Alexia M. Torke

The Patient–Doctor Relationship and Online Social Networks: Results of a National Survey

ABSTRACTBACKGROUNDThe use of online social networks (OSNs) among physicians and physicians-in-training, the extent of patient–doctor interactions within OSNs, and attitudes among these groups toward use of OSNs is not well described.OBJECTIVETo quantify the use of OSNs, patient interactions within OSNs, and attitudes toward OSNs among medical students (MS), resident physicians (RP), and practicing physicians (PP) in the United States.DESIGN/SETTINGA random, stratified mail survey was sent to 1004 MS, 1004 RP, and 1004 PP between February and May 2010.MEASUREMENTSPercentage of respondents reporting OSN use, the nature and frequency of use; percentage of respondents reporting friend requests by patients or patients’ family members, frequency of these requests, and whether or not they were accepted; attitudes toward physician use of OSNs and online patient interactions.RESULTSThe overall response rate was 16.0% (19.8% MS, 14.3% RP, 14.1% PP). 93.5% of MS, 79.4% of RP, and 41.6% of PP reported usage of OSNs. PP were more likely to report having visited the profile of a patient or patient’s family member (MS 2.3%, RP 3.9%, PP 15.5%), and were more likely to have received friend requests from patients or their family members (MS 1.2%, RP 7.8%, PP 34.5%). A majority did not think it ethically acceptable to interact with patients within OSNs for either social (68.3%) or patient-care (68.0%) reasons. Almost half of respondents (48.7%) were pessimistic about the potential for OSNs to improve patient–doctor communication, and a majority (79%) expressed concerns about maintaining patient confidentiality.CONCLUSIONPersonal OSN use among physicians and physicians-in-training mirrors that of the general population. Patient–doctor interactions take place within OSNs, and are more typically initiated by patients than by physicians or physicians-in-training. A majority of respondents view these online interactions as ethically problematic.

Effects of age, education, and gender on CERAD neuropsychological test performance in an African American sample

Abstract Eighty-three normal, healthy, African American men and women aged 65 and older completed the Consortium to Establish a Registry for Alzheimers Disease-Neuropsychological Battery (CERAD-NB). Regression analyses indicated powerful education and less marked age and gender influences on CERAD-NB test performance. Higher education was associated with better performance on nearly all CERAD-NB tests, age effects were noted only on the memory indices (younger subjects had better scores), and women performed slightly better than men on one index from the Word List Learning Test. Age and education interacted on the Word List Learning Test such that the best scores were obtained by younger subjects with more years of schooling; the other age-education combinations did not differ from each other. Factor analysis revealed a two-factor solution (i.e., a nonmemory general cognitive factor and a verbal memory factor) which accounted for 67% of the variance. Education-stratified normative data are presented for ...

Substituted Judgment: The Limitations of Autonomy in Surrogate Decision Making

Substituted judgment is often invoked as a guide for decision making when a patient lacks decision making capacity and has no advance directive. Using substituted judgment, doctors and family members try to make the decision that the patient would have made if he or she were able to make decisions. However, empirical evidence suggests that the moral basis for substituted judgment is unsound. In spite of this, many physicians and bioethicists continue to rely on the notion of substituted judgment. Given compelling evidence that the use of substituted judgment has insurmountable flaws, other approaches should be considered. One approach provides limits on decision making using a best interest standard based on community norms. A second approach uses narrative techniques and focuses on each patient’s dignity and individuality rather than his or her autonomy.

Scope and Outcomes of Surrogate Decision Making Among Hospitalized Older Adults

IMPORTANCE Hospitalized older adults often lack decisional capacity, but outside of the intensive care unit and end-of-life care settings, little is known about the frequency of decision making by family members or other surrogates or its implications for hospital care. OBJECTIVE To describe the scope of surrogate decision making, the hospital course, and outcomes for older adults. DESIGN, SETTING, AND PARTICIPANTS Prospective, observational study conducted in medicine and medical intensive care unit services of 2 hospitals in 1 Midwestern city in 1083 hospitalized older adults identified by their physicians as requiring major medical decisions. MAIN OUTCOMES AND MEASURES Clinical characteristics, hospital outcomes, nature of major medical decisions, and surrogate involvement. RESULTS According to physician reports, at 48 hours of hospitalization, 47.4% (95% CI, 44.4%-50.4%) of older adults required at least some surrogate involvement, including 23.0% (20.6%-25.6%) with all decisions made by a surrogate. Among patients who required a surrogate for at least 1 decision within 48 hours, 57.2% required decisions about life-sustaining care (mostly addressing code status), 48.6% about procedures and operations, and 46.9% about discharge planning. Patients who needed a surrogate experienced a more complex hospital course with greater use of ventilators (2.5% of patients who made decisions and 13.2% of patients who required any surrogate decisions; P < .001), artificial nutrition (1.7% of patients and 14.4% of surrogates; P < .001), and length of stay (median, 6 days for patients and 7 days for surrogates; P < .001). They were more likely to be discharged to an extended-care facility (21.2% with patient decisions and 40.9% with surrogate decisions; P < .001) and had higher hospital mortality (0.0% patients and 5.9% surrogates; P < .001). Most surrogates were daughters (58.9%), sons (25.0%), or spouses (20.6%). Overall, only 7.4% had a living will and 25.0% had a health care representative document in the medical record. CONCLUSIONS AND RELEVANCE Surrogate decision making occurs for nearly half of hospitalized older adults and includes both complete decision making by the surrogate and joint decision making by the patient and surrogate. Surrogates commonly face a broad range of decisions in the intensive care unit and the hospital ward setting. Hospital functions should be redesigned to account for the large and growing role of surrogates, supporting them as they make health care decisions.

