Robert K. Oye

The impact of serious illness on patients' families. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

OBJECTIVE To examine the impact of illness on the families of seriously ill adults and to determine the correlates of adverse economic impact. DESIGN Data were collected during the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), a prospective cohort study of outcomes, preferences, and decision making in seriously ill hospitalized adults and their families. SETTING Five tertiary care hospitals in the United States. PARTICIPANTS The 2661 seriously ill patients in nine diagnostic categories who survived their index hospitalization and were discharged home were eligible for this analysis. Surrogate and/or patient interviews about the impact of illness on the family were obtained for 2129 (80%) of these patients (mean age, 62 years; 43% women; 6-month survival, 75%). OUTCOME MEASURES Surrogates and patients were surveyed to determine the frequency of adverse caregiving and economic burdens. Multivariable analyses were performed to determine correlates of loss of family savings. RESULTS One third (34%) of patients required considerable caregiving assistance from a family member. In 20% of cases, a family member had to quit work or make another major life change to provide care for the patient. Loss of most or all of the family savings was reported by 31% of families, whereas 29% reported loss of the major source of income. Patient factors independently associated with loss of the familys savings on multivariable analysis included poor functional status (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.10 to 1.78 for patients needing assistance with three or more activities of daily living), lower family income (OR, 1.74; 95% CI, 1.37 to 2.21 for those with annual incomes below

Efficacy of intensive care for bone marrow transplant patients with respiratory failure.

25,000), and young age (OR, 2.85; 95% CI, 2.13 to 3.82 for those younger than 45 years compared with those 65 years or older). CONCLUSIONS Many families of seriously ill patients experience severe caregiving and financial burdens. Families of younger, poorer, and more functionally dependent patients are most likely to report loss of most or all of the familys savings.

Predictors of mortality in older patients following medical intensive care: the importance of functional status.

We reviewed the ICU courses of 50 bone marrow transplant recipients treated for respiratory problems. Seven of nine postoperative patients survived compared to one of 40 patients with progressive interstitial pneumonia. Nonsurvivors accounted for 94% of the ICU days, 98% of intubated days, and 99% of blood products used. All survivors were extubated within 4 days. Intensive respiratory care is effective for patients with readily reversible causes of respiratory failure, but is generally futile for patients with progressive interstitial pneumonia. We recommend providing these patients with realistic prognostic estimates early in their treatment.

Physician Understanding Of Patient Resuscitation Preferences: Insights and Clinical Implications

Objective: We examined predictors of hospital and 6‐month mortality in older Medical Intensive Care Unit (MICU) patients with particular attention to age and functional status. Age is generally thought to be strongly associated with intensive care outcomes, but this relationship may be confounded by age‐related changes. These age‐related changes may be approximated by changes in functional status (FS).

Trust in One’s Physician: The Role of Ethnic Match, Autonomy, Acculturation, and Religiosity Among Japanese and Japanese Americans

OBJECTIVE: To describe physician understanding of patient preferences concerning cardiopulmonary resuscitation (CPR) and to assess the relationship of physician understanding of patient preferences with do not resuscitate (DNR) orders and in‐hospital CPR.

Prior capacity of patients lacking decision making ability early in hospitalization

PURPOSE Trust is a cornerstone of the physician-patient relationship. We investigated the relation of patient characteristics, religiosity, acculturation, physician ethnicity, and insurance-mandated physician change to levels of trust in Japanese American and Japanese patients. METHODS A self-administered, cross-sectional questionnaire in English and Japanese (completed in the language of their choice) was given to community-based samples of 539 English-speaking Japanese Americans, 340 Japanese-speaking Japanese Americans, and 304 Japanese living in Japan. RESULTS Eighty-seven percent of English-speaking Japanese Americans, 93% of Japanese-speaking Japanese Americans, and 58% of Japanese living in Japan responded to trust items and reported mean trust scores of 83, 80, and 68, respectively, on a scale ranging from 0 to 100. In multivariate analyses, English-speaking and Japanese-speaking Japanese American respondents reported more trust than Japanese respondents living in Japan (P values <.001). Greater religiosity (P <.001), less desire for autonomy (P <.001), and physician-patient relationships of longer duration (P <.001) were related to increased trust. Among Japanese Americans, more acculturated respondents reported more trust (P <.001), and Japanese physicians were trusted more than physicians of another ethnicity. Among respondents prompted to change physicians because of insurance coverage, the 48% who did not want to switch reported less trust in their current physician than in their former physician (mean score of 82 vs 89, P <.001). CONCLUSIONS Religiosity, autonomy preference, and acculturation were strongly related to trust in one’s physician among the Japanese American and Japanese samples studied and may provide avenues to enhance the physician-patient relationship. The strong relationship of trust with patient-physician ethnic match and the loss of trust when patients, in retrospect, report leaving a preferred physician suggest unintended consequences to patients not able to continue with their preferred physicians.

