Association between advance directives and quality of end-of-life care: a national study

OBJECTIVES: To examine the role of advance directives (ADs) 10 years after the Patient Self-Determination Act. DESIGN: Mortality follow-back survey. SETTING: People who died in a nursing home, hospital, or at home. PARTICIPANTS: Bereaved family member or other knowledgeable informant. MEASUREMENTS: Telephone interviewers that asked about the use of written ADs, use of life-sustaining treatment, and quality of care by asking whether staff provided desired symptom relief, treated the dying with respect, supported shared decision-making, coordinated care, and provided family with the needed information and emotional support. RESULTS: Of the 1,587 people who died, 70.8% had an AD. Persons who died at home with hospice or in a nursing home were more likely to have an AD. In addition, those with an AD were less likely to have a feeding tube (17% vs 27%) or use a respirator in the last month of life (11.8% vs 22.0%). Bereaved family members who reported that the decedent did not have an AD were more likely to report concerns with physician communication (adjusted odds ratio (AOR)=1.4, 95% confidence interval (CI)=1.1-1.6) and with being informed about what to expect (AOR=1.2, 95% CI=1.0-1.3). No statistically significant differences were observed in other outcomes. Even in those with an AD, important quality concerns remained; one in four reported an unmet need in pain, one in two reported inadequate emotional support for the patient, and one in three stated inadequate family emotional support. CONCLUSION: Bereaved family member report of completion of an AD was associated with greater use of hospice and fewer reported concerns with communication, yet important opportunities remain to improve the quality of end-of-life care.     

Physicians "missing in action": family perspectives on physician and staffing problems in end-of-life care in the nursing home

OBJECTIVES: To understand the roles of physicians and staff in nursing homes in relation to end-of-life care through narrative interviews with family members close to a decedent. DESIGN: Qualitative follow-up interviews with 54 respondents who had participated in an earlier national survey of 1,578 informants. SETTING: Brown University interviewers conducted telephone interviews with participants throughout the United States. PARTICIPANTS: The 54 participants agreed to a follow-up qualitative interview and were family members or close to the decedent. MEASUREMENTS: A five-member, multidisciplinary team to identify overarching themes taped, transcribed, and then coded interviews. RESULTS: Respondents report that healthcare professionals often insufficiently address the needs of dying patients in nursing homes and that "missing in action" physicians and insufficient staffing create extra burdens on dying nursing home residents and their families. CONCLUSION: Sustained efforts to increase the presence of physicians and improve staffing in nursing homes are suggested to improve end-of-life care for dying residents in nursing homes.     

The effect of dementia on outcomes and process of care for Medicare beneficiaries admitted with acute myocardial infarction

OBJECTIVES: To determine differences in mortality after admission for acute myocardial infarction (AMI) and in use of noninvasive and invasive treatments for AMI between patients with and without dementia. DESIGN: Retrospective chart review. SETTING: Cooperative Cardiovascular Project. PATIENTS: Medicare patients admitted for AMI (N=129,092) in 1994 and 1995. MEASUREMENTS: Dementia noted on medical chart as history of dementia, Alzheimer's disease, chronic confusion, or senility. Outcome measures included mortality at 30 days and 1-year postadmission; use of aspirin, beta-blocker, angiotensin-converting enzyme (ACE) inhibitor, thrombolytic therapy, cardiac catheterization, coronary angioplasty, and cardiac bypass surgery compared by dementia status. RESULTS: Dementia was associated with higher mortality at 30 days (relative risk (RR)=1.16, 95% confidence interval (CI)=1.09-1.22) and at 1-year postadmission (RR=1.18, 95% CI=1.13-1.23). There were few to no differences in the use of aspirin and beta-blockers between patients with and without a history of dementia. Patients with a history of dementia were less likely to receive ACE inhibitors during the stay (RR=0.89, 95% CI=0.86-0.93) or at discharge (RR=0.90, 95% CI=0.86-0.95), thrombolytic therapy (RR=0.82, 95% CI=0.74-0.90), catheterization (RR=0.51, 95% CI=0.47-0.55), coronary angioplasty (RR=0.58, 95% CI=0.51-0.66), and cardiac bypass surgery (RR=0.41, 95% CI=0.33-0.50) than patients without a history of dementia. CONCLUSION: The results imply that the presence of dementia had a major effect on mortality and care patterns for this condition.     

