Living wills and resuscitation preferences in an elderly population.

BACKGROUND: Living wills are considered clear and convincing evidence of a person's preferences for end-of-life treatment. Unfortunately, living wills often use vague language that forces physicians and others to infer specific treatment choices, like the choice to forgo cardiopulmonary resuscitation (CPR). To test the validity of such inferences we examined the relationship between living will completion and CPR preference. We also examined whether CPR choices were fixed or could be influenced by detailed information on CPR. METHODS: We interviewed 102 retired elderly persons, many of whom had living wills. We obtained CPR preferences in five hypothetical scenarios before and after providing CPR information. We then analyzed differences in desire for CPR between the group of subjects with living wills and the group without. RESULTS: In each scenario there were subjects in both groups who desired CPR. The group with living wills desired less CPR in scenarios involving functional impairment and cognitive impairment, but not in scenarios involving current health, severe illness, and terminal illness. After receiving CPR information, both groups changed their preferences such that intergroup differences were no longer seen. CONCLUSIONS: Preferences for CPR among subjects with living wills are not homogeneous, but distributed across the clinical scenarios. Therefore, one cannot infer CPR preference from the mere presence of a living will. Cardiopulmonary resuscitation information can influence preferences even among persons with living wills, implying that preferences are neither fixed nor always based on adequate information. Physicians should view vaguely worded documents as unreliable expressions of treatment preference that should not supplant informed discussion.

Educating the elderly: cardiopulmonary resuscitation decisions before and after intervention.

Considering the limited success of cardiopulmonary resuscitation (CPR) in achieving survival to hospital discharge in older persons, it is appropriate to educate, discuss and determine patients' wishes at a time when they are able. Sixty-four ambulatory, non-depressed, non-demented veterans greater than 74 years of age were interviewed and educated. Knowledge of CPR at baseline was variable and most overestimated their survival chances. Most subjects desired routine CPR discussions with physicians. Only 17% had previously discussed their CPR preferences, and none had done so with physicians. Knowledge of CPR increased (P = 0.01) after educational intervention. There was no change in subjects' CPR decisions after education and presentation of current CPR outcome data. In considering five hypothetical scenarios, 9% never wanted CPR, and 17% always wanted CPR. Those who never wanted CPR were more realistic about their suspected survival chance (P = 0.003) and had higher educational levels (P = 0.03) Folstein (P = 0.03) and Geriatric Depression Scale (P = 0.04) scores. With the dependent variable being the number of hypothetical situations in which the patient desired CPR, a regression analysis (adjusted r2 = 0.72) limited significant variables to the patient's current CPR decision, Folstein score, religion, marital status, and previous ICU admissions. This study emphasizes that most elderly male veterans are willing and want to discuss their CPR attitude with physicians and that most have fixed CPR decisions which may be elicited under stable clinical conditions.

Life values, resuscitation preferences, and the applicability of living wills in an older population.

OBJECTIVES: To determine whether life values are related to resuscitation preferences and living will completion in an older population and to assess beliefs about the applicability of living wills. DESIGN: Individual structured interviews. SETTING: An independent retirement community. PARTICIPANTS: One hundred thirty-two subjects older than 63 years of age. MEASUREMENTS: Resuscitation preferences were elicited in five hypothetical scenarios. Subjects with living wills were asked whether their living will would play a role in the scenarios. Subjects rated the importance of 13 life value statements. RESULTS: The percentage of subjects desiring CPR in each scenario was as follows: current condition (66%); acute illness (33%); terminal disease (8%); functional impairment (8%); and dementia (7%). The percentage of those with a living will who thought their living wills would play a role in the scenarios was as follows: acute illness (84%); terminal disease (93%); functional impairment with intact cognition (66%); and dementia (91%). Factor analysis of the life value statements revealed five meaningful factors: quality of life; capacity/autonomy; family relations; physical comfort; and treatment philosophy. Multiple correlations were found between four of five life value factors and hypothetical resuscitation preferences or the presence of a living will. CONCLUSION: Subjects misinterpreted the applicability of living wills in nonterminal illness scenarios. A relationship between life values and resuscitation preferences was noted, which emphasizes the importance of eliciting and including life values when discussing advance directives.

