Self-perceived competence among medical residents in skills needed to care for patients with advanced dementia versus metastatic cancer.

To examine medical residents' perceived competence in caring for patients with dementia we conducted an online survey of all 120 second, third and fourth-year residents in Internal Medicine, Medicine/Pediatrics, and Family Medicine at University of Michigan. A structured survey elicited residents' training, experience, confidence, and perceived career needs for skills in estimating prognosis, symptom management, and communication in caring for patients with dementia, compared to patients with metastatic cancer. Among the 61 (51 %) respondents, a majority report lower confidence in assessing prognosis and eliciting treatment wishes in patients with dementia (vs. metastatic cancer), and in performing skills integral to the care of patients with dementia, including the ability to assess caregiver needs, decisional capacity, advise on place of care, and manage agitation, despite viewing these skills as important to their future careers. These findings support the need for enhanced education on optimal care of patients with advanced dementia.

Advance directives among Korean American older adults: knowledge, attitudes, and behavior.

The study objective was to explore knowledge, attitudes, and behavior about advance directives and how cultural values influence these beliefs. Three focus groups with 23 Korean American older adults were conducted. Advance directives were seen as helpful for ensuring that preferences for unwanted end-of-life treatment are honored and for relieving the decision-making burden on family members. However, some viewed completing advance directives as contrary to focusing on living. Culturally competent education about advance directives for Korean American older adults is necessary to help them make informed decisions about end-of-life care and informing family and health care providers of these preferences.

The relationship between health information sources and mental models of cancer: findings from the 2005 Health Information National Trends Survey.

This study used data from the 2005 Health Information National Trends Survey, a national sample of U.S. households (N = 5,586), to (1) explore the extent to which specific sources of health information are associated with certain beliefs about cancer; and (2) examine whether the relationship between health information sources and beliefs about cancer is moderated by psychological distress. Health information on the local news was associated with greater ambiguity about cancer prevention recommendations (OR 1.22, 95% CI 1.02-1.46, p < .05), while less ambiguity was associated with cancer-specific information (OR 0.81, 95% CI 0.69-0.94, p < .05), health information in the newspaper (OR 0.82, 95% CI 0.69-0.97, p < .05), and health information on the Internet (OR 0.71, 95% CI 0.61-0.84, p < .001). Health information on the local news was also associated with lower likelihood of higher perceived relative risk of cancer (OR 0.67, 95% CI 0.52-0.86, p < .01). No source of information was associated with the belief that cancer is primarily caused by behavior/lifestyle factors. Psychological distress greatly increased the optimistic bias of those who read health information in the news (OR 3.68, 95% CI 1.69-8.03, p < .001) but had no other moderating effect. Findings suggest that information seeking using active channels of health information decreases ambiguity and corrects for optimistic bias.

Role of children in end-of-life treatment planning among Korean American older adults.

Three focus groups (n = 23) with Korean American older adults explored the role of culture in end-of-life decision making. No participants had completed an advance directive and few had discussed end-of-life treatment preferences. Focus group themes addressed: (a) whether children are resistant or receptive to discussing their parents' end-of-life treatment preferences; (b) whether the older adults or their children should make decisions about end-of-life treatment; (c) whether decision making should be the responsibility of the eldest son or of all the children; and (d) whether children would implement the parent's preferences for end-of-life treatment. Understanding the role of children in end-of-life decision making among Korean American older adults is important for culturally competent care.

What and when Korean American older adults want to know about serious illness.

The aim of this exploratory study was to describe disclosure preferences about serious illness among Korean American older adults. Three focus groups (N = 6, 8, and 9) were conducted with Korean Americans age 65+ from two senior centers and a primary care practice in NYC. Six themes were identified: (1) Disclosure allows patients to make decisions and preparations, (2) Disclosure may cause emotional distress and hasten death, (3) Disclosure may be based on physician error or inability to know prognosis, (4) Disclosure should be based on severity of illness and the need to maintain hope, (5) Disclosure should be based on age, and (6) Disclosure practices of physicians vary by culture. Providing culturally competent care to East Asian older adults requires understanding the importance of family values and traditions, but not making assumptions about the degree to which the patient adheres to these beliefs.