End-of-life care in black and white: race matters for medical care of dying patients and their families

OBJECTIVES: To compare the end-of-life medical care experienced by African-American and white decedents and their families. DESIGN: Cross-sectional, retrospective survey with weighted results based on a two-stage probability sampling design. SETTING: Hospitals, nursing homes, and home-based medical services across the United States. PARTICIPANTS: Surrogates (N=1,447; primarily family members) for decedents from 22 states. MEASUREMENTS: Validated end-of-life care outcomes concerning symptom management, decision-making, informing and supporting families, individualized care, coordination, service utilization, and financial impact. RESULTS: Family members of African-American decedents were less likely than those of white decedents to rate the care received as excellent or very good (odds ratio (OR)=0.4). They were more likely to report absent (OR=2.4) or problematic (OR=1.9) physician communication, concerns with being informed (OR=2.5), and concerns with family support (OR=2.6). Family members of African Americans were less likely than those of whites to report that the decedent had treatment wishes (OR=0.3) or written advance care planning documents (OR=0.4). These differences persist when limiting the sample to respondents whose expectations for life-sustaining treatments matched treatments received. Family members of African-American decedents also were more likely to report financial hardship due to savings depletion (OR=2.1) or difficulty paying for care (OR=2.0) and that family/friends (OR=2.0) or home health workers (OR=1.9) provided home care. CONCLUSION: This national study brings evidence that racial disparities persist into end-of-life care, particularly regarding communication and family needs. Results also suggest different home care patterns and levels of financial impact.     

Burnout syndrome in critical care nursing staff

RATIONALE: Burnout syndrome (BOS) associated with stress has been documented in health care professionals in many specialties. The intensive care unit (ICU) is a highly stressful environment. Little is known about BOS in critical care nursing staff. OBJECTIVES: To identify determinants of BOS in critical care nurses. METHODS: We conducted a questionnaire survey in France. Among 278 ICUs contacted for the study, 165 (59.4%) included 2,525 nursing staff members, of whom 2,392 returned questionnaires with complete Maslach Burnout Inventory data. MEASUREMENTS AND MAIN RESULTS: Of the 2,392 respondents (82% female), 80% were nurses, 15% nursing assistants, and 5% head nurses. Severe BOS-related symptoms were identified in 790 (33%) respondents. By multivariate analysis, four domains were associated with severe BOS: (1) personal characteristics, such as age (odds ratio [OR], 0.97/yr; confidence interval [CI], 0.96-0.99; p=0.0008); (2) organizational factors, such as ability to choose days off (OR, 0.69; CI, 0.52-0.91; p=0.009) or participation in an ICU research group (OR, 0.74; CI, 0.56-0.97; p=0.03); (3) quality of working relations (1-10 scale), such as conflicts with patients (OR, 1.96; CI, 1.16-1.30; p=0.01), relationship with head nurse (OR, 0.92/point; CI, 0.86-0.98; p=0.02) or physicians (OR, 0.81; CI, 0.74-0.87; p=0.0001); and (4) end-of-life related factors, such as caring for a dying patient (OR, 1.39; CI, 1.04-1.85; p=0.02), and number of decisions to forego life-sustaining treatments in the last week (OR, 1.14; CI, 1.01-1.29; p=0.04). CONCLUSION: One-third of ICU nursing staff had severe BOS. Areas for improvement identified in our study include conflict prevention, participation in ICU research groups, and better management of end-of-life care. Interventional studies are needed to investigate these potentially preventive strategies.     

Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide

BACKGROUND: The practices of euthanasia and physician-assisted suicide remain controversial. OBJECTIVE: To achieve better understanding of attitudes and practices regarding euthanasia and physician-assisted suicide in the context of end-of-life care. DESIGN: Cohort study. SETTING: United States. PARTICIPANTS: 3299 oncologists who are members of the American Society of Clinical Oncology. MEASUREMENTS: Responses to survey questions on attitudes toward euthanasia and physician-assisted suicide for a terminally ill patient with prostate cancer who has unremitting pain, requests for and performance of euthanasia and physician-assisted suicide, and sociodemographic characteristics. RESULTS: Of U.S. oncologists surveyed, 22.5% supported the use of physician-assisted suicide for a terminally ill patient with unremitting pain and 6.5% supported euthanasia. Oncologists who were reluctant to increase the dose of intravenous morphine for terminally ill patients in excruciating pain (odds ratio [OR], 0.61 [95% CI, 0.48 to 0.77]) and had sufficient time to talk to dying patients about end-of-life care issues (OR, 0.79 [CI, 0.71 to 0.87]) were less likely to support euthanasia or physician-assisted suicide. During their career, 3.7% of surveyed oncologists had performed euthanasia and 10.8% had performed physician-assisted suicide. Oncologists who were reluctant to increase the morphine dose for patients in excruciating pain (OR, 0.58 [CI, 0.43 to 0.79]) and those who believed that they had received adequate training in end-of-life care (OR, 0.86 [CI, 0.79 to 0.95]) were less likely to have performed euthanasia or physician-assisted suicide. Oncologists who reported not being able to obtain all the care that a dying patient needed were more likely to have performed euthanasia (P = 0.001). CONCLUSIONS: Requests for euthanasia and physician-assisted suicide are likely to decrease as training in end-of-life care improves and the ability of physicians to provide this care to their patients is enhanced.     

Are Patient Preferences for Life‐Sustaining Treatment Really a Barrier to Hospice Enrollment for Older Adults with Serious Illness?

OBJECTIVES: To determine whether patient preferences are a barrier to hospice enrollment. DESIGN: Prospective cohort study. SETTING: Fifteen ambulatory primary care and specialty clinics and three general medicine inpatient units. PARTICIPANTS: Two hundred three seriously ill patients with cancer (n=65, 32%), congestive heart failure (n=77, 38%), and chronic obstructive pulmonary disease (n=61, 30%) completed multiple interviews over a period of up to 24 months. MEASUREMENTS: Preferences for high- and low-burden life-sustaining treatment and site of death and concern about being kept alive by machines. RESULTS: Patients were more likely to enroll in hospice after interviews at which they said that they did not want low-burden treatment (3 patients enrolled/16 interviews at which patients did not want low-burden treatment vs 47 patients enrolled/841 interviews at which patients wanted low-burden treatment; relative risk (RR)=3.36, 95% confidence interval (CI)=1.17-9.66), as were interviews at which patients said they would not want high-burden treatment (5/28 vs 45/826; RR=3.28, 95% CI=1.14-7.62), although most patients whose preferences were consistent with hospice did not enroll before the next interview. In multivariable Cox regression models, patients with noncancer diagnoses who desired low-burden treatment (hazard ratio (HR)=0.46, 95% CI=0.33-0.68) were less likely to enroll in hospice, and those who were concerned that they would be kept alive by machines were more likely to enroll (HR=5.46, 95% CI=1.86-15.88), although in patients with cancer, neither preferences nor concerns about receiving excessive treatment were associated with hospice enrollment. Preference for site of death was not associated with hospice enrollment. CONCLUSION: Overall, few patients had treatment preferences that would make them eligible for hospice, although even in patients whose preferences were consistent with hospice, few enrolled. Efforts to improve end-of-life care should offer alternatives to hospice that do not require patients to give up life-sustaining treatment, as well as interventions to improve communication about patients' preferences.     

Improving care for patients dying in the intensive care unit

It is impossible for ICU clinicians to avoid caring for dying patients and their families. For many, this is an extremely rewarding aspect of their clinical practice. There is ample evidence that there is room to improve the care of patients who are near death in the ICU. Despite the considerable holes in our knowledge about optimal care of dying critically ill patients, there is considerable agreement on the general principles of caring for these patients and about how to measure the outcomes of palliative care in the ICU. Practical approaches to improving the quality of end-of-life care exist and should be implemented.     

