Physicians' and nurses' experiences of end-of-life decision-making in geriatric settings.

BACKGROUND AND AIMS: In Italy there is a paucity of empirical data on practices concerning end-of-life decisions (ELDs) in geriatrics. We aimed to investigate the frequency and characteristics of ELDs made by Italian physicians and nurses in the geriatric setting. METHODS: In 2009, an anonymous questionnaire was sent to 54 geriatric units, 21 hospices, and 382 nursing homes in the Veneto and Trentino Alto Adige regions, and to professionals in the area who are members of the Italian Gerontology and Geriatrics Association. RESULTS: This paper reports the results of 552 questionnaires answered by 171 physicians, 368 nurses and 13 professionals who did not state their profession. Death was preceded by decisions to start or continue treatments likely to prolong the patients' life in 51.3% of cases. The proportion of deaths preceded by a decision to end life (DEL) was 20.8%; 18% of DELs concerned non-treatment decisions. There were 9 cases of ending of life without patient's explicit request. No cases of doctor-assisted suicide were reported, while there were 2 cases of euthanasia, one reported by a physician and one by a nurse. CONCLUSION: In geriatrics, DELs often precede the deaths of terminally-ill Italian patients. Nurses report making DELs more often than physicians, especially in incompetent patients. Continuous deep sedation was adopted by 39.5% of the Italian physicians for deaths not occurring suddenly and unexpectedly. Our report on physicians' and nurses' experiences of ELD making in geriatric settings can offer a valuable contribution to the current debate on end-of-life treatment, an issue that goes beyond national borders.

Advanced dementia: opinions of physicians and nurses about antibiotic therapy, artificial hydration and nutrition in patients with different life expectancies.

AIM: The aim of the present study was to investigate the proportion of physicians and nurses who agree with the administration of antibiotic therapy (AT), artificial hydration (AH), and artificial nutrition (AN) in patients with advanced dementia and different life expectancies. Furthermore, we aimed at analyzing the correlates of the opinion according to which medical treatments should no longer be given to advanced dementia patients once their life expectancy falls. METHODS: End-of-life decisions and opinions were measured with a questionnaire that was sent to geriatric units, hospices and nursing homes in three different regions of Italy. Multivariate logistic regressions were carried out to ascertain the correlates of the agreement with the administration of AH, AT or AN. RESULTS: When the patient's life expectancy was 1-6 months, 83% of respondents agreed with AH, 79% with AT and 71% with AN. When the life expectancy was less than 1 month, a large proportion of respondents still agreed with AH and AT (73% and 61%), whereas less than one in two respondents (48%) agreed with AN. CONCLUSIONS: The findings of the present study showed that AN creates more ethical dilemmas in the clinical management of end of life than other treatments, such as AH or AT. Opinions on whether or not these practices are appropriate at the end of life were related with feelings, thoughts and ethical issues that played a different part for physicians and nurses. Geriatr Gerontol Int 2017; 17: 487-493.

Effect of restoring sinus rhythm in hypertensive patients with atrial fibrillation undergoing electrical cardioversion.

INTRODUCTION: Little is known about the effects of atrial fibrillation (AF) on blood pressure (BP) levels in hypertensive patients. Some studies suggest a role for rhythm control in managing such patients' BP, but the improvement observed in cardiac performance after restoring sinus rhythm (SR) may coincide with an increase in BP. The aim of this study was to apply ambulatory BP monitoring to analyze BP changes in hypertensive patients after electrical cardioversion for persistent AF. METHODS AND RESULTS: The study included 54 hypertensive patients with persistent AF. Ambulatory BP monitoring was performed on the day before electrical cardioversion and again about a month later under conditions of stable medical treatment.Patients with a SR at follow-up (n=34) had significantly higher 24-h, night-time (P<0.05), and daytime (P=0.074) systolic BP, and significantly lower 24-h, daytime (P<0.05), and night-time (P=0.078) DBP. The number of patients with nocturnal dipping decreased from 20 to 14 and the number of those with reverse dipping increased from 1 to 7. Patients with recurrent AF at follow-up (n=20) showed no significant BP changes, except for a decrease in the mean night-time DBP. CONCLUSION: Restoring SR in hypertensive patients with AF led to a significant increase in their systolic BP (especially at night) and a decrease in their DBP. Hypertensive patients with AF should consequently undergo ambulatory BP monitoring after electrical cardioversion for the purpose of adjusting their antihypertensive treatment.