Results of Inpatient and Outpatient Cataract Surgery: A Historical Cohort Comparison

Objective: To investigate the appropriateness of hospitalization as the time to elicit patients’ medical care preferences, the authors evaluated the capability of seriously ill patients to participate in decision making early in hospitalization and their decision making capacity two weeks before hospital entry.Design: Cross-sectional study with retrospective evaluation of preadmission decision making capacity.Setting: Five acute care teaching hospitals.Patients: Four thousand three hundred one acutely ill hospitalized adults meeting predetermined severity of illness criteria in nine specific disease categories.Measurements: Surrogate decision makers’ estimates of the prior mental capacities of patients unable to be interviewed early in hospitalization about care preferences due to intubation, coma, or cognitive impairment. Comparison of the demographics, degrees of sickness at admission, and outcomes of interviewable vs noninterviewable patients.Main results: Forty percent of the patients were not interviewable concerning preferences. Of these, 83% could have participated in treatment decisions two weeks prior to hospitalization. The patients who were not interviewable were more acutely ill, had less chronic disease, and were more likely to die during hospitalization than the interviewable patients.Conclusions: Many acutely ill patients likely to die in the hospital lost their ability to make medical care decisions around the time of hospital admission. Preferences for care and advance directives should be discussed in the outpatient setting or very early in hospital admission.

Withholding versus withdrawing life-sustaining treatment: patient factors and documentation associated with dialysis decisions.

PURPOSE The transition from inpatient to outpatient cataract surgery during the last decade was not accompanied by prospective investigation of its effect on visual outcomes or surgical complications. The authors performed this study to assess the impact of this transition on surgical results. METHODS The authors reviewed 600 extracapsular cataract extractions performed by 4 experienced ophthalmic surgeons during a 36-month period; in 300 cases, patients were hospitalized after surgery (inpatient group), and, in 300 cases, patients were never hospitalized (outpatient group). The same surgical techniques were used in all cases. Visual outcome and rates for operative and postoperative complications were compared. RESULTS There were no statistically significant differences between the inpatient and outpatient groups for visual acuity. Excluding patients with pre-existing nonlenticular ocular disease, a best-corrected visual acuity of 20/40 or better was achieved in 93.1% of inpatient cases and in 97.2% of outpatient cases 6 months after surgery. Postoperative, clinically apparent cystoid macular edema was more common in the inpatient group (P = 0.03); however, after exclusion of patients with diabetes, hypertension, age younger than 65 years, and eyes with pre-existing nonlenticular disease, there was no statistically significant difference between groups. No significant differences in rates for other operative and postoperative complications were identified, including wound dehiscence, unplanned postoperative filtering blebs, infectious endophthalmitis, retinal detachment, persistent iridocyclitis, glaucoma, and corneal edema. CONCLUSION This study does not demonstrate that the transition to outpatient cataract extractions has had an adverse effect on surgical outcomes.

Detection of blood volume deficits through conjunctival oxygen tension monitoring.

OBJECTIVE: We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn.

Adult respiratory distress syndrome: hospital charges and outcome according to underlying disease.

Because acute blood loss may produce abnormal tissue perfusion and oxygenation before affecting blood pressure, we measured conjunctival (PcjO2) and arterial (PaO2) oxygen tensions and blood volume in 16 normotensive emergency department patients whose histories were consistent with significant blood loss. All eight patients with measured blood volume less than 85% of normal, as well as two euvolemic patients, had a PcjO2/Pao2 value of 0.57 or less, yielding a sensitivity of 100%, specificity of 75%, and positive predictive value of 80%. Lowering the cutoff point to 0.50 increased specificity and positive predictive value to 100% while reducing sensitivity to 88%. These results demonstrate that the Pcjo2/Pao2 ratio is an early, sensitive, and specific indicator of significant blood volume deficit.