High rates of advance care planning in New York City's elderly population

BACKGROUND: Previous studies have demonstrated low rates of advance care planning (ACP), particularly among nonwhite populations, raising questions about the generalizability of this decision-making process. OBJECTIVE: To explore factors that may influence patients' willingness to engage in ACP. DESIGN: Survey. SETTING: Thirty-four randomly selected New York City senior centers. PARTICIPANTS: A total of 700 African American (n = 239), Hispanic (n = 237), and white (n = 224) adults 60 years and older. INTERVENTION: Participants were administered a 51-item survey that assessed attitudes, beliefs, and practices regarding ACP. MAIN OUTCOME MEASURES: Attitudes and beliefs about physicians' trustworthiness, fatalism, beliefs about surrogate decision making, and comfort discussing end-of-life medical care; factors associated with health care proxy completion; and health care proxy completion rates. RESULTS: More than one third of the participants had completed a health care proxy. There were no significant differences in completion rates across the 3 ethnic groups. Respondents who had a primary care physician (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.3-3.2), were more knowledgeable about advance directives (OR, 2.0; 95% CI, 1.4-2.9), or had seen a friend or family member use a mechanical ventilator (OR, 1.5; 95% CI, 1.02-2.1) were significantly more likely to have designated a health care proxy. Respondents who were only comfortable discussing ACP if the discussion was initiated by the physician (OR, 0.6; 95% CI, 0.0-0.8) were significantly less likely to have completed a health care proxy. CONCLUSIONS: African American, Hispanic, and white community-dwelling, older adults had similarly high rates of advance directive completion. The primary predictors of advance directive completion involved modifiable factors such as established primary care physicians, personal experience with mechanical ventilation, knowledge about the process of ACP, and physicians' willingness to effectively initiate such discussions. Some of the racial/ethnic differences in desire for collective family-based decision making that were observed in this study have implications for the evolution of ACP policy that respects and operationalizes these preferences.     

Does Hospice Improve Quality of Care for Persons Dying from Dementia?

OBJECTIVES: To examine the effectiveness of hospice services for persons dying from dementia from the perspective of bereaved family members. DESIGN: Mortality follow‐back survey. SETTING: Death certificates were drawn from five states (AL, FL, TX, MA, and MN). PARTICIPANTS: Bereaved family members listed as the next of kin on death certificates when dementia was listed as the cause of death. MEASUREMENTS: Ratings of the quality of end‐of‐life care, perceptions of unmet needs, and opportunities to improve end‐of‐life care. Two questions were also asked about the peacefulness of dying and quality of dying. RESULTS: Of 538 respondents, 260 (48.3%) received hospice services. Family members of decedents who received hospice services reported fewer unmet needs and concerns with quality of care (adjusted odds ratio (AOR)=0.49, 95% confidence interval (CI)=0.33–0.74) and a higher rating of the quality of care (AOR=2.0, 95% CI=1.53–2.72). They also noted better quality of dying than those without hospice services. CONCLUSION: Bereaved family members of people with dementia who received hospice reported higher perceptions of the quality of care and quality of dying.     

Skilled care requirements for elderly patients after coronary artery bypass grafting

OBJECTIVES: To examine the extent to which elderly individuals use various skilled care facilities after coronary artery bypass grafting (CABG). DESIGN: Retrospective cohort study. SETTING: State of Michigan from 1997 to 1998. PARTICIPANTS: Residents aged 65 and older enrolled in Medicare who underwent CABG. MEASUREMENTS: Cumulative incidence of admission within 100 days of hospital discharge, relative risk (RR) of admission, readmission or extended stay at a skilled care facility, and length of stay in a skilled care facility. RESULTS: Fifty percent of patients aged 80 and older used a skilled care facility after CABG, with most requiring admission to a skilled nursing facility (SNF) or readmission to an acute-care hospital within 100 days after discharge. Patients aged 80 and older had a significantly higher risk of admission to a SNF (adjusted RR=3.3, 95% confidence interval (CI)=2.8-4.0) than did those aged 65 to 69, as did patients aged 75 to 79 (adjusted RR=2.2, 95% CI=1.8-2.6) and those aged 70 to 74 (adjusted RR=1.5, 95% CI=1.3-1.8). The length of time spent in skilled care facilities significantly increased with age (mean days=13.3 for aged 65-69, 16.9 for 70-74, 19.6 for 75-79, and 22.9 for 80 and older; P<.001). CONCLUSION: Older patients are more likely to be admitted to a SNF, be readmitted to an acute-care hospital, and have longer institutional stays after CABG. When balancing the risks and benefits of CABG, physicians, patients, families, and policy-makers need to carefully consider the likelihood of follow-up institutional care in elderly patients.     

