A More Directive Living Will for Older Adult Patients with End-Stage Medical Conditions?

OBJECTIVES: Many older adult patients want to be treated aggressively for reversible conditions, even when their current quality of life is limited; however, most standard living wills focus on the very end of life and provide little guidance to acute care providers (ACPs) should their older adult patient be admitted with a potentially treatable acute condition and temporarily lose capacity. We developed what we believe is a more informational and directive living will for this population. We sought to determine whether ACPs would find our pilot living will more helpful when caring for their older adult patients. METHODS: Convenience sample of members of the Society of Hospital Medicine (SHM). Respondents were asked to compare the pilot living will with their state form and then answer five attitudinal questions. RESULTS: In total, 125 providers from 39 states completed the survey: 86% indicated that the pilot living will better helped them understand their patients' general end-of-life preferences, 87.5% indicated the pilot living will would be more helpful in making specific treatment decisions for their patients, and 85% indicated the pilot living will would better facilitate end-of-life discussions with surrogates. CONCLUSIONS: Our results suggest that it is possible to design a functional advanced directive that better reflects the wishes of the older adult patient who wants to be treated aggressively in selected clinical situations. By more clearly defining these wishes, acute providers (eg, hospitalists, intensivists) can make more informed, patient-centered recommendations to surrogates.

Evolving treatment of popliteal artery aneurysms.

BACKGROUND: Over the past decade, the treatment of popliteal aneurysms has evolved at our institution from sole operative intervention during the initial part of the study period, to combined surgical and endovascular treatment, and finally to endovascular-centered management in more recent years. METHODS: This is a retrospective review of all patients with popliteal aneurysms treated at our institution from 2001 to 2011. Data collection included the indication for intervention, treatment details, interventional patency, limb salvage, perioperative outcome, and midterm survival. RESULTS: Eighty-eight aneurysms (72 patients) were treated during this period. Indications for intervention included symptomatic presentations in 53% (n = 47) and asymptomatic in 47% (n = 41). Treatment included endovascular exclusion in 24, surgical repair in 63 (14 posterior approach and 49 medial approach with bypass and exclusion), and primary amputation in one patient. Nine aneurysms (10.2%) received catheter-directed thrombolysis. Demographics were similar between the two treatment cohorts, except for age with endovascular stenting patients being significantly older (76.0 vs 66.0 years; P = .002). The mean length of stay was 3.9 days vs 9.5 days (P < .001), favoring endovascular treatment. There were no perioperative (30-day) deaths in the endovascular group and one in the surgical cohort. The mean patency follow-up was 21.2 vs 28.3 months. Primary patency did not differ between endovascular and surgically treated patients at 1 year (92.9% vs 83.3%; P = .26) and 3 years (63.7% vs 77.8%; P = .93). No limbs were lost in the endovascular group during the follow-up period of 22.4 months, and one late limb loss occurred in the surgical cohort (mean follow-up, 29.2 months). Endovascular patients had a midterm survival rate of 65% (mean follow-up, 33.9 months), whereas surgical patients experienced a survival rate of 80.8% (mean follow-up, 42.9 months; P = .22). CONCLUSIONS: Endovascular treatment of popliteal aneurysms provides similar short-term patency to that of the traditional gold standard approach with surgical bypass, with shorter hospitalizations in both symptomatic and asymptomatic patients. Further long-term follow-up is required to compare these two treatment modalities for durability to determine the optimal popliteal aneurysm management.

Malposition of a central venous catheter into the right internal mammary vein: review of complications of catheter misplacement.

Central venous catheters are commonly utilized to gain vascular access for varied clinical indications. Successful catheter placement requires not only technical expertise but also awareness of the potential complications. In this article, we report a malposition of a central venous catheter in a hemodialysis patient. We review the complications of this catheter misplacement, as well as complications resulting from other central venous catheter malpositions.