Caroline Vitale

American geriatrics society identifies another five things that healthcare providers and patients should question

Since 2012, the American Geriatrics Society (AGS) has also been collaborating with the American Board of Internal Medicine (ABIM) Foundation, joining its “Choosing Wisely” campaign on two separate lists of Five Things Healthcare Providers and Patients Should Question. The campaign is designed to engage healthcare organizations and professionals, individuals, and family caregivers in discussions about the safety and appropriateness of medical tests, medications, and procedures. Participating healthcare providers are asked to identify five things—tests, medications, or procedures—that appear to harm rather than help. Providers then share this information in a published article about these things on the ABIM campaigns website (www.choosingwisely.org). The first AGS list was published in February 2013.

A Call for Guidance in the Use of Left Ventricular Assist Devices in Older Adults

Left ventricular assist devices (LVADs) are approved as “destination therapy” (permanent use without plans for transplantation) in individuals with advanced heart failure who are not candidates for a cardiac transplant; as such, these devices are increasingly being used in older adults. Although LVADs have been shown to increase quality of life and survival, the associated treatment burdens and complications deserve careful consideration. The current study illustrates myriad clinical challenges that can arise during long‐term mechanical support using an older adult case history. Current data on LVAD use in older adults is reviewed, and a discussion of relevant points to consider before LVAD implantation in older adults, including advance care planning, assessment of gait and cognition, and the potential for substantial caregiver burden, is undertaken.

Tube feeding in advanced dementia: an exploratory survey of physician knowledge.

The administration of artificial nutrition by means of a percutaneous endoscopic gastrostomy (PEG) tube in older persons in the advanced stages of dementia is commonplace, yet the treatment is associated with significant treatment burdens and unclear benefits in this population. In addition, there is wide and unexplained geographic variability in the use of PEG in advanced dementia, which may stem partly from physicians’ lack of understanding about its indications, risks, benefits, and effect on quality of life in advanced dementia. This study was a mail survey undertaken to assess physician knowledge regarding tube feeding in advanced dementia and explore whether certification in geriatrics or other physician characteristics are associated with physician knowledge. To assess knowledge about tube feeding, we asked participants to rate the importance of commonly cited, but non–evidence based, indications for tube feeding in advanced dementia, including recurrent aspiration pneumonia, abnormal swallowing evaluations, abnormal nutritional parameters, preventing an uncomfortable death, and others. Discrepancies between physician knowledge and current evidence regarding tube feeding in advanced dementia were found, indicating a need for improved education of primary care physicians in order to ultimately provide better end-of-life care for patients with advanced dementia.

Antimicrobial Use at the End of Life Among Hospitalized Patients With Advanced Cancer

Background: We sought to evaluate antimicrobial use among patients with advanced cancer. Methods: Retrospective review of patients experiencing cancer-related death while hospitalized. Results: Among 145 patients, 126 (86.9%) received antimicrobials for a mean of 12.5 ± 12.9 days. 88 (69.8%) of 126 had clinical findings suggestive of infection. Sixty-one patients (48.4%) had positive cultures, the remaining were treated empirically. “Comfort care” was ultimately pursued in 99 (78.5%) of 126; 35 (35.4%) of 99 continued to receive antimicrobials after a transition to comfort care for an average of 1.6 ± 1.1 days. On average, antimicrobials were discontinued <1day prior to death. Conclusion: Antimicrobial use was common among patients with advanced cancer. Even after transition to comfort care, more than one third of patients remained on antimicrobials. The risks and burdens of antimicrobials should be carefully examined when comfort is the stated goal.

Antimicrobial Use Among Patients Receiving Palliative Care Consultation

Background: We sought to characterize antimicrobial use among patients receiving palliative care consultation. Methods: Retrospective review of patients seen by the Palliative Care Service at the University of Michigan Health System from January 2008 to May 2008. Results: Of 131 patients seen in consultation, 70 received antimicrobials. We identified 92 infections among these 70 patients; therapy for 54 (58.7%) was empiric. Empiric therapy was most commonly prescribed for respiratory infection and urinary tract infection. Piperacillin/tazobactam (P/T) was the most frequently used agent, with 26 patients receiving P/T (37.1%); 22 of 26 received this agent empirically (84.6%, P = .005). Vancomycin was prescribed to 23 patients (32.9%). Sixteen patients (22.9%) died in hospital; another 31 were enrolled in hospice care. Conclusions: Our results suggest significant use of empiric, broad-spectrum antimicrobial therapy among hospitalized patients near the end of life. We advocate for careful assessment of potential benefits and treatment burdens of antimicrobial therapy, especially when palliation is the goal.