Palliative Care for Patients with Dementia: A National Survey

OBJECTIVES: To determine the extent to which hospice and nonhospice palliative care (PC) programs provide services to patients with dementia and to describe barriers and facilitators to providing nonhospice PC.

Physicians’ Experience with Surrogate Decision Making for Hospitalized Adults

BackgroundHospitalized patients frequently lack decision-making ability, yet little is known about physicians’ approaches to surrogate decision making.ObjectiveTo describe physicians’ experiences with surrogate communication and decision making for hospitalized adults.DesignCross-sectional written survey.ParticipantsTwo hundred eighty-one physicians who recently cared for adult inpatients in one academic and two community hospitals.MeasurementsKey features of physicians’ most recent surrogate decision-making experience, including the nature of the decision, the physician’s reaction, physician-surrogate communication and physician-surrogate agreement about the best course of action.ResultsNearly three fourths of physicians (73%, n = 206) had made a major decision with a surrogate during the past month. Although nearly all patients (90%) had a surrogate, physicians reported trouble contacting the surrogate in 21% of cases. Conflict was rare (5%), and a majority of physicians agreed with surrogates about the medical facts (77%), prognosis (72%) and best course of action (65%). After adjustment for patient, physician and decision characteristics, agreement about the best course of action was more common among surrogates for older patients [prevalence ratio (PR) = 1.17 for each decade; 95% confidence interval (CI) 1.02–1.31], ICU patients (PR = 1.40; CI 1.14–1.51) and patients who had previously discussed their wishes (PR = 1.60; CI 1.30–1.76), and less common when surrogates were difficult to contact (PR = 0.59; CI 0.29–0.92) or when the physician self-identified as Asian (PR = 0.60; CI 0.30–0.94).ConclusionSurrogate decision making is common among hospitalized adults. Physician-surrogate decision making may be enhanced if patients discuss their preferences in advance and if physician contact with surrogate decision makers is facilitated.

A conceptual model of the role of communication in surrogate decision making for hospitalized adults

OBJECTIVE To build a conceptual model of the role of communication in decision making, based on literature from medicine, communication studies and medical ethics. METHODS We proposed a model and described each construct in detail. We review what is known about interpersonal and patient-physician communication, described literature about surrogate-clinician communication, and discussed implications for our developing model. RESULTS The communication literature proposes two major elements of interpersonal communication: information processing and relationship building. These elements are composed of constructs such as information disclosure and emotional support that are likely to be relevant to decision making. We propose these elements of communication impact decision making, which in turn affects outcomes for both patients and surrogates. Decision making quality may also mediate the relationship between communication and outcomes. CONCLUSION Although many elements of the model have been studied in relation to patient-clinician communication, there is limited data about surrogate decision making. There is evidence of high surrogate distress associated with decision making that may be alleviated by communication-focused interventions. More research is needed to test the relationships proposed in the model. PRACTICE IMPLICATIONS Good communication with surrogates may improve both the quality of medical decisions and outcomes for the patient and surrogate.

Timing of Do‐Not‐Resuscitate Orders for Hospitalized Older Adults Who Require a Surrogate Decision‐Maker

OBJECTIVES: To examine the frequency of surrogate decisions for in‐hospital do‐not‐resuscitate (DNR) orders and the timing of DNR order entry for surrogate decisions.

Physicians' Views on the Importance of Patient Preferences in Surrogate Decision-Making

OBJECTIVES: To explore the degree to which physicians report reliance on patient preferences when making medical decisions for hospitalized patients lacking decisional capacity.

Hospital Readmission Penalties: Coming Soon to a Nursing Home Near You!

The Protecting Access to Medicare Act of 2014 includes provisions for hospital readmission penalties for skilled nursing facilities (SNFs) starting in 2018. This presents an opportunity for care improvement but also raises several concerns regarding quality of care. The readmission measure for SNFs is similar to the current readmission measure for hospitals mandated under the Affordable Care Act, with the exception of adjustments made for sex. Because these measures for hospitals are similar, lessons can be learned from implementation of the existing hospital readmission penalties. In addition, there are three specific concerns that the authors relate to implementing the proposed measure in SNFs. There is poor communication and care coordination between care settings, including posthospitalization and post‐SNF care in the current healthcare system. Adding readmission penalties to SNF regulations may create perverse incentives for prolonged SNF stays. The evidence base for the best means of caring for individuals after a brief stay in a SNF needs enrichment. These challenges need to be addressed as part of implementation of these new hospital readmission penalties for SNFs to improve care and prevent new unintended consequences.