Neil S. Wenger

2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia

DINESH KHANNA, JOHN D. FITZGERALD, PUJA P. KHANNA, SANGMEE BAE, MANJIT K. SINGH, TUHINA NEOGI, MICHAEL H. PILLINGER, JOAN MERILL, SUSAN LEE, SHRADDHA PRAKASH, MARIAN KALDAS, MANEESH GOGIA, FERNANDO PEREZ-RUIZ, WILL TAYLOR, FREDERIC LIOTE, HYON CHOI, JASVINDER A. SINGH, NICOLA DALBETH, SANFORD KAPLAN, VANDANA NIYYAR, DANIELLE JONES, STEVEN A. YAROWS, BLAKE ROESSLER, GAIL KERR, CHARLES KING, GERALD LEVY, DANIEL E. FURST, N. LAWRENCE EDWARDS, BRIAN MANDELL, H. RALPH SCHUMACHER, MARK ROBBINS, NEIL WENGER, AND ROBERT TERKELTAUB

The Vulnerable Elders Survey: A Tool for Identifying Vulnerable Older People in the Community

OBJECTIVES: To develop a simple method for identifying community‐dwelling vulnerable older people, defined as persons age 65 and older at increased risk of death or functional decline. To assess whether self‐reported diagnoses and conditions add predictive ability to a function‐based survey.

A Prospective Study of Predictors of Adherence to Combination Antiretroviral Medication

AbstractOBJECTIVE: Adherence to complex antiretroviral therapy (ART) is critical for HIV treatment but difficult to achieve. The development of interventions to improve adherence requires detailed information regarding barriers to adherence. However, short follow-up and inadequate adherence measures have hampered such determinations. We sought to assess predictors of long-term (up to 1 year) adherence to newly initiated combination ART using an accurate, objective adherence measure. DESIGN: A prospective cohort study of 140 HIV-infected patients at a county hospital HIV clinic during the year following initiation of a new highly active ART regimen. MEASURES AND MAIN RESULTS: We measured adherence every 4 weeks, computing a composite score from electronic medication bottle caps, pill count and self-report. We evaluated patient demographic, biomedical, and psychosocial characteristics, features of the regimen, and relationship with one’s HIV provider as predictors of adherence over 48 weeks. On average, subjects took 71% of prescribed doses with over 95% of patients achieving suboptimal (<95%) adherence. In multivariate analyses, African-American ethnicity, lower income and education, alcohol use, higher dose frequency, and fewer adherence aids (e.g., pillboxes, timers) were independently associated with worse adherence. After adjusting for demographic and clinical factors, those actively using drugs took 59% of doses versus 72% for nonusers, and those drinking alcohol took 66% of doses versus 74% for nondrinkers. Patients with more antiretroviral doses per day adhered less well. Participants using no adherence aids took 68% of doses versus 76% for those in the upper quartile of number of adherence aids used. CONCLUSIONS: Nearly all patients’ adherence levels were suboptimal, demonstrating the critical need for programs to assist patients with medication taking. Interventions that assess and treat substance abuse and incorporate adherence aids may be particularly helpful and warrant further study.

Advance directives for seriously ill hospitalized patients: Effectiveness with the patient self-determination act and the SUPPORT intervention

OBJECTIVE: To assess the effectiveness of written advance directives (ADs) in the care of seriously ill, hospitalized patients. In particular, to conduct an assessment after ADs were promoted by the Patient Self‐Determination Act (PSDA) and enhanced by the effort to improve decision‐making in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), focusing upon the impact of ADs on decision‐making about resuscitation.

2012 American College of Rheumatology guidelines for management of gout. Part 2: Therapy and antiinflammatory prophylaxis of acute gouty arthritis