Educational objectives for medical training in the care of the terminally ill.

BACKGROUND: Palliative medicine is developing as a distinct clinical discipline worldwide. The U.S. literature describes goals for education in palliative medicine, yet this literature lacks validated educational objectives. METHOD: To develop and validate appropriate educational objectives for medical training in the care of the terminally ill, 200 randomly selected members of the Academy of Hospice Physicians were asked in 1992 to evaluate 39 educational objectives by an item-objective congruence procedure. Each objective was rated as -1 (inappropriate), 0 (unsure), or 1 (appropriate). RESULTS: Of the 200 members surveyed, 127 (64%) responded. Of the 39 objectives, 34 were considered valid, with a mean score of > or = .8. The index of content validity was .87. The objectives not considered valid all dealt with nonmedical issues related to hospice or palliative care. CONCLUSION: This study validated 34 educational objectives for medical training in the care of the terminally ill. Training programs using these objectives, amended for specific audiences, should be included in the various levels of U.S. medical education.

Care of the dying geriatric patient.

As the United State's population continues to age, there will be an increasing need to provide optimal care for terminally ill elderly patients. Physicians have a responsibility to provide care for elderly patients who are dying or in the end stages of an incurable illness. Hospice care has grown from an alternative health care movement to an accepted part of American medical care, and can be an ideal method of managing the terminally ill elderly patient. Hospice care incorporates the concept of palliative care and is designed to support the physical, psychosocial, and spiritual needs of patients at the end of life. The need for hospice care, its development, philosophies, and general principles are presented in this article.

Advances in hospice care.

Hospice care developed in part as a reaction to the impersonal and technology-dependent end-of-life care offered by modern medicine. Unique approaches to care that emphasize interdisciplinary team management of troublesome symptoms and the promotion of quality of life as defined by the patient, are finding their way into all aspects of health care. Symptom control measures have expanded to include chemotherapy, radiation therapy, and multimodal therapies. Both the development of a unique knowledge base and advances in research have fostered the integration of hospice and palliative care into mainstream medicine.

The case for hospice care in long-term care environments.

Hospice care typically is underused in long-term care facilities. Although these programs do provide other quality services, routine measurement of important parameters of end-of-life care, such as pain control, dyspnea, and spiritual and psychosocial issues, should also occur. Health care providers working in long-term care facilities should be held accountable for high-quality care for dying residents. In this environment, the benefits of hospice or hospicelike services may become immediately apparent. Continued attention to changes in the Medicare Hospice Benefits to improve patient access to hospice services and health care delivery for those living in long-term care facilities is warranted.

Physician board certification in hospice and palliative medicine.

The American Board of Hospice and Palliative Medicine (ABHPM) was formed in 1995 to establish and implement standards for certification of physicians practicing hospice and palliative medicine and, ultimately, accreditation of physician training in this discipline. The ABHPM has created a certification process that parallels other member boards of the American Board of Medical Specialties (ABMS). After 3(1/2) years and the administration of seven examinations, 623 physicians have achieved board certification in hospice and palliative medicine. Those with ABMS primary board certifications have been certified by anesthesiology, 4%; family practice, 23%; internal medicine, 55%; pediatrics, 1%; radiation oncology, 2%; and surgery, 2%. The majority describe their practice location as urban. Sixty-nine percent report more than 5 years of clinical experience in hospice/palliative medicine and 75% report an association with a hospice as medical director or hospice physician. Sixty-seven percent belong to the American Academy of Hospice and Palliative Medicine. Applicants were drawn from 48 states, Canada, and 3 foreign countries. The available data indicate only 20% were less than 40 years of age and that two-thirds were men. There is significant physician interest in seeking professional recognition of expertise in caring for terminally ill persons and their families through creation of a specialty in hospice and palliative medicine. Certification of physicians and accreditation of training programs are key elements in this process. This process will encourage more physicians to enter this field and provide needed expertise in the management of patients with progressive disease for whom the prognosis is limited, and the focus of care is quality of life.

