Preferences for cardiopulmonary resuscitation among patients 80 years or older: the views of patients and their physicians

OBJECTIVE: To describe the cardiopulmonary resuscitation (CPR) preferences of hospitalized patients aged 80 and older. To examine physicians' perceptions of their patients' preferences and agreement between patients' and physicians' preferences, estimation of prognosis, and assessment of quality of life. DESIGN: Prospective cohort study. SETTING: Four academic hospitals. PARTICIPANTS: Patients 80 years or older hospitalized between January 1993 and November 1994. MEASUREMENTS: Detailed clinical data were collected by chart review and interview. Patients and physicians were interviewed to determine their preferences for cardiopulmonary resuscitation (CPR). Agreement between patients and physicians was assessed using the kappa statistic, which measures agreement beyond chance. RESULTS: Of the 1266 patients studied, their median age was 85 years, and 61% were female. The majority (55%) of the 1010 patients with CPR preference information available desired CPR. Compared with patients, fewer physicians wanted CPR (36%) if they were in their patients' condition. Agreement between patients' preferences and physicians' perceptions of these preferences was low (absolute agreement 63%, kappa = 0.21). Agreement was better between physicians' perceptions of patients' preferences and physicians' desire for themselves if they were in their patients' condition (66%, kappa = 0.36). Agreement between patients' and physicians' estimates of survival was only slight (46%, kappa = 0.10). The majority of the disagreement occurred when the physician's prognostic estimate was worse than the patient's. CONCLUSIONS: The majority of hospitalized patients 80 years older wanted CPR. When asked to imagine themselves in the same clinical situation as their patients, physicians were much less likely to want CPR and viewed CPR as undesirable for most patients. Physicians' estimates of patients' prognoses were less optimistic than patients' estimates, raising the possibility that physicians' knowledge of older patients' poor outcomes from CPR explains their lack of enthusiasm about CPR for most patients 80 years and older.     

Patient and surrogate disagreement in end-of-life decisions: can surrogates accurately predict patients' preferences?

BACKGROUND: When a patient is too incapacitated to make important end-of-life decisions, doctors may ask a preappointed surrogate to predict the patient's preferences and make decisions on the patient's behalf. The current study investigates whether surrogates project their own views onto what they predict the patients' preferences are. METHODS: Using data from seriously ill patients and their surrogates, the authors created a "projection' variable that addresses the following question: When surrogates are asked to predict a patient's end-of-life preferences, do they mistakenly replace this prediction with what they would want the patient to do? The authors examined the 144 patient-surrogate pairs in which surrogates inaccurately predicted patients' CPR (cardiopulmonary resuscitation) v. DNR (do not resuscitate) decisions and the 294 pairs in which surrogates inaccurately predicted patients' extend life v. relieve pain preferences. Among these patient-surrogate pairs, the authors determined the extent to which surrogates' wishes for the patient matched their incorrect predictions of what the patient wanted. RESULTS: Of the patient-surrogate pairs who disagreed on CPR v. DNR and extend life v. relieve pain preferences, 62.5% and 88.4% of surrogates demonstrated projection for CPR v. DNR decisions and extend life v. relieve pain preferences, respectively. Age-related and demographic variables did not predict cases in which projection did and did not occur. CONCLUSION: When surrogates inaccurately predict the CPR v. DNR and extend life v. relieve pain preferences of seriously ill, hospitalized loved ones, surrogates' prediction errors often represent surrogates' own wishes for the patient.     

Preconception Health: Awareness, Planning, and Communication Among a Sample of US Men and Women

It is important to educate both men and women about preconception health (PCH), but limited research exists in this area. This paper examines men’s and women’s awareness of exposure to PCH information and of specific PCH behaviors, PCH planning, and PCH discussions with their partners. Data from Porter Novelli’s 2007 Healthstyles survey were used. Women and men of reproductive age were included in the analysis (n = 2,736) to understand their awareness, planning, and conversations around PCH. Only 27.9% of women and men reported consistently using an effective birth control method. The majority of men (52%) and women (43%) were unaware of any exposure to PCH messages; few received information from their health care provider. Women were more aware than men of specific pre-pregnancy health behaviors. Women in the sample reported having more PCH conversations with their partners than did men. PCH education should focus on both women and men. Communication about PCH is lacking, both between couples and among men and women and their health care providers. PCH education might benefit from brand development so that consumers know what to ask for and providers know what to deliver.     

