Laura C. Hanson

What Is Wrong With End‐of‐Life Care? Opinions of Bereaved Family Members

OBJECTIVE: To describe family perceptions of care at the end of life.

Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial.

IMPORTANCE For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy. OBJECTIVE To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach. INTERVENTIONS Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins. MAIN OUTCOMES AND MEASURES Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings. RESULTS A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, -3.5% to 10.5%; P=.36) and did not meet the noninferiority end point. Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P=.04). Few participants experienced cardiovascular events (13 in the discontinuation group vs 11 in the continuation group). Mean cost savings were

Families' Perception of the Added Value of Hospice in the Nursing Home

3.37 per day and

Randomized, Controlled Trials of Interventions to Improve Communication in Intensive Care: A Systematic Review

716 per patient. CONCLUSIONS AND RELEVANCE This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs. Thoughtful patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01415934.

Risk factors for nosocomial pneumonia in the elderly

OBJECTIVE: To determine if family members perceive that hospice improves the care of dying nursing home residents during the last 3 months of life.

A prospective study of the impact of patient preferences on life-sustaining treatment and hospital cost.

BACKGROUND Communication between families and providers in the ICU affects patient and family outcomes and use of health-care resources. Recent research studies have tested interventions designed to improve communication quality and outcomes between providers and families of patients in the ICU. We conducted a systematic review of these studies. METHODS We searched the MEDLINE, PsychInfo, Cochrane, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from 1995 to July 2010. We included studies that reported controlled clinical interventions designed to improve communication between providers and families of patients in the ICU aged 18 years or older. We abstracted all selected studies to a standardized data collection instrument and completed a quality checklist based on recommendations from the Consolidated Standards for Reporting Trials (CONSORT) investigators. RESULTS In all, 2,841 articles were identified. Of those articles, 180 met the criteria for full review, and 21 articles of 16 distinct interventions met the full inclusion criteria, of which five were randomized. Interventions studied included printed information or structured family conferences, with or without additional family support. Conferences aimed to communicate the diagnosis and prognosis, elicit patient values, assess family understanding, and clarify the goals of treatment. Printed information, palliative care or ethics consultation, or regular, structured communication by the usual ICU team reduced family distress, improved comprehension, and decreased the use of intensive treatments. CONCLUSIONS The evidence supports the use of printed information and structured communication by the usual ICU team, ethics consultation, or palliative care consultation to improve family emotional outcomes and to reduce ICU length of stay and treatment intensity. Evidence that these interventions reduce total costs is inconclusive. A comprehensive research agenda should ensure the future study of a full range of patient-centered outcomes.

Comfort feeding only: a proposal to bring clarity to decision-making regarding difficulty with eating for persons with advanced dementia.

PURPOSE Elderly patients have a disproportionate incidence of nosocomial pneumonia (NP) and a higher mortality rate, yet few studies have focused on this high-risk population. We undertook a study to examine risk factors for NP in elderly inpatients and to describe how these patients differ from younger patients with NP. METHODS In a public teaching hospital, all cases of NP in patients aged 65+ were ascertained by prospective surveillance during a 2-year period (n = 59). These elderly cases were compared with 59 cases of NP in patients aged 25 to 50 to describe differences in risk factors and outcomes. Elderly cases were then matched to elderly control subjects who were admitted to the same hospital service but did not develop NP. Data were collected on known risk factors and on the potential risk factors of poor nutrition, neuromuscular disease, and dementia. Significant differences in risk factors were analyzed using univariate and multivariate comparisons of cases and controls. RESULTS Elderly patients had twice the incidence of NP (RR = 2.1) as younger patients. Onset of infection was earlier for young than for older cases (6 versus 11 days, p less than or equal to 0.02), but mortality following NP was equal for the two age groups (42% versus 44%). No significant differences in risk factors were found for old and young cases, although older cases tended to have higher rates of poor nutrition, neuromuscular disease, and aspiration preceding their pneumonias. Comparison of elderly cases and elderly controls revealed significantly increased frequencies of poor nutrition, neuromuscular disease, pharyngeal colonization, aspiration, depressed level of alertness, intubation, intensive care unit admission, nasogastric tube use, and antacid use among cases. Cases were more severely ill on admission and had more pre-existing risk factors (2.8 versus 1.3, p less than or equal to 0.001) and more in-hospital risk factors (4.7 versus 1.6, p less than or equal to 0.001). Logistic regression analysis revealed low albumin, diagnosis of neuromuscular disease, and tracheal intubation to be strong independent predictors of risk for NP among elderly inpatients. CONCLUSIONS We conclude that the specific risk factors of poor nutrition, neuromuscular disease, and tracheal intubation may prove useful to target future clinical interventions to prevent NP in the elderly.

Improving Decision-Making for Feeding Options in Advanced Dementia: A Randomized, Controlled Trial

OBJECTIVES Ethicists advise that life-sustaining treatment decisions should be made in keeping with patient preferences. Until recently, there has been little systematic study of the impact of patient preferences on the use of various life-sustaining treatments or the consequent cost of hospital care. This prospective study was designed to answer the following questions: a) Do patient treatment preferences about the use of life-sustaining treatment influence the treatments they receive? and b) Do patient treatment preferences influence the total cost of their hospitalization? DESIGN A prospective, cohort study. SETTING A university teaching hospital. PATIENTS Hospitalized patients, at least 50 yrs of age, with short life expectancy due to end-stage heart, lung, or liver disease, metastatic cancer, or lymphoma. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were interviewed to determine their desire for life-sustaining treatment and other characteristics and then were followed for 6 months to determine life-sustaining treatment use and costs during hospitalization. Two hundred forty-four patients were interviewed. Fifty-eight percent of patients expressed a desire for life-sustaining treatments to prolong life for 1 wk. During 245 subsequent hospitalizations, there were 20 episodes of mechanical ventilation, 63 episodes of intensive care, and 66 cancer treatments given. Bivariate and multivariate analyses showed no significant association between patient desire to receive treatment to prolong life and either life-sustaining treatment use (p = .59) or hospital costs (p = .20). CONCLUSION In a university teaching hospital setting, there is no systematic evidence that patient preferences determine life-sustaining treatment use or hospital costs.

Symptom Experience of Dying Long-Term Care Residents

Feeding and eating difficulties leading to weight loss are common in the advanced stages of dementia. When such problems arise, family members are often faced with making a decision regarding the placement of a percutaneous endoscopic gastrostomy tube. The existing evidence based on observational studies suggests that feeding tubes do not improve survival or reduce the risk of aspiration, yet the use of feeding tubes is prevalent in patients with dementia, and the majority of nursing home residents do not have orders documenting their wishes about the use of artificial hydration and nutrition. One reason is that orders to forgo artificial hydration and nutrition get wrongly interpreted as “do not feed,” resulting in a reluctance of families to agree to them. Furthermore, nursing homes fear regulatory scrutiny of weight loss and wrongly believe that the use of feeding tubes signifies that everything possible is being done. These challenges might be overcome with the creation of clear language that stresses the patients goals of care. A new order, “comfort feeding only,” that states what steps are to be taken to ensure the patients comfort through an individualized feeding care plan, is proposed. Comfort feeding only through careful hand feeding, if possible, offers a clear goal‐oriented alternative to tube feeding and eliminates the apparent care–no care dichotomy imposed by current orders to forgo artificial hydration and nutrition.

An Exploratory Study of Spiritual Care at the End of Life

To test whether a decision aid improves quality of decision‐making about feeding options in advanced dementia.