In response to a request for proposal from the American College of Rheumatology (ACR), our group was charged with developing non-pharmacologic and pharmacologic guidelines for treatments in gout that are safe and effective, i.e., with acceptable risk-benefit ratio. These guidelines for the management and anti-inflammatory prophylaxis of acute attacks of gouty arthritis complements our manuscript on guidelines to treat hyperuricemia in patients with evidence of gout (or gouty arthritis) (1). Gout is the most common cause of inflammatory arthritis in adults in the USA. Clinical manifestations in joints and bursa are superimposed on top of local deposition of monosodium urate crystals. Acute gout characteristically presents as self-limited, attack of synovitis (also called “gout flares”). Acute gout attacks account for a major component of the reported decreased health-related quality of life in patients with gout (2, 3). Acute gout attacks can be debilitating and are associated with decreased work productivity (4, 5). Urate lowering therapy (ULT) is a cornerstone in the management of gout, and, when effective in lowering serum urate (SUA), is associated with decreased risk of acute gouty attacks (6). However, during the initial phase of ULT, there is an early increase in acute gout attacks, which has been hypothesized due to remodeling of articular urate crystal deposits as a result of rapid and substantial lowering of ambient urate concentrations (7). Acute gout attacks attributable to the initiation of ULT may contribute to non-adherence in long-term gout treatment, as reported in recent studies (8). In order to systematically evaluate a broad spectrum of acute gouty arthritis, we generated multifaceted case scenarios to elucidate decision making based primarily on clinical and laboratory test-based data that can be obtained in a gout patient by both non-specialist and specialist health care providers in an office practice setting. This effort was not intended to create a novel classification system of gout, or new gout diagnostic criteria, as such endeavors are beyond the scope of this work. Prior gout recommendations and guidelines, at the independent (i.e, non pharmaceutical industry-sponsored) national or multinational rheumatology society level, have been published by EULAR (9, 10), the Dutch College of General Practitioners (11), and the British Society for Rheumatology (BSR)(12). The ACR requested new guidelines, in view of the increasing prevalence of gout (13), the clinical complexity of management of gouty arthritis imposed by co-morbidities common in gout patients (14), and increasing numbers of treatment options via clinical development of agents(15–17). The ACR charged us to develop these guidelines to be useful for both rheumatologists and other health care providers on an international level. As such, this process and resultant recommendations, involved a diverse and international panel of experts. In this manuscript, we concentrate on 2 of the 4 gout domains that the ACR requested for evaluation of pharmacologic and non-pharmacologic management approaches: (i) analgesic and anti-inflammatory management of acute attacks of gouty arthritis, and (ii) pharmacologic anti-inflammatory prophylaxis of acute attacks of gouty arthritis. Part I of the guidelines focused on systematic non-pharmacologic measures (patient education, diet and lifestyle choices, identification and management of co-morbidities) that impact on hyperuricemia, and made recommendations on pharmacologic ULT in a broad range of case scenarios of patients with disease activity manifested by acute and chronic forms of gouty arthritis, including chronic tophaceous gouty arthropathy(1). Each individual and specific statement is designated as a “recommendation”, in order to reflect the non-prescriptive nature of decision making for the hypothetical clinical scenarios. So that the voting panel could focus on gout treatment decisions, a number of key assumptions were made, as described in Part I of the guidelines (1). Importantly, each proposed recommendation assumed that correct diagnoses of gout and acute gouty arthritis attacks had been made for the voting scenario in question. For treatment purposes, it was also assumed that treating clinicians were competent, and considered underlying medical comorbidities (including diabetes, gastrointestinal disease, hypertension, and hepatic, cardiac, and renal disease), and potential drug toxicities and drug-drug interactions, when making both treatment choicesand dosing decisions on chosen pharmacologic interventions. The RAND/UCLA methodology used here emphasizes level of evidence, safety, and quality of therapy, and excludes analyses of societal cost of health care. As such, the ACR gout guidelines are designed to reflect best practice, supported either by level of evidence or consensus-based decision-making. These guidelines cannot substitute for individualized, direct assessment of the patient, coupled with clinical decision making by a competent health care practitioner. The motivation, financial circumstances, and preferences of the gout patient also need to be considered in clinical practice, and it is incumbent on the treating clinician to weigh the issues not addressed by this methodology, such as treatment costs, when making management decisions. Last, the guidelines for gout management presented herein were not designed to determine eligibility for health care cost coverage by third party payers.

The Quality of Medical Care Provided to Vulnerable Community-Dwelling Older Patients