Quality of life in the Palestinian context: an inquiry in war-like conditions

This study aims to elucidate the concept of quality of life (QOL) in a unique environment characterized by protracted and ongoing conflict, beginning with the utilization of the WHOQOL-Bref as a starting point for discussion. It works to determine important health-related quality of life domains and items within each domain, and evaluate issues pertinent to the Palestinian population's understanding of life quality in the Occupied Palestinian Territory. Focus group discussions (FGD) were conducted with individuals living in the Gaza Strip and Ramallah District of the West Bank. Participants were asked if they understood the term QOL; and about the determinants of their own QOL, using open-ended questions. Participants were then presented with the WHOQOL-Bref questions and requested to assess their relevance and importance in determining their own QOL, and encouraged to suggest additional ones. A total of 150 men and women of various ages and socioeconomic classes participated in 13 FGD. A major finding is the all-encompassing impact of the political context on Palestinians' QOL assessment. The study demonstrates that political freedom, self-determination, participation in democratic processes and feeling involved in political decision-making are considered important contributors to people's QOL. The study raises the option of adding a new domain to the WHOQOL-Bref, allowing the study of its psychometric properties and its relationship to the rest of the instrument. This contribution should be particularly relevant to societies and cultures in conflict-affected zones and locales where violence and insecurity constitute an important part of life. The documentation of QOL, beyond fatal and non-fatal health outcomes, must remain an important objective of all evaluations in order to guide policy and resource allocation decisions directed towards improving peoples' lives in general and their health in particular.     

初产妇产褥期的生活质量评估及影响因素

目的:测量并评估初产妇产褥期的生活质量,分析影响其生活质量的主要心理和社会因素。方法:选取东莞市2 916例单胎足月的产后42天的初产妇作为研究组,同期按照东莞市的人口构成比例,分层随机抽取东莞市2 797例育龄妇女作为地方常模组,采用简明健康调查量表(SF-36量表)和一般个人情况调查表对上述两组进行调查,比较两组SF-36量表得分的差异;了解研究组的6项个人一般资料、8项临床相关因素、4项产后生活情况因素和4项心理因素,分析影响初产妇产褥期生活质量的主要因素。结果:研究组SF-36量表的8个领域得分均显著低于地方常模组(t=2.62～58.19,P<0.01);多元回归分析结果表明,影响研究组SF-36量表总分的因素有婴儿抚养困难、婴儿并发症、对婴儿性别的满意程度、夫妻关系、家庭经济状况、家庭支持、产妇并发症、睡眠质量、生活受限程度、产妇的情绪稳定性和近1年的生活事件等11项因素。结论:与地方常模相比,初产妇产褥期的生活质量有所下降,这种情况与母婴双方的身体健康状况、生活方式改变、家庭和社会支持以及产妇个人的调节能力有密切关系。     

Older persons' opinions about life-sustaining procedures in the face of dementia.

OBJECTIVE: To investigate the attitudes of cognitively normal older adults toward various life-sustaining procedures in the face of dementia. METHODS: Participants were 84 cognitively normal men and women (70% response rate), 65 years and older, from a variety of urban and suburban settings, including private homes, assisted-living apartments, transitional care facilities, and nursing homes. In-person interviews were conducted with each participant to obtain information about demographic characteristics, life and health, and desire for various life-sustaining procedures for 4 hypothesized levels of dementia. RESULTS: Approximately three fourths of participants said they would not want cardiopulmonary resuscitation, use of a respirator, or parenteral or enteral tube nutrition with the milder forms of dementia, and 95% or more of participants would not want these procedures with severe dementia. In addition, only one third or fewer participants thought they would want to be hospitalized or given antibiotics if they were severely demented. Logistic regression analysis showed a relationship between participants' desire for life-sustaining procedures and having less education, greater independence, and a higher perceived quality of life. CONCLUSIONS: Most surveyed individuals did not desire life-sustaining treatments with any degree of dementia, and the proportion of individuals not desiring such treatments increased with the projected severity of dementia. These findings indicate a need for including dementia in advance directives planning.     

Sex-Specific Content Preferences for Visual Sexual Stimuli

Although experimental studies support that men generally respond more to visual sexual stimuli than do women, there is substantial variability in this effect. One potential source of variability is the type of stimuli used that may not be of equal interest to both men and women whose preferences may be dependent upon the activities and situations depicted. The current study investigated whether men and women had preferences for certain types of stimuli. We measured the subjective evaluations and viewing times of 15 men and 30 women (15 using hormonal contraception) to sexually explicit photos. Heterosexual participants viewed 216 pictures that were controlled for the sexual activity depicted, gaze of the female actor, and the proportion of the image that the genital region occupied. Men and women did not differ in their overall interest in the stimuli, indicated by equal subjective ratings and viewing times, although there were preferences for specific types of pictures. Pictures of the opposite sex receiving oral sex were rated as least sexually attractive by all participants and they looked longer at pictures showing the female actor’s body. Women rated pictures in which the female actor was looking indirectly at the camera as more attractive, while men did not discriminate by female gaze. Participants did not look as long at close-ups of genitals, and men and women on oral contraceptives rated genital images as less sexually attractive. Together, these data demonstrate sex-specific preferences for specific types of stimuli even when, across stimuli, overall interest was comparable.     

