Preferences for cardiopulmonary resuscitation

OBJECTIVE: To describe the association between hospital resource utilization and physicians’ knowledge of patient preferences for cardiopulmonary resuscitation (CPR) among seriously ill hospitalized adult patients. DESIGN: Prospective cohort study. SETTING: Five U.S. academic medical centers, 1989–1991. PATIENTS: A sample of 2,636 patients with self- or surrogate interviews and matching physician interviews describing patient preferences for CPR, from a cohort of 4,301 patients with life-threatening illnesses enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). MEASURES: Patient, surrogate, and physician reports of preferences for resuscitation, and resource use derived from the Therapeutic Intensity Scoring System and hospital length of stay, converted into 1990 dollars. RESULTS: Nearly one-third of the patients preferred to forge resuscitation. Of the 2,636 paired physician—patient answers, nearly one-third did not agree about preferences for resuscitation. The physicians’ views of the patients’ preferences and those preferences themselves were both associated with resource use. Standardized adjusted hospital resource consumption, expressed as average cost in dollars during the enrollment hospitalization, was lowest when the physician agreed with the patient preference for a do-not-resuscitate order ($20,527), and highest when the patient did not have a preference and the physician believed the patient wanted resuscitation in the case of a cardiopulmonary arrest ($34,829) Hospital resource use was intermediate when patient—physician pairs evidenced either lack of agreement or communication, or awareness of options about resuscitation. CONCLUSIONS: Both physician and patient preferences for CPR influence total hospital resource consumption. Physician misunderstanding of patient preferences to forgo CPR was associated with increased use of hospital resources, and could have led to a course of care at odds with patients’ expressed preferences in the event of cardiac arrest. Increasing physicians’ knowledge of patient preferences, and increasing communication to help patients understand that options foi medical care that include forgoing resuscitation efforts, might reduce hospital expenditures for the seriously ill. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington. DC, April 27–29, 1994. Supported by The Robert Wood Johnson Foundation’s Program on the Care of Critically-Ill Hospitalized Adults: SUPPORT—The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. The opinions and findings in this article are those of the authors and do not necessarily represent the views of the sponsors.     

Home hospital program: a pilot study.

OBJECTIVE: To evaluate the basic safety and feasibility of hospital care at home (Home Hospital (HH)) for treating acutely ill older persons requiring hospitalization. DESIGN: Prospective case series SETTINGS AND PARTICIPANTS: Community-dwelling persons aged 65 and older requiring acute hospital admission for community-acquired pneumonia, chronic heart failure, chronic obstructive airways disease, or cellulitis. RESULTS: Seventeen subjects were treated in HH. One hundred twenty-two could not be enrolled because they presented for admission at times when HH was not operational. Six patients refused to enroll in HH. Subjects treated in HH had comparable clinical outcomes to those treated in the acute hospital and were highly satisfied with HH. Charges for HH care were 60% of those for the acute hospital care. CONCLUSIONS: In this pilot study, HH was safe, feasible, highly satisfactory, and cost-effective for certain acutely ill older persons who required acute hospitalization.     

Precipitants of emergency room visits and acute hospitalization in short-stay medicare nursing home residents