Context Many Americans 65 years of age and older are at risk for functional decline, yet we know little about the quality of care for geriatric conditions. Contribution This study used a 13-item survey about functional status to evaluate the care of 420 people 65 years of age and older whom the investigators identified as vulnerable to functional decline. Quality of care was highly variable from condition to condition but was generally better for general medical conditions, such as diabetes, than for geriatric conditions, such as incontinence. Implications Efforts to improve care for vulnerable elders should focus on the geriatric conditions that profoundly influence functional status. The Editors The quality of care among patients 65 years of age and older has not been extensively investigated, and most existing studies have focused on general adult medical conditions. This is surprising, considering that more than 40% of all medical expenditures are for persons 65 years of age and older (1). The most comprehensive study to date of quality of care among older patients evaluated 24 process indicators among U.S. Medicare beneficiaries in all 50 states between 1997 and 1999 (2). Care for acute myocardial infarction, heart failure, stroke, and pneumonia was evaluated by using inpatient medical records. Pneumonia, breast cancer, and diabetes indicators were evaluated by using survey and Medicare claims data. The investigators found that the percentage of patients receiving appropriate care varied widely by measure and state. Several other studies of older patients evaluated cardiovascular conditions, diabetes, or aspects of preventive care and medication use (3-10). No study, however, has assessed the quality of medical care provided for geriatric conditions that profoundly affect the lives of vulnerable older patients. Furthermore, surveys find that older persons often prioritize function and comfort over disease treatment and prolongation of life (11). Quality-of-care measurement for older patients that examines only a few conditions and only indicators aimed at prolonging life yields an incomplete assessment because it ignores other conditions and aspects of care that are of equal or even greater importance to older patients. For this reason, we developed a quality assessment system that assesses more conditions. Together, these conditions account for a majority of all of the care older patients receive (12) and include several geriatric syndromes. We used this quality assessment system to evaluate the care provided to a sample of vulnerable elders at increased risk for death or functional decline. Methods The Assessing Care of Vulnerable Elders (ACOVE) project developed and applied a quality assessment system for vulnerable older persons. The assessment system aimed to develop quality indicators (QIs) that cover the spectrum of care for these patients. Indicators were implemented by using medical record abstraction and patient interview. The ACOVE Quality-of-Care Assessment System The ACOVE investigators developed a system of QIs to cover the most important conditions vulnerable elders encounter in all care venues. This system focused on processes (care behaviors) rather than outcomes for 2 reasons. First, although most agree that outcomes should be adjusted for risk when quality is measured, there is little consensus regarding the best severity measurement system (13). Second, measurement of processes of care is thought to be a more direct assessment of quality than measurement of outcomes (14). The process measures were selected to represent the various domains of care: screening and prevention, diagnosis, treatment, and follow-up. The development of the assessment system was guided by a Policy Advisory Committee, which helped to direct the focus toward practical applications, and by a Clinical Committee, which provided clinical expertise for development and monitored the assembly of the QIs into a comprehensive system (15). The methods for selecting conditions and developing the QIs have been described in detail elsewhere (12, 16). In brief, the Clinical Committee used the criteria of prevalence, impact, effectiveness of prevention or treatment, need for quality improvement, feasibility of measurement, and geriatric niche in a formal group rating process to identify 22 target conditions for quality improvement (12). For each of the 22 conditions, we developed a set of evidence-based QIs for vulnerable elders using a combination of systematic reviews and expert judgment (16). Of 420 proposed QIs, the 2 expert panels, the Clinical Committee, and the American College of Physicians Task Force on Aging accepted 236 as valid indicators; these were assembled into the ACOVE QI set (17). The 236 QIs covered the domains of care as follows: Sixty-one (26%) focused on screening and prevention, 50 (21%) focused on diagnosis, 84 (36%) focused on treatment, and 41 (17%) focused on follow-up and continuity of care. Examples of ACOVE QIs for each condition are presented in Table 1. Table 1. Examples of Assessing Care of Vulnerable Elders Quality Indicators Patients and Data Collection Using the ACOVE QI set, we assessed care provided to seniors who were enrolled in 2 managed care organizations. These patients were defined as vulnerable on the basis of self-report or proxy report on a brief, 13-item screening survey (Vulnerable Elders-13 [VE-13] Survey [18]). Vulnerable elders, identified by this function-based survey, are community-dwelling persons 65 years of age and older who have 4 times the risk for functional decline or death over the next 2 years compared with individuals not identified as vulnerable (18). Each managed care organization, 1 in the northeastern United States and the other in the southwestern United States, had more than 20 000 elderly enrollees and contracted with a network of providers to deliver care. Eligibility criteria included continuous enrollment in the managed care organization for at least 13 months and no out-of-plan care or active treatment for malignant conditions (excluding nonmelanoma skin cancer) during this period. A random sample of 3207 community-dwelling elderly adults was drawn from eligible persons in each managed care organization by using a random-number generator. Vulnerable elders were identified by using the VE-13 Survey as part of a telephone interview. Patients who did not speak English were not eligible to participate. The RAND Institutional Review Board approved the study protocol. Medical Record Review Using administrative data, we identified all inpatient and outpatient medical care received by study participants during the 13-month period of 1 July 1998 to 31 July 1999. Medical records were requested from primary care and specialist providers (including eye care and mental health providers), acute care hospitals, skilled-nursing facilities, home health agencies, and facilities providing outpatient services (for example, physical therapy). Identifying information of patients and providers was removed from the medical records. Trained nurses with previous experience in quality assessment performed medical record abstraction. Abstractors were provided with written abstraction guidelines and real-time consultation with a senior nurse reviewer. The abstractor considered all of a patients records when assessing whether he or she was eligible for and received the indicated care processes. In other words, information on eligibility for a QI could have been derived from 1 record (such as an outpatient note) while the care process was delivered and documented in another setting (for example, inpatient medical record). If the care process was performed in the defined time interval, care was scored as complying with the QI. The senior nurse reviewer also assessed each completed medical record abstraction. Physicians reviewed QIs that required a more detailed level of clinical assessment. Examples include whether the elements of a delirium evaluation had been completed or whether an adequate intervention was performed for hyperlipidemia. An ophthalmologist evaluated selected data elements addressing vision care. Ten percent of all records were reabstracted to evaluate reliability of the abstraction process. Exact agreement on QI eligibility and score was 95%. (For details of abstractor preparation and abstraction materials, see the Appendix.) Quality-of-Care Interview A quality-of-care interview was conducted to ask study participants (or, if participants were incapable of responding, their proxies) about aspects of their care that might not be captured in the medical record (for example, physicianpatient counseling). On the basis of conditions and medications reported during the interview, patients were asked about specific processes of care they had received. Patients were also asked about care preferences that might affect the applicability of QIs. In addition, the interview included demographic questions and functional status items. The quality-of-care interview was conducted by telephone between August and October 2000 and required, on average, 44 minutes to complete. Statistical Analysis Of the 236 QIs, we were able to evaluate 207 using chart abstraction (n = 185 [89%]) or interview (n = 22 [11%]). Interview was used to score QIs for data elements that we did not collect from the medical record. A QI was scored for a patient if he or she satisfied the IF statement of the QI and thus was eligible to receive the specified care process (Table 1). A score of 1 was awarded if the care process was carried out, and a score of 0 was assigned if it was not. For QIs that included several triggering events, a score between 0 and 1 was possible. If the medical record indicated that the patient declined the care process, the QI was considered to be passed (the care was credited in both the numerator and the denominator of the indicator score). On the other hand, if the patient had a pre

