element of effective chronic illness care. However, the dynamics of health care communication in supporting self-care management and effective coping with various chronic diseases is not well understood. The present study examined health care communication from the perspective of 38 patients with four distinct chronic conditions: end-stage renal disease (ESRD), non-insulin dependent diabetes mellitus (NIDDM), multiple sclerosis (MS), and fibromyalgia (FM). Analysis revealed the dimensions of courtesy, respect, and engagement to be inherent in communication priorities across conditions. However, distinct "disease worlds" among and between these chronic conditions illuminated salient differences within these dimensions, thereby illustrating the way in which relevant variables such as legitimacy, the availability of conventional treatments, and lifestyle implications shape the meaning of health care communication. The findings enlarge upon patient-centered approaches to health care communication and inform further analysis of the interactional dynamics associated with chronic conditions.

Health care communication issues in multiple sclerosis: an interpretive description.

Communication between persons with chronic illness and their professional health care providers is a critical element of appropriate health care. As the field of health care communication evolves, it becomes apparent that aspects of the illness experience shared by those affected by specific diseases might be a source of particular insight into what constitutes effective or appropriate communications. This interpretive description of health care communication issues in multiple sclerosis was based on qualitative secondary analysis of a set of in-depth interviews and focus groups conducted with 12 persons with longstanding MS experience. Analysis of their accounts illustrates an intricate interplay between common features within the disease trajectory and the communications that are perceived as helpful or unhelpful to living well with this chronic illness. From the analysis of these findings, the authors draw interpretations regarding what might be considered communication competencies for those who care for patients with this disease.