OBJECTIVES: To determine what precipitates rehospitalization for residents who become acutely ill in the first 90 days of a nursing home (NH) admission. DESIGN: NH medical record review comparing acutely ill Medicare admissions transferred back to hospital with those not transferred. SETTING: Sixty skilled nursing facilities in five states during 1994. PARTICIPANTS: Six hundred thirty-six residents who became acutely ill with urinary tract infection (UTI), pneumonia, or congestive heart failure (CHF) during the first 90 days of their nursing home admission were identified from 2,414 random NH Medicare admissions, excluding those with orders not to be hospitalized. MEASUREMENTS: Diagnosis, age, gender, advance care directives, nursing shift during which problem occurred, comorbidity, symptoms, and signs of acutely ill NH residents transferred to the hospital or emergency department were compared with those not transferred. RESULTS: Rates of hospitalization varied markedly by acute illness: 11 of residents with UTI, 46 with pneumonia, and 58 with an exacerbation of CHF (P< .001). In stratified multivariate analysis, older age decreased the odds of rehospitalization only for CHF. Male gender increased odds of hospitalization for pneumonia (odds ratio (OR) = 2.94) and decreased odds of hospitalization for CHF (OR = 0.28). Do not resuscitate orders were negatively associated with hospitalization only for pneumonia (OR = 0.23), whereas weekend and evening/night shifts increased odds of hospitalization for UTI. Each illness had its own set of symptoms, signs, and comorbidities associated with hospitalization.CONCLUSIONS: Whether an acutely ill NH Medicare patient was rehospitalized depended primarily on the particular illness. The relative importance of age, gender, shift, advance care directives, symptom severity, signs, and comorbid illnesses varied by diagnosis.     

Comparing utilization of life-sustaining treatments with patient and public preferences

OBJECTIVE: The movement for advance planning of end-of-life care was motivated in part by the assumption that medical intervention for terminally ill patients varies from what these patients would prefer. We examined the validity of this assumption by comparing actual life-sustaining treatment practices for patients in critical illness scenarios and surveyed patients’ advance care preferences. MEASUREMENTS AND MAIN RESULTS: We selected at random and reviewed 7,400 inpatient medical records from a single urban teaching hospital during the period just prior to the Patient Self-Determination Act. Records of 198 patients with conditions that matched advance directive scenarios were examined, and practices to withhold or withdraw seven life-sustaining treatments were documented. Practices were compared with surveyed preferences of 102 members of the general public and 495 outpatients who were followed by the same physicians as the 198 patients. Concordance of practices and preferences for the 19 surveyed outpatients who eventually fell into one of the scenarios was also evaluated. One hundred sixty-seven inpatient cases met review criteria for the scenario coma with a small chance of recovery. Hospital patients received medical interventions that were not consistently greater or less than the preferences of the surveyed outpatients or members of the general public. Resuscitation, the most frequently withheld treatment (94% of cases), was withheld more often than surveyed preferences to decline it (56% of outpatients, p<.001). Four treatments—mechanical breathing, artificial nutrition, major surgery, and hemodialysis—were utilized comparably to suveyed outpatients’ preferences (range p=.704−.055). Antibiotics and artificial hydration were withheld (9% and 6%, respectively) less often than surveyed outpatient’s prior preferences to decline them (48% and 52%, respectively, p<.001 for each). Conversely, treatments given to the 19 surveyed patients who subsequently developed one of the illness scenarios were often incongruent with the patients’ prior preferences. Again, in some cases more interventions were provided (26 of 63 declined treatments were given), and in some cases less (10 of 21 desired treatments were withheld). CONCLUSIONS: This study does not support the assumption that, collectively, patients’ advance care preferences are less interventionist than actual practices for patients in corresponding scenarios. Nevertheless, these results do support the assumption that life-sustaining treatment decisions do not conform well to individual patients’ specific preferences. Progress in end-of-life care should focus on shared decision making at the patient-proxy-physician level rather than on overall life-sustaining treatments utilization. Received from the Division of Medical Ethics, Harvard Medical School, Boston, Mass. Supported by grants from the William F. Milton Fund and the Decamp Foundation.     