Pain and satisfaction with pain control in seriously ill hospitalized adults: Findings from the SUPPORT research investigations

OBJECTIVES To evaluate the pain experience of seriously ill hospitalized patients and their satisfaction with control of pain during hospitalization. To understand the relationship of level of pain and dissatisfaction with pain control to demographic, psychological, and illness-related variables. DESIGN Prospective, cohort study. SETTING Five teaching hospitals. PATIENTS Patients for whom interviews were available about pain (n = 5,176) from a total of 9,105 patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were interviewed after study enrollment about their experiences with pain. When patients could not be interviewed due to illness, we used surrogate (usually a family member) responses calibrated to patient responses (from the subset of interviews with both patient and surrogate responses). Ordinal logistic regression was used to study the association of variables with level of pain and satisfaction with its control. Nearly 50% of patients reported pain. Nearly 15% reported extremely severe pain or moderately severe pain occurring at least half of the time, and nearly 15% of those patients with pain were dissatisfied with its control. After adjustment for confounding variables, older and sicker patients reported less pain, while patients with more dependencies in activities of daily living, more comorbid conditions, more depression, more anxiety, and poor quality of life reported more pain. Patients with colon cancer reported more pain than patients in other disease categories. Levels of reported pain varied among the five hospitals and also by physician specialty. After adjustment for confounding variables, dissatisfaction with pain control was more likely among patients with more severe pain, greater anxiety, depression, and alteration of mental status, and lower reported income; dissatisfaction with pain control also varied among study hospitals and by physician specialty. CONCLUSIONS Pain is common among severely ill hospitalized patients. The most important variables associated with pain and satisfaction with pain control were patient demographics and those variables that reflected the acute illness. Pain and satisfaction with pain control varied significantly among study sites, even after adjustment for many potential confounders. Better pain management strategies are needed for patients with the serious and common illnesses studied in SUPPORT.

