Who decides? Physicians' willingness to use life-sustaining treatment.

BACKGROUND: Physician specialty training is associated with variations in the use of medical treatment for specific diseases. OBJECTIVE: To examine whether physicians' specialties predict differences in willingness to use life-sustaining treatments. METHODS: One hundred fifty-eight physicians (response rate, 85%) who cared for 378 hospitalized patients with end-stage congestive heart failure, chronic obstructive pulmonary disease, malignant neoplasms, or hepatic cirrhosis were interviewed to assess their thresholds for use of specific life-sustaining treatments. Their patients were then followed up to determine whether decisions were made to use or withhold cardiopulmonary resuscitation, ventilator support, or intensive care. Physicians' attitudes, their stated thresholds for treatment use, and their use of these treatments in daily practice were compared by specialty group. RESULTS: Physicians recommended cardiopulmonary resuscitation and ventilator support for patients with end-stage congestive heart failure or chronic obstructive pulmonary disease if the chance for survival was at lease 48%, but they required a predicted survival of at least 74% for patients with cancer. For a patient with end-stage congestive heart failure or chronic obstructive pulmonary disease, cardiologists were consistently more willing than other physicians to use life-sustaining treatments. In practice, decisions to use or withhold such treatments were made for 151 patients with end-stage diseases. Compared with other physicians, cardiologists were least likely to issue orders to withhold treatment and most likely to use life-sustaining treatments for patients they treated. Oncologists rarely used such treatments and issued orders to withhold these treatments much more often. CONCLUSION: Physician specialty is associated with differences in willingness to use, and in actual use of, life-sustaining treatments.

Impact of patient incompetence on decisions to use or withhold life-sustaining treatment.

PURPOSE: To study the relationship of patient incompetence to decisions to withhold life-sustaining treatments. DESIGN AND PATIENTS: This prospective cohort study consisted of 311 inpatients with end-stage congestive heart failure, chronic obstructive pulmonary disease, cancer, and cirrhosis. METHODS: Daily assessments were used to classify patients as incompetent if they had depressed consciousness, major psychiatric disease, or cognitive impairment throughout their hospital stay. Treatment decisions were assessed by observation and medical record review. RESULTS: Forty-eight (15%) patients were incompetent: 33 had depressed consciousness, 11 failed cognitive screens, and 4 had major psychoses. Incompetent patients were more severely ill (APACHE II score 14.9 versus 12.6, P < or = 0.05) and more commonly had cancer (73% versus 44%, P < or = 0.05). Decisions were made to withhold cardiopulmonary resuscitation (CPR) for 71% of incompetent patients, but for only 21% of competent patients (P < or = 0.001). Decisions to withhold other treatments were also more common for incompetent patients (42% versus 16%, P < or = 0.001). After controlling for differences in severity of illness, diagnosis, race, and insurance status, patient incompetence remained strongly associated with a decision to withhold CPR (odds ratio 4.0, 95% confidence interval 1.8 to 8.9) and with decisions to withhold other treatments (odds ratio 2.4, 95% confidence interval 1.1 to 5.3). Decisions for incompetent patients were made by physicians with family surrogates 79% of the time. No decision was based on a written advanced directive. Patient preference was the rationale for 41% of decisions to withhold CPR from incompetent patients. Major conflict occurred in only 1% of all cases where a decision was made to withhold treatment. CONCLUSIONS: Despite current legal and ethical debate, incompetent patients are far more likely than competent patients to have life-sustaining treatment withheld. Most decisions are made by a consensus of physicians and family surrogates, and major conflicts rarely occur.

Elder-proxy agreement concerning the functional status and medical history of the older person: the impact of caregiver burden and depressive symptomatology.