Medical patients’ assessments of their care during hospitalization

OBJECTIVE: To assess, from the patient’s perspective, selected aspects of the quality of inpatient hospital care in the United States. DESIGN: A cross-sectional survey, using telephone interviews of patients discharged from the medical services of a probability sample of 62 public and private, nonprofit, non-federal acute care hospitals in the United States. The participating patients reported: discrete, clinically important elements of hospital care; preferences for involvement in care; health status; sociodemographic characteristics; and overall satisfaction with their hospitalization. PATIENTS/PARTICIPANTS: 2,839 patients drawn as a probability sample. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: For 32 of the 50 questions about potential problems encountered during hospitalization, at least 10% of the patients gave a response indicating a problem. One-third of the patients having a physician (31.8%) reported that that physician did not care for them during hospitalization. Other frequently reported problems included not receiving information about the hospital routine (45.1%), not being told whom to ask for help (33.9%), having pain that could have been relieved by more prompt attention (19.9%), and not being given adequate information and guidance about activities and care after discharge from the hospital (21.4–36.1%). Most patients preferred to be informed about important aspects of their care (94.7%), but their preferences for involvement in care varied widely. CONCLUSIONS: Information from hospitalized medical patients identified several areas of concern that should be the focus of attention and could lead to systematic restructuring of hospital-based care. Dr. Daley is a Senior Research Associate in the Career Development Program of the Department of Veterans Affairs Health Services Research and Development Service. Research supported by The Commonwealth Fund, NY. The views expressed are solely those of the authors.     

The decision-making process for unplanned admission to hospital unveiled in hospitalised older adults: a qualitative study

Background

The hazards of hospitalisation, and the growing demand for goal-oriented care and shared decision making, increasingly question whether hospitalisation always aligns with the preferences and needs of older adults. Although decision models are described comprehensively in the literature, little is understood about how the decision for hospitalisation is made in real life situations, especially under acute conditions. The aim of this qualitative study was to gain insight into how the decision to hospitalise was made from the perspective of the older patient who was unplanned admitted to hospital.

Methods

Open interviews were conducted with 21 older hospitalised patients and/or their next of kin about the decision-making process leading to hospitalisation. Data were analysed according to the Constructivist Grounded Theory approach.

Results

Although a period of complaints preceded the decision to unplanned hospitalisation, ranging from hours to years, the decision to hospitalise was always taken acutely. In all cases, there was an acute moment in which the home as a care environment was no longer considered adequate. This conclusion was based on a combination of factors including factors related to complaints, general practitioner and home environment. Three parties were involved in this assessment: the patient, his next of kin and the general practitioner. At the same time, a very positive value was attributed towards the hospital. Depending on the assessment of the home as care environment by the various parties, there were four routes to hospitalisation: referral, shared, demanding and bypassing.

Conclusions

For all participants, the decision to hospitalisation was taken acutely, even if the problems evoking admission were not acute, but present for a longer period. Participants saw admission as inevitable, due to the negative perceptions of the care environment at home at that moment, combined with the positive expectations of hospital care. Advance care planning, nor shared decision making were rarely seen in these interviews. An ethical dilemma occurred when the next of kin consented to hospitalisation against the wishes of the patient. More attention for participation of older adults in decision making and their goals is recommended.

     

Predicting the need for hospitalization of ambulatory patients with pneumonia

Objective:To develop clinical guidelines to identify patients with pneumonia who might be safely treated as outpatients. Design:Retrospective chart review to derive guidelines, with subsequent prospective validation. Setting:Initial review completed for patients seen in the emergency room (ER) of a university hospital and a community-based internal medicine practice. Validation conducted in the ERs of a university hospital and a community teaching hospital. Patients/participants:Individuals aged 16 years and older presenting with newly diagnosed pneumonia. Follow-up obtained through mail or telephone contact and chart review. Interventions:None. Measurements and main results:During the initial retrospective review, 141 pneumonia patients without obvious reasons for hospital admission were identified and then classified as hospitalization necessary or unnecessary. Of these patients, 33 were classified as requiring admission. Multivariate analysis identified five variables that differentiated low-risk from high-risk study patients. These variables (and their relative weights) were: serious comorbid illness (3 points); preexisting lung disease (2 points); multilobar lung involvement by the disease by chest x-ray (2 points); observed or likely aspiration (2 points); and symptom duration of <7 or >28 days (1 point). Risk scores were calculated using these variables. Patients with low scores (0–2 points) rarely bad complications, and only one of 53 such patients (2%) was judged to require hospitalization. In contrast, patients with high scores (≥6 points) had frequent complications and 20 of 29 (69%) were felt to need hospitalization. Similar results were found during the validation phase. Conclusions:Clinical findings appear to help distinguish patients who need admission for treatment of pneumonia from those who do not. If validated in other settings, the clinical utility of these guidelines in assisting decision making about hospitalization should be determined. Presented in part at the 23rd and 26th annual meetings of the American Federation for Clinical Research, Washington, DC, May 1, 1983, and May 3, 1986. Supported in part by Grant #6343 from the Commonwealth Foundation. Dr. Black was a Henry J. Kaiser Family Foundation Fellow in General Internal Medicine during a portion of this study.     