Racial variations in end-of-life care

OBJECTIVES: To identify differences in advanced care planning and end-of-life decision-making between whites and blacks aged 70 and older. DESIGN: The Asset and Health Dynamics Among the Oldest Old (AHEAD) study is a nationally representative survey of adults who were aged 70 and older in 1993. Relatives (proxy respondents) for 540 persons who died between the first (1993) and second (1995) waves of the study were surveyed about advanced care planning and end-of-life decisions that were made for their family member who died. SETTING: Respondents were interviewed at home by telephone (n = 444) or in person (n = 95). PARTICIPANTS: The 540 proxy respondents included 454 whites and 86 blacks. MEASUREMENTS: Questions were asked about advance care planning and end-of-life decisions. RESULTS: Whites were significantly more likely than blacks to discuss treatment preferences before death (P = .002), to complete a living will (P = .001), and to designate a Durable Power of Attorney for Health Care (DPAHC) (P = .032). The treatment decisions for whites were more likely to involve limiting care in certain situations (P = .007) and withholding treatment before death (P = .034). In contrast, the treatment decisions for blacks were more likely to be based on the desire to provide all care possible in order to prolong life (P = .013). Logistic regression models revealed that race continued to be a significant predictor of advance care planning and treatment decisions even after controlling for sociodemographic factors. CONCLUSIONS: These findings suggest that there are important differences between blacks and whites regarding advanced care planning and end-of-life decision-making. Health professionals need to understand the diverse array of end-of-life preferences among various racial and ethnic groups and to develop greater awareness and sensitivity to these preferences when helping patients with end-of-life decision-making.     

Predictors of cardiologist care for older patients hospitalized for heart failure

Background

Studies have suggested that cardiologists may provide higher quality heart failure care than generalists. However, national rates of specialty care during hospitalization for heart failure and factors associated with care by a cardiologist are unknown.

Methods

We assessed specialty care in a sample of Medicare patients hospitalized nationwide with heart failure between 1998 and 1999 (n = 25,869). Multivariable hierarchical logistic regression models were used to identify factors independently associated with treatment by a cardiologist.

Results

One-quarter (25.5%) of patients had a cardiologist as their attending physician, 31.3% of patients received a cardiology consult, and 43.2% of patients were not treated by a cardiologist during hospitalization. Older patients (age <75 years: referent; age 75-84 years: risk ratio [RR], 0.92; 95% CI, 0.86-0.98; age ≥85 years: RR, 0.81; 95% CI, 0.74-0.88) and women (RR, 0.87; 95% CI, 0.83-0.93) were less likely to have an attending cardiologist. Patients with a history of heart failure (RR, 1.13; 95% CI, 1.06-1.20), coronary disease (RR, 1.23; 95% CI, 1.14-1.32), coronary artery bypass grafting (RR, 1.42; 95% CI, 1.32-1.42), or percutaneous transluminal coronary angioplasty (RR, 1.30; 95% CI, 1.19-1.42) were more likely to be treated by a cardiologist, whereas patients with chronic obstructive pulmonary disease (RR, 0.74; 95% CI, 0.70-0.79) and dementia (RR, 0.61; 95% CI, 0.54-0.70) were less likely to be treated by a cardiologist. Patient race was not associated with treatment by a cardiologist. The strongest predictors of attending cardiology care were hospital factors, including large volume (>300 beds; RR, 1.45; 95% CI, 1.32-1.42) and geographic location (RR, 1.00 Northeast (referent) vs RR, 0.55; 95% CI 0.46-0.65 Midwest).

