Robert A. Pearlman

Involuntary weight loss in older outpatients: incidence and clinical significance.

OBJECTIVES: To describe the incidence, anthropometric parameters, and clinical significance of weight loss in older outpatients.

Ethics Consultation in United States Hospitals: A National Survey

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the “best informant” within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices.

Good Deaths, Bad Deaths, and Preferences for the End of Life: A Qualitative Study of Geriatric Outpatients

OBJECTIVES: Patient involvement in decision‐making has been advocated to improve the quality of life at the end of life. Although the size of the oldest segment of the population is growing, with greater numbers of older adults facing the end of life, little is known about their preferences for the end of life. This study aimed to explore the attitudes of older adults with medical illness about the end of life, and to investigate whether current values could be extended to end‐of‐life preferences.

Quality of life and resuscitation decisions in elderly patients.

Quality of life considerations may be an important factor in medical decisions, but it is not known how well physician’s assessments match those of their patients. The authors studied the assessments of elderly inpatients (n=65) and their physicians (n=50) concerning patient quality of life and resuscitation decisions for the patients’ current health situations and for two hypothetical situations. Physicians rated current patient quality of life more negatively than did patients; differences ranged from 0.35 to 0.80 on a 5-point scale with end points labeled “very poor quality of life” and “possible to have good quality of life.” Physicians were also less likely to favor resuscitation in the two hypothetical scenarios (p<0.01); differences ranged from 0.66 to 1.40 on a 5-point scale with end points labeled “definitely yes” and “definitely no.” In both patient and physician groups, quality of life assessments were significantly correlated with resuscitation decisions for some situations but not for others. These results indicate that elderly patients and their physicians may differ on patient quality of life assessments and that these assessments may be associated with resuscitation decisions.

Functional status and perceived quality of life in adults with and without chronic conditions

The objective of this study was to evaluate the association between self-reported functional status and quality of life in adults with and without chronic conditions. Data were obtained on functional status (Sickness Impact Profile, SIP), and perceived quality of life (Perceived Quality of Life Scale, PQoL) from 454 persons in nine groups with widely varying levels of functional status and disability. Multiple regression was used to analyze the association controlling for demographic characteristics (age, gender, educational level, income, marital status), self-rated health status, and depressive symptoms. PQoL was lowest for persons using wheelchairs and highest for older well adults. Scores decreased as SIP scores increased. Overall, being older, reporting better functional status, and having fewer depressive symptoms were significantly associated with higher quality of life (adjusted R(2) = 0.60). This pattern held for most subgroups, although the association was much lower for adults with AIDS and younger well adults where ceiling effects were observed in functional status. Functional status and perceived quality of life are highly associated but are distinct in many populations. Depressive symptoms and self-rated health are important mediators of the relationship to include in future studies. Amelioration of depressive symptoms through environmental modification and individual treatment are potential strategies for improving on this association in adults with chronic conditions.

Risk factors for early unplanned hospital readmission in the elderly

Study objective:To determine the prevalence of early (in 14 days or less) readmissions to the hospital, and to identify risk factors for readmission. Design:Matched case-control. Cases (n=155) were readmitted to the hospital within 14 days of a hospital discharge, while controls ( n=155) were not. Controls and cases were matched by week of hospital discharge. Patients:Two-year sequential sample of male veterans aged 65 years and over admitted to the Seattle Veterans Affairs (VA) Medical Center. Measurements:Data about 31 potential risk factors were abstracted from the medical records. Results:Three risk factors associated with readmission risk were identified and include two or more hospital admissions in the previous year [odds ratio (OR)=3.06], any medication dosage change in the 48 hours prior to discharge (OR=2.34), and a visiting nurse referral for follow-up (OR=2.78). One protective factor—discharge from the geriatric evaluation unit (GEU) (OR=0.09)—was also determined. Conclusions:Early unplanned readmissions were frequent at this VA facility. Since the strongest risk factor for readmission was the number of admissions in the previous year, readmissions appeared most commonly among high utilizers of inpatient VA care. This risk factor and others may be useful in identifying a group at high readmission risk, which could be targeted in intervention studies. The reduced readmission rate associated with the GEU suggests one potential intervention to decrease readmission risk.Study objective:To determine the prevalence of early (in 14 days or less) readmissions to the hospital, and to identify risk factors for readmission.Design:Matched case-control. Cases (n=155) were readmitted to the hospital within 14 days of a hospital discharge, while controls ( n=155) were not. Controls and cases were matched by week of hospital discharge.Patients:Two-year sequential sample of male veterans aged 65 years and over admitted to the Seattle Veterans Affairs (VA) Medical Center.Measurements:Data about 31 potential risk factors were abstracted from the medical records.Results:Three risk factors associated with readmission risk were identified and include two or more hospital admissions in the previous year [odds ratio (OR)=3.06], any medication dosage change in the 48 hours prior to discharge (OR=2.34), and a visiting nurse referral for follow-up (OR=2.78). One protective factor—discharge from the geriatric evaluation unit (GEU) (OR=0.09)—was also determined.Conclusions:Early unplanned readmissions were frequent at this VA facility. Since the strongest risk factor for readmission was the number of admissions in the previous year, readmissions appeared most commonly among high utilizers of inpatient VA care. This risk factor and others may be useful in identifying a group at high readmission risk, which could be targeted in intervention studies. The reduced readmission rate associated with the GEU suggests one potential intervention to decrease readmission risk.