Short- and longer-term predictive capacity of the Multidimensional Prognostic Index: The timing of the assessment is of no consequence.

BACKGROUND: Several studies have tested the ability of the Multidimensional Prognostic Index (MPI) to predict mortality for acute elderly patients admitted to hospital. We compared the reliability of MPI scores obtained both on admission to, and at discharge from hospital. We tested MPI performance in predicting short- and longer-term mortality grouped into three risk groups and according to single MPI scores. METHODS: A longitudinal prospective study was conducted on 699 elderly patients admitted to the Geriatric Unit at Padua General Hospital. MPI scores were obtained on admission and at discharge. In-hospital and one-year mortality was recorded. Adjusted Cox's regression models were used to assess the prognostic value of the MPI scores. RESULTS: 691 were included in the study: 459 (66.4%) women and 232 (33.6%) men, mean age=85.2 ± 7.0 years. Patients were grouped as: low risk MPI 12.5%; moderate risk MPI 28.6%; severe risk MPI 58.9%. The cumulative in-hospital mortality rate was 7.4%. In the adjusted model, only MPI score (not MPI risk group) was significantly associated with in-hospital death ([HR]=1.22, 95%CI 1.07-1.39). 1-Year crude mortality rate: 39.2%. The patients' MPI scores at admission and at discharge were equally predictive of death (adjusted HR of MPI on admission 1.20 [1.15-1.27], p<0.0001; at discharge 1.24 [1.18-1.30], p<0.0001). The performance (AUC) of the MPI score on admission and at discharge proved much the same. CONCLUSIONS: This study confirmed the value of the MPI in predicting mortality for acute elderly patients. Grouping MPI scores into risk levels may not be appropriate when applied to hospitalized acute geriatric patients. The prognostic value of MPI scores was confirmed only for MPI value ≥0.68. Judging from our study, the timing of the assessment during a patient's hospital stay (on admission or at discharge) may be irrelevant for longer-term prognostic purposes.

Reliability of Oscillometric Blood Pressure Monitoring in Atrial Fibrillation Patients Admitted for Electric Cardioversion.

The reliability of automated oscillometric blood pressure (BP) monitors in atrial fibrillation (AF) has been poorly investigated, only comparing different patients with AF and sinus rhythm (SR), and is a method influenced by individual characteristics. This study compared the reliability of the oscillometric device A&D TM-2430 (A&D Company, Tokyo, Japan) with that of a mercury sphygmomanometer in AF patients whose SR was restored after electric cardioversion (ECV). Three consecutive BP measurements were obtained on the day before and about 30 days after ECV in stable treatment conditions. Of the 100 patients studied, 63 reported an SR at follow-up, with a significant increase in systolic BP and a significant decrease in diastolic BP according to both devices. There were no significant differences between the systolic and diastolic biases before and after ECV using Bland Altman analysis (P > .05 each). The oscillometric device analyzed, using three repeated measurements, is reliable in measuring BP in AF patients.

Artificial nutrition and hydration in terminally ill patients with advanced dementia: opinions and correlates among Italian physicians and nurses.

BACKGROUND: Although their benefits are controversial, artificial nutrition and hydration are often administered as a form of basic care to terminally ill patients. An important reason for this may be that these treatments have strong emotional and psychological meanings. AIMS: In the present article we investigated the opinions of Italian physicians and nurses on the administration of artificial nutrition and hydration to terminally ill patients with advanced dementia. We also investigated the antecedents of these opinions, considering feelings and thoughts related to death, ethical issues and training in palliative care. METHOD: A questionnaire was administered to Italian physicians (n=288) and nurses (n=763). We analyzed the percentages of agreement with the administration of artificial nutrition and hydration and, using multivariate logistic regressions, the possible antecedents of these opinions. RESULTS: Agreement with the provision of artificial hydration was higher (73%) than for artificial nutrition (48%), suggesting that artificial hydration may be seen as a form of basic care. Agreement with their administration was generally lower among professionals in northern Italy working in geriatrics wards who had received training in palliative care. We also found that death-related feelings and thoughts and ethical issues played a different part for physicians and nurses. CONCLUSIONS: Our findings suggest that opinions concerning artificial nutrition and hydration not only derive from scientific background, but also relate to cultural, ethical, and psychological issues. Our results also reveal important differences between physicians' and nurses' opinions, providing useful information for interpreting and overcoming obstacles to the effective cooperation between these professionals.