Amy M. Corcoran

Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions.

Aspiration pneumonia is a leading cause of morbidity and mortality of elderly residents in long-term care facilities. The microflora present in the oral cavity because of poor oral hygiene has been associated with aspiration pneumonia. There is evidence that improved oral care can reduce the risk of developing aspiration pneumonia in the elderly. The purpose of this paper is to review aspiration pneumonia and provide oral health care guidelines in an effort to help reduce the risk of aspiration pneumonia in the elderly residing in long-term care facilities.

Chronic Obstructive Pulmonary Disease Diagnosis and Management in Older Adults

Chronic obstructive pulmonary disease (COPD) in older adults is a complex disorder with several unique age‐related aspects. Underlying changes in pulmonary lung function and poor sensitivity to bronchoconstriction and hypoxia with advancing age can place older adults at greater risk of mortality or other complications from COPD. The establishment of the Global Initiative for Obstructive Lung Disease criteria, which can be effectively applied to older adults, has more rigorously defined the diagnosis and management of COPD. An important component of this approach is the use of spirometry for disease staging, a procedure that can be performed in most older adults. The management of COPD includes smoking cessation, influenza and pneumococcal vaccinations, and the use of short‐ and long‐acting bronchodilators. Unlike with asthma, corticosteroid inhalers represent a third‐line option for COPD. Combination therapy is frequently required. When using various inhaler designs, it is important to note that older adults, especially those with more‐severe disease, may have inadequate inspiratory force for some dry‐powder inhalers, although many older adults find the dry‐powder inhalers easier to use than metered‐dose inhalers. Other important treatment options include pulmonary rehabilitation, oxygen therapy, noninvasive positive airway pressure, and depression and osteopenia screening. Clinicians caring for older adults with an acute COPD exacerbation should also guard against prognostic pessimism. Although COPD is associated with significant disability, there is a growing range of treatment options to assist patients.

Advance Care Planning and Hospice Enrollment: Who Really Makes the Decision To Enroll?

PURPOSE The purpose of this study was to assess patient participation in advance care planning (ACP) and the decision to enroll in hospice. METHODS One hundred sixty-five family members of patients who died in hospice between January 2004 and September 2004 returned an anonymous survey (165/380; 43% response rate). RESULTS Forty-nine percent of family members reported that the patient was not involved in the hospice enrollment decision. The majority of respondents (78%) reported one or more people helped make the decision to enroll in hospice. For patients reported as being involved in the decision to enroll in hospice (either independently or in a shared capacity) they were more likely to have cancer (odds ratio [OR] = 2.3, p = 0.02), die at home (OR = 3.3, p = 0.006), have a length of stay in hospice greater than 7 days (OR = 2.1, p = 0.03), and less likely to have dementia (OR = 0.43, p = 0.001). White respondents were more likely to report having ACP discussions with the patient about: feeding tubes (OR = 4.7; p = 0.001), cardiopulmonary resuscitation (CPR; OR = 3.9; p = 0.002), or mechanical ventilation (OR = 2.7; p = 0.02) than non-white respondents. White respondents were more likely than non-white respondents to report that the patient had a written advance directive (OR = 4.2, p = 0.001). DISCUSSION These data indicate that some patients are not actively involved in the decision to enroll in hospice and that others, often physicians and family members, are making these decisions for the patient collaboratively. These data support the need for early education and interventions that assist patients and families in discussing ACP preferences and the need for greater understanding of how involved patients want to be with the decision to enroll in hospice.

Palliative Care for Patients With Dementia in Long-Term Care

Seventy percent of people in the United States who have dementia die in the nursing home. This article addresses the following topics on palliative care for patients with dementia in long-term care: (1) transitions of care, (2) infections, other comorbidities, and decisions on hospitalization, (3) prognostication, (4) the evidence for and against tube feeding, (5) discussing goals of care with families/surrogate decision makers, (6) types of palliative care programs, (7) pain assessment and management, and (8) optimizing function and quality of life for residents with advanced dementia.

Piloting a Medical Student Observational Experience With Hospital-Based Trauma Chaplains

INTRODUCTION Medical students have typically received relatively modest training in approaches for engaging the concerns of patients and families facing life-threatening situations and terminal illnesses. We propose that medical students would perceive benefits to their communication skills, understanding of the role of the chaplain, and knowledge of emotional and spiritual needs of grieving patients and families after shadowing hospital-based trauma chaplains whose work focuses on emergency department traumas and intensive care units. METHODS The authors developed a pilot program in which medical students shadowed a trauma chaplain during an on-call shift in an urban level 1 trauma center. Students subsequently completed an evaluative survey of their experience. RESULTS Of 21 participants, 14 (67%) completed the questionnaire. Students observed an average of 1.50 traumas and 3.57 interactions with patients or families. One-third of the students witnessed a death. More than 90% of respondents agreed or strongly agreed that (1) the program provided them with a greater understanding of how to engage patients and families in difficult conversations; (2) they learned about the chaplains role in the hospital; and (3) the experience was useful for their medical education, careers, and personal development. About two-thirds (9/14) perceived that they learned how to discuss spirituality with patients and families. All recommended the experience be part of the medical school curriculum. DISCUSSION Observational experiences with hospital-based trauma chaplains might be an effective nondidactic approach for teaching medical students effective communication with patients and families, collaboration with chaplains, and spirituality in patient care.

Hospice and Non-Hospice Models of Palliative Care Delivery in Long-Term Care (327)

medicine provider. Some of the most difficult of these cases are those at occur at the extremes of childhood. This session will discuss medical decision-making in four cases, including an unborn with life-limiting pathology, a terminally ill neonate in the NICU, an adolescent with advanced cancer and no parental support, and a previously independent 19-year-old who is suddenly ventilator-dependent with a devastating neurologic condition. These illustrative cases will demonstrate surrogate decision-making for the not-yet-competent individual, principles of assent versus consent, continuation of pregnancy against medical advice, adolescent parents as surrogates, loss of recently acquired adult maturation, withdrawal of medical therapies in children, and other unique aspects of medical decision-making with and for vulnerable child patients. Components of good pediatric palliative decision-making will become evident to the participant via interaction with the presenters. Tools to facilitate good pediatric medical decisionmaking will be presented. Application of principles of pediatric palliative care learned in four geographic, cultural, academic, and clinically diverse care settings will be shared by multidisciplinary, multispecialty faculty. AAHPM Pediatric Special Interest Group members suggested this presentation as most likely to be helpful to the Annual Assembly attendee as well as the pediatric palliative care provider. Exposure to these cases of pediatric medical decision-making at the extremes of life will build skills and enhance the participants comfort in the practice of palliative care.