Socioeconomic and behavioral correlates of body mass index in black adults: the Pitt County Study.

BACKGROUND. Obesity is more prevalent among Black women than Black men, but there is little information on the correlates of obesity in Blacks. This study describes the relations of sociodemographic factors and health behaviors to body mass index in a southern, Black population. METHODS. In 1988, a community probability sample of 1784 Black adults, aged 25 to 50, was examined in Pitt County, NC. RESULTS. More women than men were at least 20% overweight (57% vs 36%). The relation of socioeconomic status (a composite of education and occupation) to age-adjusted body mass index level was inverse in women but not in men. Body mass index did not differ with either current energy intake or energy expenditure. Smokers and drinkers had lower age-adjusted levels than non-smokers and abstainers. CONCLUSIONS. Since the excess body mass index levels associated with low socioeconomic status in women could not be explained after controlling for adverse health behaviors, further epidemiologic study of risk factors for obesity in Black women is recommended.     

Perceptions and attitudes in relation to reproductive tract infections including sexually transmitted infections in rural Vietnam: a qualitative study

OBJECTIVE: To explore perceptions, attitudes and health-seeking patterns for reproductive tract infections including sexually transmitted infections (RTI/STI) among men and women in rural Vietnam. METHOD: Ten focus group discussions (FGDs) were conducted with 46 women and 27 men aged 15-49 in Bavi district, northern Vietnam. A pre-designed discussion guide was used during the discussions. Content analysis was applied for data analysis. Each sentence/paragraph was coded. Similar codes were clustered and collapsed into sub-categories and categories. Two main themes 'community perceptions of RTI/STI' and 'attitudes towards RTI/STI' were created, based on the relationship between categories. FINDINGS: Complex terminology with many different terms was used by participants to describe and discuss RTI/STI. "Inflammation" [RTI], Gonorrhoea, Syphilis was described as three stages of STI. Health-seeking patterns for RTI/STI were reported to differ between men and women: self-medication was mentioned as a common practice among women, while men were more likely to seek health care from private providers. Complaints were voiced about clinicians' negative attitudes towards RTI/STI patients. CONCLUSION: Rural dwellers in a district of Vietnam expressed a variety of misconceptions regarding RTI/STI. Designing health education strategies to provide comprehensive RTI/STI information to the community and improving communication between RTI/STI patients and clinicians are urgently needed.     

You can't prevent everything anyway: a qualitative study of beliefs and attitudes about refusing health screening in general practice

OBJECTIVE: The aim of this study was to explore beliefs and attitudes about refusing health screening in general practice. METHODS: In 1991, in Ebeltoft, Denmark people aged between 30 and 50 years were invited to participate in a 5-year randomized, controlled, population-based project testing the value of health screenings and health discussions in general practice. In 1994, non-participants who declined the offered health screening but expressed willingness to be contacted in the future were asked to participate in a qualitative interview. They were drawn by stratified purposeful sampling which reflected variation in perceived health, body mass index, age and sex. The sample comprised six men and 12 women RESULTS: Some had not participated because they were busy, felt healthy or had recently been examined. The non-participants emphasized the limitations of health screening and did not want possible risk factors to be revealed, or their feeling of good health to be disturbed. They stressed the individual's own responsibility for maintaining good health and believed that a positive attitude promoted health. They would contact their GP if they had symptoms. CONCLUSION: Non-participants have rational views on risk factor testing and on their own responsibility for maintaining health. Non-attendance was due to a conscious choice which included consulting their own GP.     

Physician Use of Advance Care Planning Discussions in a Diverse Hospitalized Population

Two decades after the Patient Self Determination Act it is unknown how often physicians have advance care planning (ACP) discussions with hospitalized patients. The objective of this study is to investigate use of ACP discussions in a multi-ethnic, multi-lingual hospitalized population. Cross-sectional communication study of hospitalized patients. The Participants are 369 patients at one urban county hospital and one academic medical center. Interventions are not applicable. Participants were asked at baseline and a post-discharge interview whether hospital physicians had discussed either (a) what type of treatment they would want if they could not make decisions for themselves or (b) whether they would want cardiopulmonary resuscitation if needed. We compared patient characteristics for those who did and did not have an ACP discussion. Only 151 (41%) participants reported an ACP discussion. Rates of ACP were low across ethnic, language, education and age groups. In a multivariate model, scoring higher on a co-morbidity scale was associated with higher odds of reporting having had an ACP discussion during hospitalization; this finding remained after adjusting for time period and site of data collection. Multiethnic, multi-lingual hospitalized patients reported low rates of ACP discussions with their physicians regardless of ethnicity, English proficiency, education level or age.     