AGS Position Statement: Making Medical Treatment Decisions for Unbefriended Older Adults

In this position statement, we define unbefriended older adults as patients who: (1) lack decisional capacity to provide informed consent to the medical treatment at hand; (2) have not executed an advance directive that addresses the medical treatment at hand and lack capacity to do so; and (3) lack family, friends or a legally authorized surrogate to assist in the medical decision‐making process. Given the vulnerable nature of this population, clinicians, health care teams, ethics committees and other stakeholders working with unbefriended older adults must be diligent when formulating treatment decisions on their behalf. The process of arriving at a treatment decision for an unbefriended older adult should be conducted according to standards of procedural fairness and include capacity assessment, a search for potentially unidentified surrogate decision makers (including non‐traditional surrogates) and a team‐based effort to ascertain the unbefriended older adults preferences by synthesizing all available evidence. A concerted national effort is needed to help reduce the significant state‐to‐state variability in legal approaches to unbefriended patients. Proactive efforts are also needed to identify older adults, including “adult orphans,” at risk for becoming unbefriended and to develop alternative approaches to medical decision making for unbefriended older adults. This document updates the 1996 AGS position statement on unbefriended older adults.

Management of Intractable Hiccups An Illustrative Case and Review

Often thought of as a benign and self-limited condition, hiccups can become persistent or intractable, and thus be associated with substantial morbidity and distress. In such cases, an underlying etiology is often present, and may be overlooked. Debilitating hiccups can present a major challenge to optimal symptom management. Various causes of protracted hiccups have been identified including metabolic abnormalities, central nervous system pathology, malignancy, medications, and disorders attributed to cardiac, pulmonary and gastrointestinal etiologies. We present a case of intractable hiccups in a patient with an advanced hematological malignancy and review specific therapies for the management of persistent hiccups.

Management of Bleeding Associated with Malignant Wounds

Bleeding malignant wounds in palliative care patients can be anxiety-provoking for patients, their caregivers, and healthcare providers, and can be difficult to manage. We present the case of a 60-year-old man with a bleeding neck wound due to squamous cell carcinoma of the hypopharynx admitted to our inpatient palliative care unit. Management of bleeding included local wound care measures and psychosocial support for the patient and his wife. We review therapeutic approaches to managing bleeding malignant wounds with the aim of providing clinically useful information.

Enhancing provider knowledge and patient screening for palliative care needs in chronic multimorbid patients receiving home-based primary care.

This article describes a pilot model to increase palliative care (PC) knowledge and collaboration among providers and to systematically identify chronic multimorbid home care patients who would benefit from focused discussion of potential PC needs. Thirty health care providers from a home-based primary care team attended interdisciplinary trainings. The Palliative Performance Scale (PPS) tool was used to trigger discussions of potential palliative needs at team rounds for patients who scored below a cutoff point on the tool. Palliative Performance Scale implementation added little burden on nurses and triggered a discussion in 51 flagged patients. The tool successfully identified 75% of patients who died or were discharged. Screening was systematic and consistent and resulted in targeted discussions about PC needs without generating additional burden on our PC consult service. This model shows promise for enhancing collaborative patient care and access to PC.

Advance Directives and Care Received by Older Nursing Home Residents

Background: Research shows variable success as to whether care provided aligns with individual patient preferences as reflected in their advance directives (AD). Objective: We aimed to study AD status and subsequent care received in older nursing home (NH) residents deemed at risk for infections and care transitions: those with a urinary catheter (UC), feeding tube (FT), or both. Design/participants/measurements: A subgroup analysis of a prospective cohort of 90 residents with a UC and/or FT from 15 NHs in southeast Michigan. Outcomes assessed at enrollment and at 30-day intervals were hospitalizations and antibiotic use. The ADs were divided as follows: (1) comfort oriented: comfort measures only, no hospital transfer; (2) palliative oriented: comfort focused, allowing hospital transfer (except intensive care unit), antibiotic use, but no cardiopulmonary resuscitation; (3) usual care: full code, no limitations to care. We calculated incidences for these outcomes. Results: Seventy-eight (87%) residents had ADs: 18 (23%) comfort oriented, 32 (41%) palliative oriented, and 28 (36%) usual care. The groups did not differ regarding demographics, comorbidity, function, device presence, or time in study. Using the usual care group as comparison, the comfort-oriented group was hospitalized at a similar rate (Incidence rate [IR] = 15.6/1000 follow-up days vs IR = 8.8/1000 follow-up days, Incident rate ratio [IRR] 0.6 [95% confidence interval, CI, 0.3 -1.1], P value .09) but received fewer antibiotics (IR = 18.9/1000 follow-up days vs IR = 7.5/1000 follow-up days, IRR 0.4 [95% CI, 0.2-0.8], P value .005). Conclusion: Nursing home residents with comfort-oriented ADs were hospitalized at a rate similar to those with usual-care ADs but received fewer antibiotics, although the small sample size of this analysis suggests these findings deserve further study.