Motivations for Physician-assisted Suicide

AbstractOBJECTIVE: To obtain detailed narrative accounts of patients’ motivations for pursuing physician-assisted suicide (PAS). DESIGN: Longitudinal case studies. PARTICIPANTS: Sixty individuals discussed 35 cases. Participants were recruited through advocacy organizations that counsel individuals interested in PAS, as well as hospices and grief counselors. SETTING: Participants’ homes. MEASUREMENTS AND RESULTS: We conducted a content analysis of 159 semistructured interviews with patients and their family members, and family members of deceased patients, to characterize the issues associated with pursuit of PAS. Most patients deliberated about PAS over considerable lengths of time with repeated assessments of the benefits and burdens of their current experience. Most patients were motivated to engage in PAS due to illness-related experiences (e.g., fatigue, functional losses), a loss of their sense of self, and fears about the future. None of the patients were acutely depressed when planning PAS. CONCLUSIONS: Patients in this study engaged in PAS after a deliberative and thoughtful process. These motivating issues point to the importance of a broad approach in responding to a patient’s request for PAS. The factors that motivate PAS can serve as an outline of issues to explore with patients about the far-reaching effects of illness, including the quality of the dying experience. The factors also identify challenges for quality palliative care: assessing patients holistically, conducting repeated assessments of patients’ concerns over time, and tailoring care accordingly.

Quality of Life While Dying: A Qualitative Study of Terminally Ill Older Men

Objectives: To characterize the experience of quality of life while dying from the perspective of terminally ill men.

Consent in medical decision making

Informed participation in medical decisions is important because it demonstrates respect for the ethical principle of individual autonomy and increases the likelihood of reaching therapeutic goals. Twenty hospitalized patients were randomly selected and observed for six and a half hours to assess the degree to which informed participation was possible with diagnostic and therapeutic procedures. Resident physicians and patients were then interviewed about the rationale, benefit, risk, and alternative for each observed procedure. Commonly observed activities were injecting and giving oral medications, and performing invasive diagnostic procedures. Clinicians’ communication involved rationale (43%) more often than benefits (34%), risks (14%), and alternatives (12%). Communication was similar when the procedures proposed were important and risky. Residents’ and patients’ interviews demonstrated limited congruence in shared understanding of rationale (57%), benefit (45%), risk (19%), and alternatives (25%). These results suggest that clinicians selectively impart information essential for informed patient participation, and highlight areas of clinician-patient communication in need of attention.Informed participation in medical decisions is important because it demonstrates respect for the ethical principle of individual autonomy and increases the likelihood of reaching therapeutic goals. Twenty hospitalized patients were randomly selected and observed for six and a half hours to assess the degree to which informed participation was possible with diagnostic and therapeutic procedures. Resident physicians and patients were then interviewed about the rationale, benefit, risk, and alternative for each observed procedure. Commonly observed activities were injecting and giving oral medications, and performing invasive diagnostic procedures. Clinicians’ communication involved rationale (43%) more often than benefits (34%), risks (14%), and alternatives (12%). Communication was similar when the procedures proposed were important and risky. Residents’ and patients’ interviews demonstrated limited congruence in shared understanding of rationale (57%), benefit (45%), risk (19%), and alternatives (25%). These results suggest that clinicians selectively impart information essential for informed patient participation, and highlight areas of clinician-patient communication in need of attention.

Advance care planning: eliciting patient preferences for life-sustaining treatment

Patient autonomy is a guiding principle in medical decision-making in America. This is challenging when patients become mentally incapacitated and cannot express their preferences. Advance care planning (ACP) addresses this challenge. ACP is a deliberative and communicative process that helps people formulate and communicate preferences for future medical care in the event of mental incapacity. Advance directives are mechanisms for communicating and/or documenting ACP, and are either instructional (e.g. statement of treatment preferences in living wills) or proxy types (e.g. appointment of another person to speak on the patients behalf). ACP discussions between patients and health care providers and patient-orientated educational ACP materials often ignore insights from 2 related activities, health promotion and human information processing. More effective ACP should occur with greater attention to the concepts of stages of change and self-efficacy, the Health Belief Model, and the necessary requisites for cognitive integration.