Quality of life and autonomy preferences in stable asthmatics: A developing country scenario

Background and objective: The quality of life (QOL) and autonomy preferences of asthmatics in developing countries have been sparingly researched, with a resulting lack of management strategies. This study determined the asthma‐specific QOL and autonomy preferences of a population of asthmatics in a developing country and their association with relevant sociodemographic and clinical characteristics. Methods: A cross‐sectional study using the Asthma Quality of Life Questionnaire and the Asthma Autonomy Questionnaire was performed on a population of stable asthmatics recruited from a tertiary care centre in India. Severity of the disease was assessed by spirometry. Results: The study population comprised 80 asthmatics. The mean (SD) overall QOL score was 5.04 (0.97). This was significantly associated with history of hospitalization during the previous year for an asthma attack (P < 0.01) and with FEV₁ (P < 0.05) on univariate analysis; on multivariate analysis, only history of hospitalization was significant. Autonomy preferences of the patients showed higher scores for information‐seeking (mean (SD) = 78.95 (16.35) ) than decision‐making (mean (SD) = 38.21 (14.6)). The information‐seeking preferences had a negative correlation with age (P < 0.01) and a positive correlation with education status (P < 0.01) and decision‐making correlated with education status (P < 0.05). A minority of patients (19%) indicated a preference for a greater say in decision‐making than their physicians. There was a lower tendency for decision‐making when given a ‘severe exacerbation’ scenario than in ‘mild exacerbation’ (P < 0.001) or ‘stable disease’ (P < 0.001). Conclusions: Hospitalization history and FEV₁ values are the parameters having the most significant impact on the QOL of asthmatics. There is a clear desire to obtain more information about the disease but most patients do not endorse the idea of making independent disease‐related decisions.     

Factors predicting readmission of older general medicine patients

Objectives:1) Identify demographic, clinical, social support, functional, and psychological factors about which data are available within 24 hours of hospital admission associated with emergent unscheduled readmission for a group of older general medicine patients; 2) develop a model to predict emergent readmission. Design:Interview- and cbart-based study of emergent admissions that occurred within 60 days of discharge. Setting:General medicine wards of the Memphis Veterans Affairs Medical Center, an 862-bed university-affiliated tertiary care facility. Patients/participants:General medicine patients ≥ 65 years old (n=173). Inclusion criteria were willingness to participate, written consent (patient or family member), and patient interview within 36 hours of admission. Measurements and main results:The dependent variable was emergent readmission within 60 days of discharge from the hospital. Independent variables included demographic (age, race, income, education), social support (marital status, living arrangements), psychological (cognition, depression), activities of daily living functioning, and clinical (diagnoses, type and source of admission, length of stay, numbers of hospitalizations and days of hospitalizations in the past year, illness severity) parameters. Readmitted patients were emergently admitted and more severely ill, had more diagnoses of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), less ischemic heart disease, and more hospitalizations and hospital days in the past year (all p<0.05). Logistic regression identified diagnostic group (COPD or CHF), emergent admission, and admission severity of illness as predictive of readmission. The likelihood of being readmitted was 5.4. Accuracy of the three-variable model was 76%, predicted value positive, 73%, and predictive value negative, 77%. Conclusions:Chronically ill patients who are severely ill at index admission and who have had several hospitalizations in the past year tend to be readmitted. Using this model, high-risk patients may be prospectively targeted to reduce readmissions. Presented in part at the 41st annual meeting of the Gerontological Society of America, San Francisco, CA, November 1988. Supported by a grant from the Health Services Research and Development Field Program, Little Rock, Arkansas. Opinions expressed are the authors’ own and do not necessarily reflect those of the Department of Veterans Affairs.     