Geriatric oncology.

The incidence and prevalence of cancer will continue to rise in the elderly. Malignancies can present differently and have altered courses in the elderly. Heterogeneity exists within the geriatric population, and chronologic age alone should not be used to exclude older cancer patients from consideration for standard diagnostic therapeutic approaches. Early detection of malignancies in the aged remains a problem, and geriatric screening issues are discussed.

Review of Medicare's proposed hospice eligibility criteria for select noncancer patients.

Recent events have challenged our health system to increase access to and provide high quality care for patients near the end of life. Simultaneously, Medicare is developing review policies to determine eligibility for hospice patients with select noncancer diagnoses. The purpose of this study was to determine whether the proposed policies met one of their chief goals: accurate identification of patients with a less-than-six-months prognosis. Only 35 percent of 104 patients who died within six months of admission to the hospice used for this study, LifePath Hospice, met the Medicare proposed criteria for hospice eligibility. The median and mean survival time of the sample was 14 and 30 days respectively. Based on this review, it is recommended that Medicare alter their proposed review policies and not limit access to hospice eligible patients who desire and are in need of such services.

Assessment and management of pain in palliative care patients.

BACKGROUND: Pain affects more than 70% of cancer patients but is often undertreated. METHODS: The authors review and present methodologies to maximize proper palliative approaches to this symptom for the majority of patients. RESULTS: The World Health Organization's stepwise guide to pain control serves as an excellent basis for management. Around-the-clock dosing, using adjuvant treatments, and using noninvasive routes of administration provide good pain control for 80% of patients. CONCLUSIONS: Barriers to effective pain control will be reduced as new JCAHO standards regarding pain control are implemented.

Chronic Morganella morganii arthritis in an elderly patient.

This report describes the first case of septic arthritis caused by Morganella morganii. The elderly patient's course of pyoarthritis was atypical in its benign clinical presentation, having little inflammatory response over a prolonged period. Septic arthritis should be considered as a possible diagnosis in all elderly patients with joint effusions.

Hospice care in the nursing home.

Hospice care is being used more frequently to provide skills and services that are not otherwise available in nursing homes. For eligible terminally ill patients, the Medicare Hospice Benefit supplies an interdisciplinary team with skills in pain management, symptom control and bereavement assistance. The Medicare Hospice Benefit also covers the cost of durable medical equipment and drugs, except for a nominal drug copayment fee. The services of the hospice team supplement the usual nursing home care at a time when staff, family members and the patient are facing the increased and urgent needs associated with the dying process. The Medicare Hospice Benefit can make it much easier for physicians and nursing home staff to provide comprehensive palliative care for terminally ill patients.

The lack of advance directives among hospice patients.

This study reported a lower than expected prevalence of advance directives among hospice patients. The presence of an advance directive was related to certain sociodemographic factors, diagnosis, and previous physician-patient advance directive discussions. Barriers that precluded the completion of an advance directive primarily involved a lack of physician-patient advance directive discussions or a lack of patient understanding. This study confirmed the importance of physician-patient discussion toward completion of an advance directive. Improving physician-patient communication about this issue should increase the prevalence of advance directive completion among hospice patients.

Prognostic factors for survival in terminal lung cancer patients.

