Bruce E. Robinson

Resuscitation decision making in the elderly: the value of outcome data

Objective: To assess the relationship between cardiopulmonary resuscitation (CPR) information and desire for CPR in an elderly population and to determine the influence of outcome data on desire for CPR in older persons.Design: An interventional study utilizing an educational program.Setting: Elderly independent retirement community.Participants: One hundred two persons, all more than 62 years old, who were neither demented nor depressed.Intervention: Participants received an educational intervention consisting of descriptive CPR information and quantitative information about CPR outcomes. CPR information, survival estimates, and preferences were recorded prior to and after the intervention.Measurements and main results: Subjects exhibited a high level of basic knowledge about CPR, which did not change with the intervention. While subjects consistently overestimated their chances of survival post CPR, these estimates decreased toward more realistic levels after the intervention (p<0.001). CPR preferences changed in three of five hypothetical clinical scenarios after the intervention (p<0.05). Those who were more realistic in their estimates of CPR survival desired less CPR in the hypothetical scenarios (p<0.01). A trend in our data suggests that quantitative outcome information may have a greater influence on CPR preferences than has descriptive information (p=0.07).Conclusions: CPR preferences changed after an educational intervention. An improved understanding of quantitative outcome data appears to influence the desire for CPR and therefore should be included in CPR discussions with older patients.

Incidence of pancreatitis in patients undergoing sphincter of Oddi manometry (SOM)

Objective:Sphincter of Oddi manometry (SOM) is a useful diagnostic procedure when evaluating patients with unexplained biliary pain or idiopathic recurrent pancreatitis. Acute pancreatitis is a recognized complication of SOM whose pathogenesis appears to be multifactoral. We conducted this study to determine the incidence of pancreatitis in patients after SOM and to identify any variables that may lead to an increased incidence of pancreatitis.Methods:A retrospective review of 100 consecutive patients who underwent SOM between 1992 and 1996 at two university-affiliated hospitals was done. SOM was performed using a triple lumen catheter with each lumen perfused at a rate of 0.25 cc/min using an Arndorfer pneumohydraulic capillary perfusion system. The following data were recorded: age, gender, clinical type of sphincter of Oddi dysfunction, length of procedure, doses of medications used, duct cannulated, sphincter of Oddi pressure, whether endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy was performed, and the number of patients developing pancreatitis. Statistical analysis was performed using a T test, χ2, and multiple regression analysis.Results:The overall incidence of pancreatitis was 17%. Six patients with type II SO dysfunction and 11 patients with type III SO dysfunction developed pancreatitis. The incidence of pancreatitis was significantly lower in those patients who only had SOM, compared with those patients who had SOM and ERCP (9.3%vs 26.1%, p < 0.026). There was no significant correlation between age, gender, duration of procedure, dose of midazolam used, sphincter of Oddi pressure, or type of SO dysfunction with the development of SOM-induced pancreatitis. Multiple regression analysis showed that sphincterotomy added no additional risk, beyond that associated with ERCP, for the development of pancreatitis.Conclusions:The results of this study indicate that the incidence of pancreatitis was highest when SOM was followed by ERCP. A potential method of decreasing the incidence of pancreatitis after SOM is performing ERCP with or without sphincterotomy at another session, separated from the SOM by at least 24 h. Before this can be definitely recommended, the results of this study must be validated by others or by a prospective study.

Decisions for Hospice Care in Patients with Advanced Cancer

OBJECTIVES: To identify factors that may influence the decision of whether to enter a hospice program or to continue with a traditional hospital approach in patients with advanced cancer and to understand their decision‐making process.

Are hyperplastic rectosigmoid polyps associated with an increased risk of proximal colonic neoplasms

Diminutive polyps are frequent findings on screening flexible sigmoidoscopy. To determine the significance of distal diminutive polyps, we conducted a prospective study of 162 asymptomatic, average-risk subjects who were 50 years of age or older. Subjects were divided into four groups: 42 control subjects with no polyps in the rectosigmoid, 66 subjects with at least one diminutive adenoma in the rectosigmoid, 12 subjects with a mixed hyperplastic-adenomatous polyp in the rectosigmoid, and 42 subjects with only hyperplastic polyps in the rectosigmoid. Total colonoscopy was performed on all subjects. The prevalence of proximal adenomas was 42% in the adenoma group, 25% in the mixed group, 14% in the hyperplastic group and 12% in the control group. The prevalence of proximal adenomas was significantly higher (p = 0.006) in the adenoma group as compared with the control and hyperplastic groups. Increasing age was associated with an increased prevalence of proximal adenomas. Nearly two thirds of those over 65 years of age with distal diminutive adenomas had proximal colonic neoplasms. These results indicate that diminutive rectosigmoid adenomas are good markers for proximal neoplasms. Rectosigmoid hyperplastic polyps are not associated with an increased prevalence of proximal neoplasms. Total colonoscopy is not indicated if hyperplastic polyps are the only finding on flexible sigmoidoscopy.