Older persons’ preferences for site of treatment in acute illness

OBJECTIVE: To explore how older persons form preferences for site of medical care by examining their perceptions of home care and hospital care. DESIGN: Qualitative analysis of in-depth interviews using the constant comparative method. SETTING: Respondents’ homes. PARTICIPANTS: Twenty-nine persons age 65 to 89 years who had been hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were receiving home care services. MAIN RESULTS: Respondents, who thought of home care only as a means to provide low-intensity and low-frequency services, were initially skeptical about expanded home care services to treat acute illness. Regardless of their opinions about home and hospital, all respondents preferred the site associated with the greatest chance of survival. If the sites offered equal survival, 52% of the respondents preferred treatment at home because of freedom from the constraints of the hospital and the comfort of familiar surroundings. For respondents who preferred the hospital, the home represented a frightening and lonely place to be sick. Respondents’ views of the home and hospital were shaped by their social supports, self-reliance, religious beliefs, and past illness experiences. CONCLUSIONS: Because survival appears to be the most important determinant of preference, home treatment of acute illness is a viable alternative only if it provides outcomes equivalent to those of hospitalization. Strongly held perceptions that home care can only be a low-intensity service may limit preferences for home treatment. When expected outcomes at the two sites are similar, the challenge to the health care system will be incorporating patient preference about the process of care into decisions about the appropriate site of care. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, May 1997. This research was supported by the Picker/Commonwealth Scholars Program.     

Patients’ perceptions of physicians’ recommendations for comfort care differ by patient age and gender

OBJECTIVE: To determine patient characteristics associated with patient and proxy perceptions of physicians’ recommendations for life-prolonging care versus comfort care, and with acceptance of such recommendations. DESIGN: Cross-sectional. SETTING: Five teaching hospitals in Denver, Colo. PATIENTS: We studied 239 hospitalized adults believed by physicians to have a high likelihood of dying within 6 months. MEASUREMENTS AND MAIN RESULTS: Interviews with patients or proxies were conducted to determine perceptions of physicians’ recommended goal of care and roles in decision making. RESULTS: Patients’ mean age was 66.6 years; 44% were women. In adjusted analysis, age greater than 70 years and female gender were associated with a higher likelihood of believing that comfort care had been recommended by the physician (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.89 to 7.24; OR, 1.99; 95% CI, 1.04 to 3.84, respectively). Patients and proxies gave substantial decision-making authority to physicians: 29% responded that physicians dominate decision making, 55% that decision making is equally shared by physicians and patients, and only 16% that patients make decisions, Increasing age was associated with an increased likelihood of believing that physicians should dominate decision making (P<.005). CONCLUSIONS: Among patients with advanced illness, perceived comfort care recommendations were related to patient age and gender, raising concern about possible gender and age bias in physicians’ recommendations. Although all patients and proxies gave significant decision-making authority to physicians, older individuals were more likely to give physicians decision-making authority, making them more vulnerable to possible physician bias. Presented at the annual meeting of the American Geriatrics Society, May 19, 1999. Financial support for this work was received from the Hartford/Jahnigen Center of Excellence in Geriatrics at the University of Colorado and the Colorado Collective for Medical Decisions, a nonprofit organization to improve care of the dying in the state of Colorado.     

