Margaret R. Helton

A Cross-Cultural Study of Physician Treatment Decisions for Demented Nursing Home Patients Who Develop Pneumonia

PURPOSE We wanted to explore factors that influence Dutch and US physician treatment decisions when nursing home patients with dementia become acutely ill with pneumonia. METHODS Using a qualitative semistructured interview study design, we collected data from 12 physicians in the Netherlands and 12 physicians in North Carolina who care for nursing home patients. Our main outcome measures were perceptions of influential factors that determine physician treatment decisions regarding care of demented patients who develop pneumonia. RESULTS Several themes emerged from the study. First, physicians viewed their patient care roles differently. Dutch physicians assumed active, primary responsibility for treatment decisions, whereas US physicians were more passive and deferential to family preferences, even in cases when they considered families’ wishes for care as inappropriate. These family wishes were a second theme. US physicians reported a perceived sense of threat from families as influencing the decision to treat more aggressively, whereas Dutch physicians revealed a predisposition to treat based on what they perceived was in the best interest of the patient. The third theme was the process of decision making whereby Dutch physicians based decisions on an intimate knowledge of the patient, and American physicians reported limited knowledge of their nursing home patients as a result of lack of contact time. CONCLUSION Physician-perceived care roles regarding treatment decisions are influenced by contextual differences in physician training and health care delivery in the United States and the Netherlands. These results are relevant to the debate about optimal care for patients with poor quality of life who lack decision-making capacity.

Nutritional Issues in Long-Term Care

Because long-term care residents often have chronic illnesses and complex care regimens, nutritional issues are common in these populations. Furthermore, management is complicated because some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings. Quality nutritional practice in long-term care involves careful assessment of barriers to adequate nutrition; reduction of risk factors; attention to specialized diets, food presentation, and supplements, when appropriate; awareness of the importance of psychosocial and environmental issues; and consideration of the role of medication both as a cause and a therapeutic adjunct. Optimal practice at a facility level would involve a systematic approach to applying the best evidence-based approaches, with a focus on individualizing each residents nutritional management.

The Importance of Physician Presence in Nursing Homes for Residents with Dementia and Pneumonia

OBJECTIVE To study whether physician presence in the nursing home is related to clinical decision making, certainty, and honoring care preferences for patients with dementia and pneumonia. DESIGN Cross-sectional survey of physicians. SETTING Nursing homes in the United States and the Netherlands. PARTICIPANTS Twenty-four US and 38 Dutch physicians who provide care for nursing home patients. MEASUREMENTS Physicians reported their presence in the nursing home, diagnostic and treatment decisions for patients with dementia who had pneumonia, certainty about the diagnosis and patient and family preferences, and the extent to which they honored these preferences. These variables were examined in reference to physician presence in the nursing home. RESULTS Physicians with higher nursing home presence were less likely to order a chest x-ray and to hospitalize patients with dementia and pneumonia, although this difference was not significant when adjusted for country. They also were more likely to be certain of family preferences, a difference that held even when adjusted for the strong confounder of country. CONCLUSION Physician presence in the nursing home relates to some treatment decisions for patients with dementia and pneumonia. Policies that affect physician presence may change health care practices and related costs. Future studies should more closely examine how physicians use their time so as to better understand the importance of presence and what the US health care system might learn from the Dutch system.

Prognosis is important in decisionmaking in Dutch nursing home patients with dementia and pneumonia.

To explore how physicians treating nursing home residents with dementia and pneumonia in the Netherlands consider prognosis in their treatment decision.

Een cultuurvergelijkend onderzoek naar behandelbesluiten van artsen met betrekking tot demente verpleeghuispatiënten met pneumonie

A cross-cultural study of physician treatment decisions for demented nursing home patients who develop pneumoniaThis qualitative interview study in the Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and the Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families’ wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.SamenvattingUit dit kwalitatieve onderzoek op basis van interviews in Nederland en in North Carolina (VS) bleek dat medische beslissingen door de arts worden beïnvloed door contextuele verschillen in de opleiding van artsen en in de structuur van de gezondheidszorg in de Verenigde Staten en Nederland. De Nederlandse artsen die verpleeghuispatiënten met dementie en pneumonie behandelden, namen actief de primaire verantwoordelijkheid voor behandelbesluiten, terwijl de Amerikaanse artsen zich passiever opstelden en zich meer voegden naar de voorkeuren van de familie, zelfs wanneer zij deze medisch niet zinvol vonden. De Nederlandse artsen kenden hun patiënten goed; zij namen hun beslissingen op basis van wat zij als het meest in overeenstemming achtten met het belang van de patiënt, terwijl Amerikaanse artsen aangaven hun patiënten in het verpleeghuis niet erg goed te kennen, omdat zij slechts beperkt tijd hadden voor contact met hen. Bij verbetering van zorg voor wilsonbekwame patiënten met een beperkte kwaliteit van leven dient rekening te worden gehouden met deze contextuele factoren en met de processen die bepalen hoe artsen zorgvoorkeuren van patiënt en familie vaststellen en bespreken.

Nursing Home Care

Nursing homes are an important part of the healthcare system. People residing in nursing homes are generally classified as being short stay, such as for rehabilitation or reconditioning after surgery or illness, or long stay, meaning they and their families are no longer able to meet their needs at home. Dementia and behavior challenges are common in that population. Nursing home staff consists of nurses, physical and occupational therapists, social workers, physicians and nurse practitioners, and administrators. Nursing homes are highly regulated environments and are subjected to government oversight, which is in response to long-standing concerns about quality of care in these facilities. Nursing home care is now incorporated into the healthcare system and costs

End-of-Life Care

175 billion a year, payed mostly by Medicaid, though Medicare will cover some short-term care. Innovation in long-term care includes new models of care, professionalization of staff, ensuring the needed workforce, and ongoing efforts to improve the quality of care. New payment models may include reimbursement systems that are a better fit for long-term care.

The changing nature of women’s sexual health concerns through the midlife years

Most people now die from chronic diseases. Attitudes and practices toward care as people near the end of life have changed dramatically over the past decades. Public advocacy and interest in self-determination have led to laws and policies that allow patients to indicate their wishes regarding end-of-life care. The medical community has responded, and end-of-life care has matured and been professionalized with the emphasis on compassionate and timely care. Determining when it is time to shift from curative efforts to an approach that focuses on comfort and quality of life is often not clear, and palliative care has evolved to include symptom relief while patients are still receiving curative treatment, allowing for a gradual transition in the focus of care. New quality metrics set a standard of excellence in practicing end-of-life care. Financing of end-of-life care continues to evolve. Populations such as children, patients with dementia, or those without the cognitive ability to make decisions require special consideration. Future initiatives in end-of-life care will focus on workforce preparedness, alternative financing models, innovations in electronic medical records, and support for the health-care workforce who serve the growing population of people who die from chronic diseases.