OBJECTIVE: To determine the factors that are related to short-term survival and to develop a model that can be used to estimate prognosis in terminal lung cancer patients. DESIGN: Longitudinal cohort study of hospice lung cancer patients followed from date of admission to hospice until death. SETTING: Community-based nonprofit home hospice service. PATIENTS: Three hundred ten consecutive lung cancer patients admitted to hospice, with a separate validation sample of 78 consecutive hospice lung cancer patients. MEASUREMENTS: The relationships between survival and admission demographic characteristics, information from the history and physical examination, assessments of performance and nutrition, particular symptoms, and the presence of a living will were evaluated. RESULTS: Mean survival was 51 days, with a median survival of 27 days. Shorter survival was independently associated with those who had no living will on admission to hospice (p = 0.008), those who had tissue types other than squamous cell or adenocarcinoma (p = 0.008), those who had liver metastases (p = 0.04), those who were tachycardic (p < 0.001), those who required assistance or were dependent in their toileting (p < 0.001) and feeding (p = 0.001), those who had dry mouths (p = 0.01), and those who had severe or incapacitating pain (p < 0.05). A model estimating survival time based on the number of these significant variables present is reported (r = 0.53 in the original sample; r = 0.38 in the validation sample). CONCLUSIONS: Multiple factors, including tissue type, the presence of metastases, assessments of functional status, specific symptoms, and the presence of a living will, were related to short-term survival in terminal lung cancer patients admitted to hospice. A model utilizing these specific factors allows useful estimates of short-term survival for these patients.

Resuscitation decision making in the elderly: the value of outcome data.

OBJECTIVE: To assess the relationship between cardiopulmonary resuscitation (CPR) information and desire for CPR in an elderly population and to determine the influence of outcome data on desire for CPR in older persons. DESIGN: An interventional study utilizing an educational program. SETTING: Elderly independent retirement community. PARTICIPANTS: One hundred two persons, all more than 62 years old, who were neither demented nor depressed. INTERVENTION: Participants received an educational intervention consisting of descriptive CPR information and quantitative information about CPR outcomes. CPR information, survival estimates, and preferences were recorded prior to and after the intervention. MEASUREMENTS AND MAIN RESULTS: Subjects exhibited a high level of basic knowledge about CPR, which did not change with the intervention. While subjects consistently overestimated their chances of survival post CPR, these estimates decreased toward more realistic levels after the intervention (p < 0.001). CPR preferences changed in three of five hypothetical clinical scenarios after the intervention (p < 0.05). Those who were more realistic in their estimates of CPR survival desired less CPR in the hypothetical scenarios (p < 0.01). A trend in our data suggest that quantitative outcome information may have a greater influence on CPR preferences than has descriptive information (p = 0.07). CONCLUSIONS: CPR preferences changed after an educational intervention. An improved understanding of quantitative outcome data appears to influence the desire for CPR and therefore should be included in CPR discussions with older patients.

Review: patient-related predictors of cardiopulmonary resuscitation of hospitalized patients.

We reviewed 32 studies to determine whether patient-related factors predict the effectiveness of cardiopulmonary resuscitation (CPR) of hospitalized patients. Limitations of individual studies are described. Single factors and multiple factors, as used in the Pre-arrest Morbidity (PAM) Index, were examined for their ability to predict CPR outcome. Although certain clinical conditions appear to predict CPR survival best, other individual patient-related factors influence the effectiveness of CPR. The PAM Index is superior to single factors in predicting survival after CPR in hospitalized patients, possibly because it is multifactorial. As some studies reveal efficacy of only some of the variables of the PAM Index, a modification of the PAM Index is proposed as an effective tool for predicting CPR outcome. Such a modification may offer geriatricians a practical basis on which some difficult 'do not resuscitate' decisions can be based.

Estimation of survival time in terminal cancer patients: an impedance to hospice admissions?

Accurate estimation of survival time in terminal cancer patients is difficult yet may provide useful information. A historical prospective study on 172 patients admitted to a home based hospice service was performed to determine which variables were best correlated with survival time. Mean and median survival were 48 and 22 days, respectively, representing a highly skewed distribution of life span in this sample. As age increased, survival time decreased. All Activities of Daily Living (ADLs) recorded (Bathing, Continence, Dressing and Transfer) as well as other measures of performance (mobility and pulse) and nutrition (appetite and nourishment) were each strongly associated with survival. Multivariate analysis limited significant variables to dressing ability, pulse rate, level of appetite and transferring ability. Outliers (survival greater than 180 days) were differentiated from the remainder of the sample by significant differences in all ADLs recorded as well as the level of appetite. These findings establish the importance of assessing ADLs, a measure of functional status, and reinforce the importance of performance and nutrition measures when estimating length of survival in terminal cancer patients.