Gender, race, and obesity-related quality of life at extreme levels of obesity

OBJECTIVE: Research investigating obesity-related quality of life (QOL) has shown that at increasing levels of overweight, individuals report more impaired QOL. Further, some research has indicated that white women suffer more impairment than men and African Americans. The current study sought to expand the existing literature by investigating an extreme subsample of the obese population. It was expected that participants in the current study would report more impaired obesity-related QOL than in previous research conducted with less obese individuals. It was also hypothesized that race and gender groups would differ in obesity-related QOL and that the relationship between degree of overweight and QOL would not be consistent across race and gender groups. RESEARCH METHODS AND PROCEDURES: Impact of Weight on Quality of Life Questionnaire-Lite Version data were collected from 512 individuals seeking gastric bypass surgery (mean BMI = 53.3) RESULTS: Results confirmed the study hypotheses. In general, white women reported the most QOL impairment, despite having significantly lower BMI than other race/gender groups. Compared with previous studies, the observed relationships between BMI and QOL were somewhat attenuated. DISCUSSION: Various domains of QOL may be differentially affected by degree of obesity; these relationships are not homogeneous throughout the obese population.     

Life-sustaining treatments: what doctors do, what they want for themselves and what elderly persons want.

In view of the current social dilemmas regarding the use of life-sustaining treatments (LST) at the end of life, the purpose of the study was to reveal sources of interpersonal and intrapersonal conflict among the most involved parties, in a society where open doctor-patient communication about end-of-life treatment is rare. Two comparative analyses were conducted: (a) between physicians' practice and elderly persons' preferences regarding the use of different life-sustaining treatments in different illness conditions, and (b) between physicians' hypothetical practice for an elderly person in a metastatic cancer condition, elderly persons' preferences and physicians' preferences for themselves, should they be in the same illness condition. Data were collected in Israel from 339 physicians working in two medical centers, and from a random sample of 987 elderly persons. Attitudes and practice regarding artificial tube feeding, mechanical ventilation and cardiopulmonary resuscitation (CPR) in three different illness conditions were evaluated by close-ended questions. The findings indicate disagreements between the elderly and the physicians on a number of issues: in general, physicians report that they would use more LST than what the elderly report that they would want. Physicians differentiate among different illness conditions and different LST more than elderly persons do. Physicians are more likely to use artificial feeding than CPR, while elderly persons prefer the use of CPR more than artificial feeding. The comparison of physicians' hypothetical practice, the wishes of the elderly, and physicians' wishes for themselves regarding the use of LST in a metastatic cancer condition, shows that physicians would use LST differently from what the elderly want, and that they want less LST for themselves than they would order for elderly patients. The discrepancies found between the physicians' practice and the elderly persons preferences reflect differences in perceptions of artificial feeding and a lack of public knowledge regarding the effectiveness of CPR. They also reflect differences in attitudes regarding the prolongation of life in various illness conditions. The discrepancy between physicians' practice and their preferences for themselves underscores the personal and professional dilemmas related to these issues, which are faced daily by many physicians, and impede their compassionate behavior toward patients. Increasing the awareness of physicians of such discrepancies, and providing them with appropriate behavioral tools, including communication skills, is a timely need which should be addressed by the medical profession, medical services and medical schools.     

Married men's opinions and involvement regarding family planning in rural areas

As men play a prominent role in reproduction, it is therefore extremely useful to assess and encourage them to be involved in contraception, particularly in developing countries, where contraceptive goals have not been reached. This study was carried out in Kayseri, Turkey, in order to determine the attitudes and behavior of married men concerning family planning. A questionnaire was presented to 123 married men. In our study, 91.9% of men approved of family planning, but only 54.4% actually used any contraceptive methods; 66.7% of the men said that the decision should be a joint one, 66.4% wanted to limit their family size. Approximately one fourth of the men had never heard of voluntary sterilization. No one in the study group was aware of the mini-pill, diaphragm or Norplant. In the study group, 26.8% of the men did not want their wives to use intrauterine devices and 31.7% of them did not agree with women using the contraceptive pills. Among those unwilling to use a condom (46.3%), 70.1% stated that it might interrupt intercourse. If a contraceptive pill for males could be used, 25.2% of members of the group would be prepared to use it. Only 17.5% men in the study group had contacted a doctor or a health foundation to obtain information. The main sources of family planning information were TV/radio, followed by friends and newspapers/magazines. In order to encourage men's involvement in family planning, the use of mass media and continual training programs, to try to reach both men and women, could be very useful.     