OBJECTIVES: To examine the influence of caregiver burden and depressive symptomatology on elder-proxy response concordance regarding the older person's functional status and medical history. DESIGN: Cross-sectional study via telephone interviews. SETTING: Community-dwelling older people and caregivers in North Carolina. PARTICIPANTS: 340 matched pairs of frail persons aged 65 and older and their respective caregivers. MEASUREMENTS: Multidimensional Functional Assessment: The OARS methodology RESULTS: Percent agreement on the ADL items ranged from 97.6% on personal hygiene to 99.7% for toileting, with moderate kappa coefficients. IADL percent agreement ranged from 71.5 to 93.7%, with fair to moderate kappa coefficients. Agreement among the medical history items ranged from 76.3 to 98.5% (kappa = .138-.831). Response bias for the IADL composite measure is influenced marginally by caregiver burden (F[259] = 1.751, P = .098). Five of the individual IADL bias items are influenced significantly by burden, such that an increase in burden results in a greater likelihood that the caregiver will overstate disability compared with the rating by the older person. Response bias on the ADL scale was increased among persons who experienced more caregiver burden (OR = 1.096, 95% CI = 1.000, 1.192) and those who spent more hours providing care (OR = 1.012, 95% CI = 1.001, 1.024). Additionally, black caregivers were more likely than white caregivers to disagree with the older people on the ADL scale (OR = 2.73, 95% CI = 1.642, 3.809). A composite of the medical history items is influenced by the relationship of the caregiver to the older person; bias is more likely among adult children ((F[227] = 1.56, P = .081). CONCLUSION: Elder-proxy concordance is highest among ADL items, followed by medical history items and IADL items. Caregiver depressive symptomotology had no significant impact on elder-proxy response concordance on any of the three outcomes of interest: IADL and medical history bias and ADL disagreement. However, caregiver burden was marginally predictive of bias on the total ADL and IADL scales. Additionally, increased burden was significantly predictive of bias on five of the seven individual items of the IADL scale, suggesting that the more burden a caregiver feels, the greater likelihood that s/he will overstate the older person's disability compared with self-report. These findings suggest that clinicians and researchers who use proxy reports to determine treatment regimens and complete data collection efforts may do so with confidence on ADL individual items and medical history items when the older person's frailty is marginal. However, caregiver burden may result in misleading representation of the older person's functional status, specifically in regard to IADL items.

Effect of satisfaction with one's abilities on positive and negative affect among individuals with recently diagnosed rheumatoid arthritis.

OBJECTIVE: The purpose of this study was to examine the effect that self-evaluation processes have on psychologic well-being among individuals with rheumatoid arthritis (RA). METHODS: The study used a longitudinal research design with 4 data collection points. Participants were 227 adults with recently diagnosed RA. Data were collected via mailed questionnaire and telephone interview. Two dimensions of psychologic well-being were assessed--positive affect and negative affect. RESULTS: We found that, among participants who viewed the abilities being evaluated as very important, greater satisfaction at time 1 was associated with less negative affect at time 2 and time 4. Satisfaction was not associated with positive affect at any of the time points, however. CONCLUSION: Study findings indicate that dissatisfaction with illness-related abilities can exacerbate psychologic distress. The findings also highlight the need for research examining the role that positive affect plays in adaptation to RA.

The effect of Channeling on in-home utilization and subsequent nursing home care: a simultaneous equation perspective.

OBJECTIVE: This study explored the relationship between participation in a home/community-based long-term care case management intervention (known as the Channeling demonstration), use of formal in-home care, and subsequent nursing home utilization. STUDY DESIGN: Structural analysis of the randomized Channeling intervention was conducted to decompose the total effects of Channeling on nursing home use into direct and indirect effects. DATA COLLECTION METHOD: Secondary data analysis of the National Long-Term Care Data Set. PRINCIPAL FINDINGS: The use of formal in-home care, which was increased by the Channeling intervention, was positively associated with nursing home utilization at 12 months. However, the negative direct effect of Channeling on nursing home use was of sufficient magnitude to offset this positive indirect effect, so that a small but significant negative total effect of Channeling on subsequent nursing home utilization was found. CONCLUSIONS: This study shows why Channeling did not have a large total impact on nursing home utilization. The analysis did not provide evidence of direct substitution of in-home care for nursing home care because the direct reductions in nursing home utilization due to other aspects of Channeling (including, but not limited to case management) were substantially offset by the indirect increases in nursing home utilization associated with additional home care use.

Wishes regarding the use of life-sustaining treatments among elderly persons in Israel: an explanatory model.

This study investigates the wishes of Israeli elderly concerning the use of life-sustaining treatments (LST) at the end of life, and suggests an explanatory causal model for these wishes. The data include 1138 Israeli elderly (70+) respondents. The results indicate that most of the elderly want to prolong their life in mild health conditions, including having cancer with a relatively good prognosis, while only a small percentage want LST in severe illness. Structural equation analysis (LISREL) of wishes for LST in severe illness conditions revealed that personal experience with other people's illnesses is the single most powerful explanatory factor affecting choice regarding LST directly and indirectly, channeled through fear of death and fear of dying. The results of such experiences whether positive or negative affect wishes for LST in the same direction; however, since they are mostly negative, past experience mostly weakens the will to prolong life by LST. Beliefs and feelings regarding life and death, such as fear of death, fear of dying, the will to live and religiosity, are also good predictors of wishes for LST. Those who fear death, have a strong will to live, and those who are more religious are more likely than others to want to prolong their life by LST, while those who fear dying want it less. Religiosity affects these wishes directly and indirectly through fear of death, fear of dying, and the will to live. Health status and social support have only a minor effect on wishes for LST: the higher the present quality of life, the more likely are the elderly to want LST. Most of the socio-demographic characteristics have no significant effect on elderly persons' wishes for LST. Only gender has a minor direct and indirect effect, channeled through the fear of dying and the will to live. Women in comparison to men want less LST because they fear dying more and have a weaker will to live. The results of this study shed some light on the explanatory factors of wishes for LST in severe illness conditions. More research is needed in order to promote social understanding of the concerns and wishes of the most relevant parties regarding the use of LST. This is a necessary condition for the formulation of new societal guidelines for general policy and daily behavior.