Efficient and accurate measurement of physical restraint use in acute care.

OBJECTIVES: Describe and evaluate a method for assessing whether physical restraint prevalence differs by timing and frequency of data collection and to determine the minimum period of observation necessary to provide accurate prevalence estimates on both Intensive Care Unit (ICU) and medical-surgical units. DESIGN: Two-period, cross-sectional design with repeated observations in year 1 for 18 consecutive days and in year 2 for 21 consecutive days with method modifications. SETTING: 400-bed urban teaching hospital. PARTICIPANTS: All beds on general medical, surgical, and intensive care units. MEASUREMENT: Direct observation of patients, nurse interview, and medical record review conducted by trained observers. RESULTS: There were no significant differences in mean restraint use prevalence rates comparing: (a) morning and evening periods; (b) weekdays and weekend days; and (c) observation periods of 7, 14, or 21 consecutive days or for 7 days using every 3rd day on either medical-surgical units or ICUs. Analyses using data from an increasing number of days of observation indicates that the mean prevalence rate stabilizes after 16 days. There were larger mean differences for comparisons on ICU-ventilator units and lack of significant differences may be due to low statistical power. CONCLUSION: Direct observation by trained observers, supplemented by nurse report and medical record documentation over brief monitoring periods, results in accurate, nonintrusive, cost-efficient estimates of physical restraint prevalence. As few as seven consecutive or nonconsecutive days in measuring restraint prevalence is sufficient to obtain accurate estimates, although the number of days may vary depending on patient mix and unit type.

Tube feeding in advanced dementia: an exploratory survey of physician knowledge.

The administration of artificial nutrition by means of a percutaneous endoscopic gastrostomy (PEG) tube in older persons in the advanced stages of dementia is commonplace, yet the treatment is associated with significant treatment burdens and unclear benefits in this population. In addition, there is wide and unexplained geographic variability in the use of PEG in advanced dementia, which may stem partly from physicians' lack of understanding about its indications, risks, benefits, and effect on quality of life in advanced dementia. This study was a mail survey undertaken to assess physician knowledge regarding tube feeding in advanced dementia and explore whether certification in geriatrics or other physician characteristics are associated with physician knowledge. To assess knowledge about tube feeding, we asked participants to rate the importance of commonly cited, but non-evidence based, indications for tube feeding in advanced dementia, including recurrent aspiration pneumonia, abnormal swallowing evaluations, abnormal nutritional parameters, preventing an uncomfortable death, and others. Discrepancies between physician knowledge and current evidence regarding tube feeding in advanced dementia were found, indicating a need for improved education ofprimary care physicians in order to ultimately provide better end-of-life care for patients with advanced dementia.

Assessing medical students' training in end-of-life communication: a survey of interns at one urban teaching hospital.

PURPOSE: Although interns are responsible for caring for dying patients, little is known about end-of-life education and training, including communication skills, in U.S. medical schools. This study of three consecutive cohorts of new interns assessed their perceptions of the amount and types of classroom and clinical instructional strategies used during medical school, their self-rated skill and comfort levels in different aspects of end-of-life communication, and the associations between these measures. METHOD: A self-administered questionnaire was given to three consecutive cohorts (1996-1998) of incoming interns (n = 162). Measures were self-reported amount and type of education and clinical experience with four end-of-life communication domains (giving bad news, discussing advance directives, discussing prognosis with the patient, and discussing with the patient's family) and self-perceived comfort and skill levels in relation to different types of end-of-life communication. RESULTS: A total of 157 interns completed the questionnaire. They reported very little classroom teaching, clinical observation, or clinical experience with end-of-life communication during medical school. They lacked comfort and skill in the end-of-life communication domains that were studied. More reported clinical observation and experience with caring for and communicating with dying patients was associated with greater perceived comfort and skill, while classroom teaching was not. CONCLUSIONS: These interns, mostly U.S. medical school graduates (98.7%, n = 155) reported little training and low self-perceived comfort and skill with important elements of end-of-life communication that might contribute to a lack of preparedness to address these issues during their internship. Further research that confirms and explains the underlying reasons for these findings seems warranted.