Conclusions

Slightly more than half of older patients with heart failure received care from a cardiologist. Several patient characteristics, including age and sex, were associated with the use of specialty care, suggesting that factors other than clinical presentation may independently influence the use of specialty care.     

Quality of dying in the ICU: ratings by family members

STUDY OBJECTIVES: To explore the quality of the dying experience and associations to higher quality ratings for people who died in an ICU. DESIGN: Retrospective study using medical record review and surveys of family members with the Quality of Dying and Death (QODD) instrument. SETTING: Four ICUs affiliated with a university and a Veterans Affairs Medical Center. PARTICIPANTS: Ninety-four family members of 38 ICU decedents. MEASUREMENTS AND RESULTS: We explored associations between components of the ICU experience and the overall rating of the quality of the dying experience. Overall, family members reported that symptoms were poorly controlled: pain under control most or all of the time in 47%, and breathing comfortably most or all of the time in 3% of patients. Families expressed a moderate and variable view of the quality of dying resulting in an overall ICU QODD score of 60 +/- 14 (on a scale of 0 to 100) [mean +/- SD]. Higher ICU QODD scores were associated with control of pain (r = 0.42, p = 0.009), control of events (r = 0.62, p < 0.001), a "preparation for death" aspect of the dying experience--feeling at peace with dying (r = 0.69, p < 0.001), and a "whole-person concern"--keeping one's dignity and self-respect (r = 0.50, p < 0.001). CONCLUSIONS: After adjusting for symptom and personal care scores, certain whole-person and preparation-for-death aspects of the dying process, and not aggressiveness of end-of-life care, remained the most associated to quality ratings. While future research should explore the important predictors of quality of dying in the ICU, this study suggests that care at the end of life in the ICU include not only managing pain, but also supporting dignity, respect, and peace, and maximizing patient control.     

Dying with advanced dementia in the nursing home

BACKGROUND: Nursing homes are important providers of end-of-life care to persons with advanced dementia. METHODS: We used data from the Minimum Data Set (June 1, 1994, to December 31, 1997) to identify persons 65 years and older who died with advanced dementia (n = 1609) and terminal cancer (n = 883) within 1 year of admission to any New York State nursing home. Variables from the Minimum Data Set assessment completed within 120 days of death were used to describe and compare the end-of-life experiences of these 2 groups. RESULTS: At nursing home admission, only 1.1% of residents with advanced dementia were perceived to have a life expectancy of less than 6 months; however, 71.0% died within that period. Before death, 55.1% of demented residents had a do-not-resuscitate order, and 1.4% had a do-not-hospitalize order. Nonpalliative interventions were common among residents dying with advanced dementia: tube feeding, 25.0%; laboratory tests, 49.2%; restraints, 11.2%; and intravenous therapy, 10.1%. Residents with dementia were less likely than those with cancer to have directives limiting care but were more likely to experience burdensome interventions: do-not-resuscitate order (adjusted odds ratio [OR], 0.12; 95% confidence interval [CI], 0.09-0.16), do-not-hospitalize order (adjusted OR, 0.33; 95% CI, 0.16-0.66), tube feeding (adjusted OR, 2.21; 95% CI, 1.51-3.23), laboratory tests (adjusted OR, 2.53; 95% CI, 2.01-3.18), and restraints (adjusted OR, 1.79; 95% CI, 1.23-2.61). Distressing conditions common in advanced dementia included pressure ulcers (14.7%), constipation (13.7%), pain (11.5%), and shortness of breath (8.2%). CONCLUSIONS: Nursing home residents dying with advanced dementia are not perceived as having a terminal condition, and most do not receive optimal palliative care. Management and educational strategies are needed to improve end-of-life care in advanced dementia.     