Perceptions of Illness, Coping, and Well-being in Persons With Mild Cognitive Impairment and Their Care Partners

Despite greater attention to mild cognitive impairment (MCI), little is known about reactions to this potentially threatening diagnosis among persons with MCI (PWMCI) and their care partners. Psychologic reactions, perceptions of illness, and coping responses of 46 individuals recently diagnosed with MCI and 29 care partners were assessed with questionnaires assessing psychologic well-being, illness perceptions, coping, and perceived needs for services. Care partners and PWMCI report normal levels of psychologic well-being, showing less distress than is commonly found in Alzheimer disease (AD) caregivers. Problem-focused (eg, active coping) and emotion-focused coping strategies (eg, acceptance) were used more often than dysfunctional coping strategies (eg, self-distraction) by PWMCI and care partners. Both groups tended to minimize the likelihood of conversion to AD, and endorsed mental and physical exercise, optimism, dietary changes, and stress reduction as strategies to prevent conversion. Although PWMCI minimized their impairment, care partners reported providing an average of 24 hours per week of caregiving and reported that the PWMCI did need significant help with complex activities. Respondents reported using few formal services but they anticipate substantial future need for services. Results suggest that PWMCI and care partners are likely to minimize the threat of AD and to perceive that conversion is controllable and preventable with health promotion activities. Study implications for the development of intervention programs for PWMCI and their care partners are discussed.

Life Values, Resuscitation Preferences, and the Applicability of Living Wills in an Older Population

OBJECTIVES: To determine whether life values are related to resuscitation preferences and living will completion in an older population and to assess beliefs about the applicability of living wills.

Practicing Physician Education in Geriatrics: Lessons Learned from a Train‐the‐Trainer Model

Evidence of poor performance in the evaluation and management of common geriatric conditions suggests the need for changing physician behavior in these areas. Traditional lecture‐style continuing medical education (CME) has not been shown to be effective. Expert faculty initially trained 60 nonexpert peer educators to conduct small‐group, learner‐centered CME using tool kits on memory loss, incontinence, and depression. Peer educators presented 109 community‐based sessions to 1,309 medical practitioners. Surveys were administered to community participants immediately and 6 months after a session. Evidence of effectiveness included statistically significant increases in self‐reported knowledge, attitudes, and office‐based practices on the target topics at the time of training and at the 6‐month follow‐up (P<.001) and two‐thirds of respondents reporting continued use of three or more tools at 6 months. Participants reported that the interactive presentation aided their understanding of and ability to use the tool kits more than an off‐the‐shelf review (mean rating±standard deviation 4.1±0.71, with 1=not at all and 5=significantly). After the formal evaluation period, additional information about the project dynamics and tool kits was obtained through a small interview sample and an on‐line survey, respectively. Receiving copies of the tool kits was an important factor in enabling educators to offer sessions. Barriers to offering sessions included finding time, an audience, and space. Findings suggest that modest positive changes in practice in relation to common geriatric problems can be achieved through peer‐led, community‐based sessions using principles of knowledge translation and evidence‐based tool kits with materials for providers and patients.

Prognostic factors for survival in terminal lung cancer patients

AbstractObjective: To determine the factors that are related to short-term survival and to develop a model that can be used to estimate prognosis in terminal lung cancer patients. Design: Longitudinal cohort study of hospice lung cancer patients followed from date of admission to hospice until death. Setting: Community-based nonprofit home hospice service. Patients: Three hundred ten consecutive lung cancer patients admitted to hospice, with a separate validation sample of 78 consecutive hospice lung cancer patients. Measurements: The relationships between survival and admission demographic characteristics, information from the history and physical examination, assessments of performance and nutrition, particular symptoms, and the presence of a living will were evaluated. Results: Mean survival was 51 days, with a median survival of 27 days. Shorter survival was independently associated with those who had no living will on admission to hospice (p=0.008), those who had tissue types other than squamous cell or adenocarcinoma (p=0.008), those who had liver metastases (p=0.04), those who were tachycardic (p<0.001), those who required assistance or were dependent in their toileting (p<0.001) and feeding (p=0.001), those who had dry mouths (p=0.01), and those who had severe or incapacitating pain (p<0.05). A model estimating survival time based on the number of these significant variables present is reported (r=0.53 in the original sample; r=0.38 in the validation sample). Conclusions: Multiple factors, including tissue type, the presence of metastases, assessments of functional status, specific symptoms, and the presence of a living will, were related to short-term survival in terminal lung cancer patients admitted to hospice. A model utilizing these specific factors allows useful estimates of short-term survival for these patients.

Educational objectives for medical training in the care of the terminally ill

BACKGROUND. Palliative medicine is developing as a distinct clinical discipline worldwide. The U.S. literature describes goals for education in palliative medicine, yet this literature lacks validated educational objectives. METHOD. To develop and validate appropriate educational objectives for medical training in the care of the terminally ill, 200 randomly selected members of the Academy of Hospice Physicians were asked in 1992 to evaluate 39 educational objectives by an item-objective congruence procedure. Each objective was rated as −1 (inappropriate), 0 (unsure), or 1 (appropriate). RESULTS. Of the 200 members surveyed, 127 (64%) responded. Of the 39 objectives, 34 were considered valid, with a mean score of > or = .8. The index of content validity was .87. The objectives not considered valid all dealt with nonmedical issues related to hospice or palliative care. CONCLUSION. This study validated 34 educational objectives for medical training in the care of the terminally ill. Training programs using these objectives, amended for specific audiences, should be included in the various levels of U.S. medical education.

The use of the opinion leader in continuing medical education

This paper describes a process evaluation of an opinion leader (OL) project for a geriatric medical education program in dementia. Structured interviews with OLs were conducted to understand their experience as formal OLs from their initial training to the projects completion. Thirteen of 15 physicians involved in an OL project were interviewed. The adoption of a formal educational OL role was not an easy transition for most identified OLs. Some physicians struggled with the role and would have preferred more specific guidance. For this subject some content expertise was felt to be essential. Strong project leadership and some measures of success are important to sustain the OL commitment to a project. More attention needs to be devoted to the appropriate selection and training of OLs for educational projects to ensure that they have the relevant clinical expertise and skills to be effective and feel comfortable adopting a formal OL role.