Tube feeding in patients with advanced dementia: knowledge and practice of speech-language pathologists.

CONTEXT: Speech-language pathologists (SLP) are often called on to evaluate eating difficulties in patients with dementia. OBJECTIVES: To assess factors associated with SLPs' knowledge and recommendations about feeding tubes in patients with advanced dementia. METHODS: A mail survey was administered to a probability sample of 1500 SLPs from the American Speech-Language-Hearing Association mailing list; 731 usable surveys were received (response rate=53.7%). Self-perceived preparedness, knowledge, and care recommendations were measured. Knowledge items were scored as "evidence based" or not according to the best evidence in the literature. RESULTS: Only 42.1% of SLP respondents felt moderately/well prepared to manage dysphagia. Only 22.0% of respondents recognized that tube feeding is unlikely to reduce risk of aspiration pneumonia whereas a slight majority understood that tube feeding would not likely prevent an uncomfortable death (50.2%), improve functional status (54.5%), or enhance quality of life (QOL) (63.2%). A majority (70.0%) was willing to consider recommending oral feeding despite high risk of aspiration. Logistic regression analyses indicated that those willing to consider this recommendation gave the most evidence-based responses to knowledge questions about tube feeding outcomes: aspiration pneumonia (odds ratio [OR]=1.75, 95% confidence interval [CI]=1.07-2.87), functional status (OR=1.43, 95% CI=1.0-2.06), QOL (OR=2.19, 95% CI=1.52-3.17), and prevent uncomfortable death (OR=1.97, 95% CI=1.37-2.88). Logistic regression analyses also indicated that those with more experience evaluating patients with dementia gave the most evidence-based response to two knowledge questions: aspiration pneumonia (OR=2.64, 95% CI=1.48-4.72) and prevent uncomfortable death (OR=2.03, 95% CI=1.35-3.05) whereas those with higher self-perceived preparedness in managing dysphagia in dementia had less knowledge in two areas: aspiration pneumonia (OR=0.57, 95% CI=0.38-0.84) and QOL (OR=0.72, 95% CI=0.51-1.01). CONCLUSION: Misperceptions among SLPs about tube feeding in advanced dementia are common, especially in relation to risk of aspiration. Knowledge about tube feeding outcomes was positively associated with experience and inversely associated with self-perceived higher preparedness in evaluating patients with dementia.

Preferences for disclosure of information about serious illness among older Korean American immigrants in New York City.

BACKGROUND: The majority of persons of Western European background want to know their diagnosis and prognosis of serious illness, but minimal information is preferred by some ethnic groups, including Asians. Little is known about disclosure preferences of Korean Americans, the fourth largest East Asian immigrant group in the United States. OBJECTIVE: The objective was to describe disclosure preferences about serious illness of Korean Americans in New York City and characteristics associated with disclosure preferences. METHODS: A cross-sectional study of a volunteer sample of 26 Korean Americans, 65 years and older, was conducted. Interviews were conducted in Korean. Measures included comfort in talking about death and dying, disclosure preferences, disclosure to relatives, self-rated physical and mental health, and sociodemographic characteristics. RESULTS: Most agreed doctors should tell patients (n = 23) and relatives (n = 25) if they have cancer, and should tell patients (n = 22) and relatives if they are likely to die from this disease. Less than half (n = 9) agreed doctors should not discuss death and dying with patients, yet 15 agreed it is best to avoid talking about serious illness and dying before they occur. Participants who agreed a doctor should tell patients their cancer diagnosis were younger and had lived in the United States longer than those who disagreed. Self-rated physical health and mental health were associated with disclosure preferences. CONCLUSIONS: Health professionals are advised to determine the disclosure preferences about serious illness of older Korean Americans and avoid stereotypical assumptions that do not apply to many in this population.