Women patients' preferences for female or male GPs

OBJECTIVE: We aimed to investigate general preferences to see a male or female GP either some or all of the time, and specific preferences to see a female primary health care (PHC) worker for individual health issues; to compare these preferences with reported consultation behaviour; and to explore women's evaluations of the quality of PHC services in relation to their preferences and consultation behaviour. METHOD: Results are reported on 881 women aged 16-65 years who had consulted their GP in the previous 6 months. Logistical regression analysis was undertaken to evaluate whether a general preference to see another woman is more important than specific women's health issues in determining why some women regularly choose to consult a female GP. RESULTS: General preference was 2.6 times more important than specific health issues in predicting choice of a female GP in a mixed-sex practice. Nearly a half (49.1 %) of women attending male-only practices stated that they wanted to see a female GP in at least some circumstances, compared with 63.8% of women in mixed-sex practices. In total, 65.5% of the sample stated that there was at least one specific health issue for which they would only want to be seen by a woman PHC worker. The most positive evaluations of the quality of GP services were made by women normally seeing a male GP in mixed-sex practices and the least positive evaluations were given by women in male-only GP practices CONCLUSIONS: In order to meet women's expressed preferences, every GP practice should have at least one female GP available at least some of the time and every GP practice should employ a female PHC worker.     

Influence of exercise activity on quality of life in long-term breast cancer survivors

Background: Behavioral and lifestyle factors may influence quality of life (QOL) outcomes in breast cancer survivors. Methods: Information on QOL (Short Form-36, SF-36), lifestyle and survivorship was collected during telephone interviews with 374 breast cancer patients, diagnosed between 1983 and 1988 at ages 40 years or younger and interviewed, on average 13.2 years following diagnosis. These women previously participated in a case-control study soon after their diagnoses, providing information on breast cancer risk factors including exercise activity. We examined the impact of changes in exercise activity (comparing pre- to post-diagnosis levels) on the SF-36 mental and physical health summary scales using regression analyses. Results: A positive change in exercise activity was associated with a higher score on the SF-36 physical health summary scale at follow-up (p= 0.005). Change in exercise activity was not associated with the SF-36 mental health summary scale score. Patients who increased their activity levels did not differ from those who did not in terms of medical or demographic characteristics. Conclusion: This study provides one of the longest follow-up periods of breast cancer survivors to date among studies that focus on QOL and is unique in its focus on women diagnosed at a young age. Our results confirm high levels of functioning and well-being among long-term survivors and indicate that women whose exercise activity increased following diagnosis score higher on the SF-36 physical health summary scale. These findings suggest a potential role for exercise activity in maintaining well-being after a cancer diagnosis.     

Women's higher likelihood of disability pension: the role of health, family and work. A 5-7 years follow-up of the Hordaland Health Study

ABSTRACT: BACKGROUND: Women's higher risk of disability pension compared with men is found in countries with high female work participation and universal welfare schemes. The aim of the study was to examine the extent to which self-perceived health, family situation and work factors explain women's higher risk of disability pension. We also explored how these factors influenced the gender difference across educational strata. METHODS: The population-based Hordaland Health Study (HUSK) was conducted in 1997--99 and included inhabitants born in 1953--57 in Hordaland County, Norway. The current study included 5,959 men and 6,306 women in paid work with valid information on education and self-perceived health. Follow-up data on disability pension, for a period of 5--7 years, was obtained by linking the health survey to a national registry of disability pension. Cox regression analyses were employed. RESULTS: During the follow-up period 99 (1.7 %) men and 230 (3.6 %) women were awarded disability pension, giving a twofold risk of disability pension for women compared with men. Except for a moderate impact of self-perceived health, adjustment for family situation and work factors did not influence the gender difference in risk. Repeating the analyses in strata of education, the gender difference in risk of disability pension among the highly educated was fully explained by self-perceived health and work factors. In the lower strata of education there remained a substantial unexplained gender difference in risk. CONCLUSIONS: In a Norwegian cohort of middle-aged men and women, self-perceived health, family situation and work factors could not explain women's higher likelihood of disability pension. However, analyses stratified by educational level indicate that mechanisms behind the gender gap in disability pension differ by educational levels. Recognizing the heterogeneity within gender may contribute to a deeper understanding of women's higher risk of disability pension.