Stability of elderly persons' expressed preferences regarding the use of life-sustaining treatments.

The purpose of the study was to assess the stability of expressed preferences for the use of life-sustaining treatments (LST) in severe illness conditions over two years. The two year longitudinal study included three structured interviews with a one-year interval (1994, 1995, and 1996). At baseline, 1138 Israeli elderly persons (70+) were interviewed, 802 and 638 were interviewed in the following stages. Stability over time was assessed on the basis of score differences on two different indices that measured the wish to prolong life. Overall 70% of the respondents had stable preferences for the use of LST over time. This result was similar on both indices. The large majority of those with stable preferences (86%) did not want to prolong life already in the baseline interview. This was the most stable group. Among those who changed their wishes, the group that wanted LST less at stage 3 (20%) was twice as large as the group that wanted LST more (10%). These findings, which are similar to those reported in a study of an American sample, indicate a high level of stability in elderly persons' expressed preferences for LST at the end of life, and, therefore, strengthen the ethical basis for using advance directives. They also indicate that elderly persons of different cultural backgrounds may face similar problems regarding the prolongation of life and respond to them similarly.

The effect of channeling on home care utilization and satisfaction with care.

This study examined the relationship between participation in two home and community-based long-term care case management interventions (collectively known as the Channeling demonstration), use of formal in-home care, and satisfaction with care. Maximum likelihood estimation techniques were used to analyze the National Long-Term Care Demonstration data set. It was hypothesized that participation in the two Channeling interventions would indirectly (rather than directly) enhance satisfaction by operating through the increased use of formal in-home care. However, both Channeling models were found to have favorable direct and indirect effects on patient satisfaction.

Elders' preferences for care setting in short- and long-term disability scenarios.

Preference for long-term care (LTC) location among community-dwelling elders was assessed using short- and long-term disability scenarios (N = 537). Using Wilcoxon rank sum tests, we assessed differences in perceptions of financial difficulty, family strain, and personal stress by predisposing, enabling, and need factors. Using logistic regression we determined which factors were predictive of preference for LTC location. Frail and poor elders and those who lived alone had more financial and familial concerns; elders of higher social class anticipated more personal stress; elders with negative attitudes toward LTC facilities, who had fewer financial, familial and personal concerns, and who were married were more likely to prefer home care.

Does retirement hurt well-being? Factors influencing self-esteem and depression among retirees and workers.

A set of older workers from the Raleigh-Durham-Chapel Hill metropolitan area were followed for two years in order to explore the social psychological consequences of retirement. Three findings are of particular interest. First, when we separated workers who retired from those who continued to work and compared their self-esteem and depression scores over the two-year interval, we found that self-esteem scores did not change for either group, but that depression scores declined for workers who retired. Turning to differences between retirees and those who continued to work, regression analyses revealed that retirement had a positive influence on self-esteem and a negative influence on depression. In addition, earlier worker identity meanings had a stronger negative effect on the depression scores of respondents who continued to work than on those who retired.

Ethnicity, gender, and depressive symptoms in older workers.

We used data from a prospective investigation of full-time workers aged 58 to 64 years and residing in a North Carolina metropolitan area at baseline to examine a causal model for depressive symptomatology among White men, White women, African American men and African American women. We found significant group differences. (1) White men were more vulnerable to social network losses than White women; (2) Work stressors had long-term effects on African American men whose levels of depressive symptoms were also elevated by poor health and retirement; and (3) The influence of income was more dominant among African Americans and its effect was greater for African American women.

Attitudes of the critically ill toward prolonging life: the role of social support.

Desires to prolong life were investigated in a hospitalized sample of 212 persons over age 50 whose illnesses were severe and who had an average life expectancy of six to twelve months. The importance of social support was emphasized in defining the context in which the stressors of unfinished business and fear of death prompted desires to prolong life. Interactions existed in predicting desires for prolonging life based on ethnicity and whether respondents did or did not have sustained family contact. Family contact and salience increased the desire to live longer for African Americans, but not for Whites.

Models of adult day care: findings from a national survey.

We examined a nationally representative sample of 60 adult day care centers to describe the state of this evolving care modality after a decade's growth. Results indicate that day care centers can be categorized into three models of care, each of which serves a distinctive subpopulation. Model appropriateness was tested with analysis of variance of differences in participant characteristics. Services, staffing, costs, and other program features are contrasted among the three models.