The Quality of Pharmacologic Care for Vulnerable Older Patients

Context Prescription and management of medications are important issues for older adults. Contribution Among elders enrolled in two managed care organizations, most quality problems were related to failure to prescribe indicated medications; failure to monitor medications; and failure to provide medication along with proper documentation and education in concert with other physicians. Implications Prescribing inappropriate medications for older adults is less of an issue than other aspects of drug therapy. Quality improvement efforts should focus on avoiding errors of omission in prescribing indicated medications, monitoring, patient education, and follow-up. The Editors Pharmacotherapy is an essential component of medical treatment for older patients, but medications are also responsible for many adverse events in this group. Ninety percent of people 65 years of age or older take at least one medication (1). This age group, which represents only 13% of the population, accounts for one third of all prescription drug expenditures in the United States (2). Many older persons take multiple drugs for the treatment of several conditions, which increases the chance of adverse drug reactions, drugdrug interactions, and drugdisease interactions. The frequency of adverse drug events in elderly outpatients ranges from 10% to 35%, depending on the setting (3-5). Recognizing the magnitude of medication-related issues, panels of geriatric experts rate medication problems among the most important quality-of-care problems for older patients (6-8). Reflecting the severity and frequency of adverse drug events in older patients, many investigations have focused on the appropriateness of medication prescribing to elderly persons. Implicit review mechanisms include the Medication Appropriateness Index, which consists of 10 medication characteristics (including indication, effectiveness, and dosage) that a trained pharmacist reviewer can judge as appropriate, marginally appropriate, or inappropriate. An application of the Medication Appropriateness Index to elderly veterans taking 5 or more prescription medications found that 74% had at least 1 inappropriate aspect to their prescriptions (9, 10). Reviews using explicit criteria usually focus on medications that should be avoided in the care of older patients. The list of medications to avoid, which was developed by Beers and colleagues on the basis of a formal consensus of geriatric experts (11-13), has been applied to various groups of patients, revealing a high prevalence of inappropriate drug use (14-20). In addition, explicit criteria about drugdrug interactions, treatment duration, and drug contraindications were created by Tamblyn and colleagues and applied to medications prescribed to older patients in Canada (21). They found that more than half of older patients took at least one high-risk medication. Health policy efforts, on the other hand, have focused predominantly on finding ways to pay for the medication needed by older patients. Proposals aim to improve access to pharmacologic care but do not strive to develop mechanisms to evaluate or improve the quality of medication management for older patients. Improvement in access to medications without quality assurance may result in a mere increase in care without change in outcomes. To provide a more comprehensive evaluation of the quality of pharmacologic care for older patients, we systematically evaluated medication management for a sample of older patients by taking advantage of a set of explicit process of care quality indicators developed and implemented in the Assessing Care of Vulnerable Elders (ACOVE) project (22). Whereas the earlier ACOVE analysis described overall quality of care and compared care quality for geriatric and medical conditions, this study focuses on pharmacologic care and identifies improvement needs in medication management. Our quality evaluation covered the continuum of pharmacologic care, from recognizing the indications for medications to choosing medication, prescribing appropriately, educating and documenting, and monitoring after prescribing. Methods The ACOVE project developed a set of explicit quality indicators to evaluate the care provided to vulnerable older persons (22-24). The system focuses on processes of care within the domains of prevention, diagnosis, treatment, and follow-up and covers the spectrum of care contained in 22 conditions that are important in the care of older patients (7). The methods for selecting conditions and developing the quality indicators are described in detail elsewhere (7, 23). Methods included systematic literature reviews and multiple layers of expert judgment (23). The literature review resulted in proposal of candidate quality indicators, which were reviewed by an expert panel that rated each of the proposed quality indicators for validity and feasibility. This set was modified and approved by a clinical committee of national geriatric experts and by the American College of Physicians Task Force on Aging (24). From the final ACOVE set of quality indicators, 43 quality indicators (Table 1 and Appendix Table) that pertained to pharmacologic care and had more than 5 eligible patients are included in this analysis. Table 1. Medication Quality Indicators, Number of Eligible Patients, and Pass Rates Patients and Data Collection We assessed care provided to older persons who were enrolled in 2 managed care organizations. Each managed care organization, one in the U.S. Northeast and the other in the Southwest, had more than 20 000 senior enrollees and contracted with a network of providers to deliver care. A random sample of community-dwelling persons 65 years of age or older was drawn from enrollees in each managed care organization. Eligibility criteria included continuous enrollment in the managed care organization for at least 13 months, no out-of-plan care, and no active treatment for malignant conditions (excluding nonmelanoma skin cancer) during the period. In addition, persons who did not speak English were excluded because our interview instruments were not available in other languages. Among the enrollees, we targeted vulnerable elders, defined as persons 65 years of age and older who are at increased risk for death or functional decline. Vulnerable elders were identified on the basis of self-report (or proxy report) by using a brief screening survey (the Vulnerable Elders-13 [VE-13] Survey [25]) administered by telephone. The RAND Institutional Review Board approved the study protocol. Data were derived mainly from abstracting medical records. For participating patients, we identified all inpatient and outpatient medical records during the 13-month period of 1 July 1998 to 31 July 1999. These medical records were abstracted by trained nurses with experience in quality assessment. The abstractor considered all of a patients medical records when assessing whether a patient was eligible for and received the indicated care processes. Information on eligibility for a quality indicator could be derived from one medical record (such as a primary care physician starting an appropriate antidepressant) and the care process delivered and documented from records in another setting (such as a psychiatric consultant escalating the antidepressant dosage in response to lack of improvement). A senior nurse-reviewer assessed each completed medical record abstract, and physician overreaders reviewed quality indicators that required a clinical assessment, such as whether there was follow-up to newly started long-term therapy with a medication or whether newly started therapy with a highly anticholinergic drug had acceptable alternatives. We evaluated inter-rater reliability by re-abstracting a random sample of 10% of the medical records. These records contained 698 quality indicators; 97% had identical eligibility and 95% demonstrated identical eligibility and score. Details of study enrollment and data collection can be found elsewhere (22). Because some aspects of care might not be adequately captured in the medical record (for example, patient education about medications), these data were supplemented by a quality-of-care interview with study participants (or, if necessary, their proxies). During the interview, patients were asked to list all of their medications. On the basis of conditions and medications reported during the interview, patients were asked about specific processes of care they had received. The interview was conducted by telephone between August and October 2000. To minimize recall bias, we asked about most recent care when implementing quality indicators that may include multiple events (for example, education about newly started therapy with a medication). Information was obtained from medical records for 37 quality indicators and from the patient interview for 6 quality indicators. For 4 quality indicators reported previously by using medical record data (22), we used interview data in this analysis because subsequent evaluation revealed that interview data on information transfer quality indicators yielded higher pass rates that were aligned with a priori hypotheses and provided more conservative estimates of quality of care. Statistical Analysis A quality indicator was scored for a patient if he or she met the eligibility criteria to receive the specified care process. The quality indicator was passed if the care process was implemented for the patient. If the medical record indicated that the patient declined the care process, the quality indicator was considered to be passed. On the other hand, if the patient had a prespecified contraindication to the care process (such as a patient with asthma who otherwise was eligible to receive a -blocker after a myocardial infarction), the patient was considered ineligible for the quality indicator. Quality scores were calculated as the proportion of eligible patients who received indicated care. I