The relation between managed care market share and the treatment of elderly fee-for-service patients with myocardial infarction

PURPOSE: To determine if greater managed care market share is associated with greater use of recommended therapies for fee-for-service patients with acute myocardial infarction. SUBJECTS AND METHODS: We examined the care of 112,900 fee-for-service Medicare beneficiaries aged > or = 65 years who resided in one of 320 metropolitan statistical areas and who were admitted with an acute myocardial infarction between February 1994 through July 1995. Use of recommended medical treatments and 30-day survival were determined for areas with low (<10%), medium (10% to 30%), and high (>30%) managed care market share. RESULTS: After adjustment for severity of illness, teaching status of the admission hospital, and area characteristics, areas with high levels of managed care had greater use of beta-blockers (relative risk [RR] for greater use = 1.18; 95% confidence interval [CI]: 1.06 to 1.29) and aspirin at discharge (RR = 1.05; 95% CI: 1.02 to 1.07), but less appropriate coronary angiography (RR = 0.93; 95% CI: 0.86 to 1.01) and reperfusion (RR = 0.95; 95% CI: 0.85 to 1.03) when compared with areas with low levels of managed care. CONCLUSIONS: Medicare beneficiaries with fee-for-service insurance who resided in areas with high managed care activity were more likely to have received appropriate treatment with beta-blockers and aspirin, and less likely to have undergone coronary angiography following admission for myocardial infarction. Thus, the effects of managed care may not be limited to managed care enrollees.     

Ethnic differences in the frequency and circumstances of falling in older community-dwelling women

OBJECTIVES: To examine ethnic differences in fall rates and fall circumstances in older community-dwelling Caucasian and African-American women. DESIGN: Prospective analysis of incident falls and a nested retrospective analysis of fall circumstances over 5.7 years. SETTING: Monongahela Valley, Pennsylvania. PARTICIPANTS: A total of 1,821 Caucasian and African-American women (mean age+/-standard deviation 76+/-5) enrolled in the Study of Osteoporotic Fractures and participating in 1993/94. Circumstances of 338 falls were collected on a subsample of 197 women who fell. MEASUREMENTS: Fall rates and fall circumstances. RESULTS: Women reported 4,547 falls in 9,508 person-years, averaging 0.48 falls per woman annually (95% confidence interval (CI)=0.43-0.53). Age-adjusted fall rates were nonsignificantly higher in Caucasians than African Americans (relative risk (RR)=1.30, 95% CI=0.93-1.83%). In women younger than 75, fall rates were similar in Caucasians and African Americans (RR=1.17, P=.46). In women aged 75 and older, fall rates were 50% higher in Caucasians than in African Americans (RR=1.50, 95% CI=0.90-2.49), although this difference was not significant (P=.12). Fall circumstances differed by ethnicity. Caucasian women were significantly more likely than African Americans to fall outdoors versus indoors (odds ratio (OR)=1.6, 95% CI =1.0-2.7) and laterally versus forward (OR=2.0, 95% CI =1.1-3.4) but less likely to fall on the hand/wrist (OR=0.6, 95% CI =0.3-1.0). Ninety-eight percent of individuals falling on their hand/wrist reported that they extended their hand to attempt to break their fall. CONCLUSION: Although the circumstances of falling differed for older Caucasian and African-American women, there were no differences in the frequencies of falling. These findings suggest that ethnic differences in fracture risk in older women may be due in part to the different ways in which older Caucasian and African-American women fall, rather than how often they fall. More information will be needed on fall circumstances to determine whether interventions need to be tailored by ethnic group.     

Decision-making and outcomes of feeding tube insertion: a five-state study

OBJECTIVES: To examine family member's perceptions of decision‐making and outcomes of feeding tubes. DESIGN: Mortality follow‐back survey. Sample weights were used to account for oversampling and survey design. A multivariate model examined the association between feeding tube use and overall quality of care rating regarding the last week of life. SETTING: Nursing homes, hospitals, and assisted living facilities. PARTICIPANTS: Respondents whose relative had died from dementia in five states with varying feeding tube use. MEASUREMENTS: Respondents were asked about discussions, decision‐making, and outcomes related to their loved ones' feeding problems. RESULTS: Of 486 family members surveyed, representing 9,652 relatives dying from dementia, 10.8% reported that the decedent had a feeding tube, 17.6% made a decision not to use a feeding tube, and 71.6% reported that there was no decision about feeding tubes. Of respondents for decedents with a feeding tube, 13.7% stated that there was no discussion about feeding tube insertion, and 41.6% reported a discussion that was shorter than 15 minutes. The risks associated with feeding tube insertion were not discussed in one‐third of the cases, 51.8% felt that the healthcare provider was strongly in favor of feeding tube insertion, and 12.6% felt pressured by the physician to insert a feeding tube. The decedent was often physically (25.9%) or pharmacologically restrained (29.2%). Respondents whose loved ones died with a feeding tube were less likely to report excellent end‐of‐life care (adjusted odds ratio=0.42, 95% confidence interval=0.18–0.97) than those who were not. CONCLUSION: Based on the perceptions of bereaved family members, important opportunities exist to improve decision‐making in feeding tube insertion.     