Reducing unnecessary coronary care unit admissions

Objective:To determine whether published decision rules for ischemic heart disease have practical value in reducing unnecessary admissions to coronary care units. Design:Prospective cohort study. Setting:A community hospital emergency room. Patients:235 consecutive patients presenting to an emergency room with a chief complaint of chest pain. Measurements:Clinical information, including observations needed to use previously published decision aids, was collected on special forms at the time of the emergency room visit. Follow-up information was obtained from the medical records of patients who were admitted and by telephone interviews with patients who were discharged. The authors compared the residents’ actual decisions with the predictions of the decision aids regarding their ability to predict complications (that is, to identify patients who needed admission or intensive care). Main results and conclusions:None of the decision aids could reduce unnecessary admissions without seriously increasing the rate of inappropriate discharges. However, within the clinically relevant subgroup of patients for whom the decision to admit or discharge was not obvious on clinical grounds (those without complications on presentation whom the residents chose not to discharge), the decision aids examined, used in combination to verify the need for admission, might have safely averted some unnecessary admissions. Received from the General Medicine Unit of Highland Hospital, and the University of Rochester School of Medicine and Dentistry, Rochester, New York. Dr. Goldstein is currently at the Joslin Diabetes Center, Boston, Massachusetts. Supported in part by HHS Grant HL-07496 from the National Institutes of Health. Presented at the annual meeting of the Society for Medical Decision Making, Richmond, Virginia, October 19, 1988.     

A Geriatric Emergency Service for Acutely Ill Elderly Patients: Pattern of Use and Comparison with a Conventional Emergency Department in Italy

The current disease‐oriented, episodic model of emergency care does not adequately address the complex needs of older adults presenting to emergency departments (EDs). Dedicated ED facilities with a specific organization (e.g., geriatric EDs (GEDs)) have been advocated. One of the few GED experiences in the world is described and its outcomes compared with those of a conventional ED (CED). In a secondary analysis of a prospective observational cohort of 200 acutely ill elderly patients presenting to two urban EDs in Ancona, Italy, identifiers and triage, clinical, and social data were collected and the following outcomes considered: early (30‐day) and late (6‐month) ED revisit, frequent ED return, hospital admission, and functional decline. Death, functional decline, any ED revisit and any hospital admission were also considered as a composite outcome. Odds ratios and 95% confidence intervals (CIs) were calculated. Overall, GED patients were older and frailer than CED patients. The two EDs did not differ in terms of early, late, or frequent ED return or in 6‐month hospital admission or functional decline. The mortality rate was slightly but significantly lower in the GED patients (hazard ratio=0.47, 95% CI=0.22–0.99, P=.047). The data suggest noninferiority and, indirectly, a slight superiority for the GED system in the acute care of elderly people, supporting the hypothesis that ED facilities specially designed for older adults may provide better care.     

Patient desire for information and decision making in health care decisions

OBJECTIVES: To compare results on the Autonomy Preference Index (API) and the Health Opinion Survey (HOS), two instruments that measure patient desire for information and involvement in decision making. DESIGN: Cross-sectional survey. SETTING: University-based primary care outpatient longitudinal and acute care clinic. PATIENTS: 167 patients with benign prostatic hyperplasia, back pain, or mild hypertension seen from October 1991 to December 1992. MEASUREMENTS AND MAIN RESULTS: On the API and the HOS (both scaled from 0 to 1), the patients had intermediate desire for involvement in decision making (median API: 0.42; HOS: 0.36) and higher desire for information (median API: 0.97; HOS: 0.57). With either instrument, the desire for information exceeded that for involvement in decision making (p<0.0001). The API information scores were higher than the HOS information scores (p < 0.0001), probably because the HOS focuses on patient behavior rather than desire. Variation in desire for information and involvement in decision making was substantial and largely unexplained. CONCLUSIONS: Most patients have a high desire for information, the desire for information and involvement in decision making varies substantially among patients, and the API is preferable to the HOS for researchers interested in focusing solely on patient desire for information. Received from the Department of Medicine, Dartmouth — Hitchcock Medical Center, Lebanon, New Hampshire. Preliminary analyses were presented at the annual meeting of the Society for Medical Decision Making, Portland, Oregon, October 17–20, 1992. Supported by a grant from the Pew Charitable Trusts. Dr. Nease is a Picker/Commonwealth Scholar.     