Preferences for different life-sustaining treatments among elderly persons in Israel.

The purpose of this study was to assess elderly persons' wishes regarding the use and choice of different life-sustaining treatments (LST). Data were collected from a random sample of 987 Israeli elderly persons, aged 70+. Interviewees were questioned about their wishes for artificial feeding, mechanical ventilation, and cardiopulmonary resuscitation in five different illness conditions. Results indicate that significantly more of the respondents would want to prolong their life in mild rather than in severe illness conditions. Significant differences are found, however, among subgroups who differ on religiosity, gender, education, and health status. The findings also indicate that in all five illness conditions, elderly persons are more likely to want cardiopulmonary resuscitation than artificial feeding. This is explained by the fact that the public's main source of information is television dramas, and that there is a lack of communication about the use of LST among physicians and patients and their families.

Social support, depression, and recovery of walking ability following hip fracture surgery.

The importance of social support and depression to recovery from illness is examined with reference to hip fracture. Subjects were community-dwelling, ambulatory White females 59 years of age and over who were recovering from hip fracture surgery. The respondents were interviewed at baseline and clinically interviewed 2 and 6 months postsurgery. Inadequacy of social support and depression resulted in less improvement in walking ability at 2 months. By 6 months, the flow of casual influence was in the reverse direction, with low improvement in walking ability leading to increased level of depression. Social support's influence mediated the impact of health and background factors, but this was primarily at 2 months. If social support is to influence recovery, it must be present early in the recovery process. Social support's long-term consequences are indirectly operating through recovery measures taken shortly after the illness event.

Preretirement influences on postretirement self-esteem.

Data derived from in-depth telephone interviews with 300 retired workers from the Raleigh-Durham-Chapel Hill, North Carolina, metropolitan area are used to investigate whether preretirement self-investments in the roles of worker and spouse have positive or negative consequences for postretirement self-esteem. We find evidence that suggests that: (a) self-esteem does not decline in the transition into retirement; (b) commitment to the role of worker and worker identity meanings have a positive influence on postretirement self-esteem; but it may be indirect, operating through preretirement self-esteem; (c) commitment to the role of spouse has a positive impact on self-esteem in retirement; and (d) preretirement self-esteem continues to exert a positive effect on postretirement self-esteem. Thus, the findings suggest that preretirement self and identity factors continue to influence postretirement self-esteem.

Self-esteem and subjective responses to work among mature workers: similarities and differences by gender.

This study addressed three questions that underlie the experiences of middle-aged working individuals: (1) What factors influence workers' quality of time spent at work, their feelings of competence as a worker, and their satisfaction with work? (2) What is the impact of subjective responses to work on self-esteem? and (3) What effect does gender have on subjective responses and self-esteem? These data are derived from an ongoing study of full-time working men and women (N = 770). Subjective responses to work are affected by poor health. Quality of time at work (meaningful, not boring), job satisfaction, and an identity as a competent worker are associated with self-esteem. Self-esteem was higher among women in highly autonomous jobs, and nonmarried women had higher self-esteem than others. The strongest effect on self-esteem was that of feeling competent as a worker. Positive perceptions of work increased self-esteem, facilitating the transition into retirement.

Queues and care: how medical residents organize their work in a busy clinic.

How do medical residents organize their work in settings where queue demands are heavy and resources are limited? Under such conditions, a queue theory would predict the delivery of care that is indifferent to clients' needs or that gets rid of clients as quickly as possible. In an exploratory case study of medical residents in a Veterans Administration outpatient clinic, we found instead that the medical residents' work was characterized by a high level of professional commitment: they provided thorough medical examinations and attempted to expedite patient care in other ways. We attribute the residents' professional ethos to opportunities provided in the VA hospital to learn the craft of routine medicine and to be directly responsible for patient care; such opportunities were not available in other settings.

Patient age, visit purpose, and the ordering of consultations in a primary care clinic.

In this study we examine what factors determine whether patients seen in a Veterans Administration primary care clinic will be referred to specialty clinics. It is based on a 25% sample of all patients seen by the medical residents in one clinic over an 18-month period. Our dependent variable is whether the patient was referred for a consultation or not. We performed separate regression analyses for patients who visited the clinic with acute complaints, with chronic-flareup complaints, and with chronic-routine complaints. Within each of these three categories, we further subdivided our sample into patients under and over 65. In each of the six regression equations we controlled for the medical diagnosis and for each resident's work load, residency year, and training. Work load and residency year had opposite (and unpredicted) effects for patients over the age of 65 compared to those under the age of 65. Higher work loads were associated with higher consultation rates for patients over 65 and with lower rates for those under 65. Residency year had a negative effect on referrals for patients over 65 and a positive effect for patients under 65.