The quality of patient-doctor communication about end-of-life care: a study of patients with advanced AIDS and their primary care clinicians.

OBJECTIVE: To assess prevalence and quality of end-of-life communication between persons with advanced AIDS and their clinicians and to identify patient and clinician characteristics associated with this communication. DESIGN: Prospective cohort study of 57 patients with AIDS and their primary care clinicians. SETTING: University-based and private clinics in Seattle, Washington. PATIENTS: Patients had a prior AIDS-defining illness and a CD4 cell count of less than 100 x 10(6) cells/l. MAIN OUTCOME MEASURES: Quality of patient-clinician communication about end-of-life care, validated against patient satisfaction and patient-clinician concordance on advance directives and treatment preferences. RESULTS: Patients reported they had communication about end-of-life care with their clinician in 31 of 57 cases (54%) while clinicians reported they had this discussion in 36 of 57 cases (64%). Patients and clinicians gave concordant answers in 42 patient-clinician pairs. In 15 pairs (26%), patients and clinicians disagreed about whether end-of-life communication had occurred. African-American and Hispanic patients were less likely to report having communication than non-Hispanic white patients (chi-square analysis: chi2 = 4.67; P < 0.05); injection drug users and women with high-risk sexual partners were less likely to report communication than homosexual or bisexual men (chi2 = 4.67; P < 0.05). A four-item measure of patients' assessment of the quality of communication about end-of-life care had good internal consistency (Cronbach's alpha 0.81) and was significantly correlated with overall satisfaction with medical care (r2 = 0.76; P < 0.0001). Patients with lower income reported lower quality of communication (chi2 = 5.82; P = 0.05). If patients assessed quality of communication as high, their clinicians were more likely to know if the patient had a durable power of attorney for health care (chi2 = 4.95; P = 0.03) but were not more likely to predict patients' preferences for life-sustaining treatments. CONCLUSIONS: Quality of patient-clinician communication about end-of-life care can be measured in a brief questionnaire; higher quality of this communication is associated with higher satisfaction with care and increased clinician knowledge of patients' advance directives. Since socioeconomic status and ethnicity are associated with both the occurrence and quality of this communication, future interventions in end-of-life care should assess the effect of these variables. Given the important and independent goals of improving patient-clinician communication about end-of-life care and improving the quality of care at the end of life, future studies should test interventions to improve the quality of communication and determine whether improving this communication improves the quality of care at the end of life.     

Quality Improvement in End-of-Life Critical Care

Patients, clinicians and policy makers are increasingly interested in measuring and improving the quality of health care at the end of life. The intensive care unit (ICU) is characterized by high mortality and frequent use of life-sustaining treatments, making critical care a natural target for these efforts. Indeed, multiple local and regional quality improvement efforts now specifically target the dying experience for ICU patients, patients at risk for ICU admission, and their families. These activities either target ICU caregivers through educational programs and quality incentives, or target patients and their families directly through palliative care and efforts to improve decisions around the end of life. Although these initiatives hold great promise, they also face inherent challenges-it is difficult to measure the quality of end-of-life care, we lack practical targets for affecting quality, and uncertain political climates can often preclude serious discussions about end-of-life care. Moreover, these programs may lead to unintended consequences, potentially negatively impacting the very care they seek to improve. Future innovations surrounding how we measure the quality of end-of-life care and paradigm shifts in the way we think about ICU quality may help us to fully realize the goal of improving the dying process for ICU patients.