A prediction rule for the use of postdischarge medical services

OBJECTIVE: To develop and validate a prediction rule screening instrument, easily incorporated into the routine hospital admission assessment, that could facilitate discharge planning by identifying patients at the time of admission who are most likely to need postdischarge medical services. DESIGN: Prospective cohort study with separate phases for prediction rule development and validation. SETTING: Urban teaching hospital. PATIENTS/PARTICIPANTS: General medical service patients, 381 in the derivation phase and 323 in the validation phase, who provided self-reported medical history, health status, and demographic data as a part of their admission nursing assessment, and were subsequently discharged alive. MEASUREMENTS AND MAIN RESULTS: Use of postdischarge medical services such as visiting nurse or physical therapy, medical equipment, or placement in a rehabilitation or long-term care facility was determined. A prediction rule based on a patient’s age and Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) physical function and social function scores stratified patients with regard to their risk of using postdischarge medical services. In the validation set, the rate of actual postdischarge medical service use was 15% (15 of 97), 36% (39 of 107), and 58% (57 of 98) among patients characterized by the prediction rule as being at “low”, “intermediate,” and “high” risk of using postdischarge medical services, respectively. CONCLUSIONS: This prediction rule stratified general medical patients with regard to their likelihood of needing discharge planning to arrange for postdischarge medical services. Further research is necessary to determine whether prospective identification of patients likely to need discharge planning will make the hospital discharge planning process more efficient. Presented at the Society of General Internal Medicine annual meeting, April 1994.     

Physicians’ attitudes towards living wills and cardiopulmonary resuscitation

Objective:To determine whether a physician’s familiarity with the living will directly relates to an expressed willingness to discuss resuscitation issues with patients. Design:Survey of selected primary care and medical subspecialist physicians most likely to care for seriously or terminally ill patients. Setting:Private-practice clinicians practicing in an urban county. Participants:Internists, family practitioners, cardiologists, oncologists, and neurologists in private practice. Interventions:None. Results:Almost all responding physicians (97.2%) knew of the living will, although few (13.5%) had executed one for themselves. Most were willing to keep a copy of their patients’ living wills with their office records. However, only a few physicians (20%) indicated they routinely discussed extraordinary care issues with their patients. In fact, most (70%) reported they rarely or never discussed cardiopulmonary resuscitation (CPR) with their patients. With terminally ill patients, physician initiative was greater: 69% reported discussing resuscitation preferences. Comparable discussions with elderly patients were undertaken only if the physician believed they would be warranted by the clinical circumstances. When questioned about their own sentiments towards resuscitation, most physicians indicated they would not want CPR if they were terminally ill (86%) or mentally incompetent (93%). A similar number (92%) would refuse artificial feeding if permanently comatose. Conclusions:Many physicians recognize the importance of living wills as an expression of patient treatment preferences. Nevertheless, discussion of patient preferences is unlikely because of physicians’ reluctance, except in limited circumstances, to initiate a dialogue about life-sustaining measures. Because patients also are often unwilling to begin such discussions, better methods of facilitating discussion of CPR and other extraordinary health care measures must be sought. Presented at the Southern Regional Meeting of the Society of General Internal Medicine, New Orleans, Louisiana, January 19, 1990. Supported by a grant from the Charlotte-Mecklenburg Health Services Foundation, Inc.     