Physician recognition of cognitive impairment: Evaluating the need for improvement

Objectives: To assess physician recognition of dementia and cognitive impairment, compare recognition with documentation, and identify physician and patient factors associated with recognition.

End-of-life decision making: a qualitative study of elderly individuals.

OBJECTIVE: To identify the desired features of end-of-life medical decision making from the perspective of elderly individuals.DESIGN: Qualitative study using in-depth interviews and analysis from a phenomenologic perspective.SETTING: A senior center and a multilevel retirement community in Los Angeles.PARTICIPANTS: Twenty-one elderly informants (mean age 83 years) representing a spectrum of functional status and prior experiences with end-of-life decision making.MAIN RESULTS: Informants were concerned primarily with the outcomes of serious illness rather than the medical interventions that might be used, and defined treatments as desirable to the extent they could return the patient to his or her valued life activities. Advanced age was a relevant consideration in decision making, guided by concerns about personal losses and the meaning of having lived a “full life.” Decisionmaking authority was granted both to physicians (for their technical expertise) and family members (for their concern for the patient’s interests), and shifted from physician to family as the patient’s prognosis for functional recovery became grim. Expressions of care, both by patients and family members, were often important contributors to end-of-life treatment decisions.CONCLUSIONS: These findings suggest that advance directives and physician-patient discussions that focus on acceptable health states and valued life activities may be better suited to patients’ end-of-life care goals than those that focus on specific medical interventions, such as cardiopulmonary resuscitation. We propose a model of collaborative surrogate decision making by families and physicians that encourages physicians to assume responsibility for recommending treatment plans, including the provision or withholding of specific life-sustaining treatments, when such recommendations are consistent with patients’ and families’ goals for care.