Functional recovery of elderly patients hospitalized in geriatric and general medicine units. The PROgetto DImissioni in GEriatria Study

OBJECTIVES: To investigate the characteristics of patients who regain function during hospitalization and the differences in terms of functional outcomes between patients admitted to geriatric and general medicine units. DESIGN: Multicenter, prospective cohort study. SETTING: Acute care geriatric and medical wards of five Italian hospitals. PARTICIPANTS: One thousand forty‐eight elderly patients hospitalized for acute medical diseases. MEASUREMENTS: Functional status 2 weeks before hospital admission (baseline), at admission, and at discharge, as measured using the Barthel Index (BI). RESULTS: Geriatric patients were older (P<.001) and had lower preadmission functional levels (P<.001) than medical patients. Between baseline and discharge, 43.2% of geriatric and 18.9% of medical patients declined in physical function. In the subpopulation of 464 patients who had declined before hospitalization (between baseline and admission), 59% improved during hospitalization (45% of geriatric and 75% of medical patients), whereas only approximately 1% declined further. High baseline function (odds ratio (OR)=1.03, 95% confidence interval (CI)=1.02–1.04, per point of BI) and greater functional decline before hospitalization (OR 0.95, 95% CI 0.94–0.97, per % point of BI decline) were significant predictors of in‐hospital functional improvement; type of hospital ward and age were not. CONCLUSION: Although geriatric patients have overall worse functional outcomes, in‐hospital functional recovery may be frequent even in geriatric units, particularly in patients with greater preadmission functional loss and high baseline level of function.     

Unique educational program in critical care medicine for the general internist

Objective: To determine the effect of a unique educational program in critical care medicine on the attitudes, knowledge, and skills of general internists who care for critically ill patients. Design: Comparison of objective assessments and self-assessments obtained before and after the one-year educational program. Setting/participants: Eighteen general internists practicing in a 350-bed university-affiliated community teaching hospital. Results: After the program, the internists felt significantly more competent in, knowledgeable about, comfortable with, and satisfied with caring for critically ill patients than they did when completing the precourse self-assessments (p<0.05). Participants felt particularly more comfortable with managing ventilator patients and leading the advanced cardiac life-support team (p<0.05). Comfort levels for other commonly performed critical care procedures did not vary. No significant change in knowledge test scores was noted from before to after the one-year program (61% vs 60%). Residents and nurses rated the internists’ overall ability in critical care medicine to be the same as that of senior medical residents. They also favorably rated the internists on humanism, teaching skills, and interpersonal interactions. Residents also appreciated the decrease in their night call because of the program. Conclusions: This unique educational program increased comfort and satisfaction of general internists caring for critically ill patients. The program was well accepted by residents and nurses because of favorable interaction with the internists and a decrease in resident night-call responsibility. This curriculum is recommended to other teaching hospitals. Presented at the 14th annual meeting of the Society of General Internal Medicine, May 2, 1991, Seattle, Washington.     

A one-year mortality study of the most acutely ill patients in a medical-surgical intensive care unit: toward developing a model for selection of recipients of intensive care

This study over a 1-year period of time in a medical-surgical ICU in a large metropolitan teaching hospital was conducted to determine the mortality rate among a select group of acutely ill patients. By operational definition the acutely ill patients included in this study were those who were admitted to the medical-surgical ICU and treated with at least two out of three of the following: MA-1 ventilator, flow-directed balloon-tipped catheter, and vasopressor(s). Of 158 patients in the study, 117 died during hospitalization. The personnel in this oversubscribed unit were constantly faced with the decision of who should and who should not be admitted and who should be transferred out. Statistics on intensive care management are converted into daily costs for intensive care for those who did and did not survive. Model building is discussed as a process necessary in determining who shall receive intensive care and who shall not. The basic premise for conducting the study was that decisions regarding who shall receive care that is expensive and in limited supply should be based on facts to the extent that they can be elucidated.