Terri R. Fried

Redefining the “Planning” in Advance Care Planning: Preparing for End-of-Life Decision Making

The traditional objective of advance care planning has been to have patients make treatment decisions in advance so that clinicians can attempt to provide care consistent with their goals. The authors contend that the objective for advance care planning ought to be the preparation of patients and surrogates to participate with clinicians in making the best possible in-the-moment medical decisions. They provide practical steps for clinicians to help patients and surrogate decision makers achieve this objective in the outpatient setting. Preparation for in-the-moment decision making shifts the focus from having patients make premature decisions based on incomplete information to preparing them and their surrogates for the types of decisions and conflicts they may encounter when they do have to make in-the-moment decisions. Advance directives, although important, are just one piece of information to be used at the time of decision making.

Designing Health Care for the Most Common Chronic Condition—Multimorbidity

The most common chronic condition experienced by adults is multimorbidity, the coexistence of multiple chronic diseases or conditions. In patients with coronary disease, for example, it is the sole condition in only 17% of cases.1 Almost 3 in 4 individuals aged 65 years and older have multiple chronic conditions, as do 1 in 4 adults younger than 65 years who receive health care.2 Adults with multiple chronic conditions are the major users of health care services at all adult ages, and account for more than two-thirds of health care spending.2 Despite the predominance of multiple chronic conditions, however, reimbursement remains linked to discrete International Classification of Diseases diagnostic codes, none of which are for multimorbidity or multiple chronic conditions. Specialists are responsible for a single disease among the patient’s many. Quality measurement largely ignores the unintended consequences of applying the multiple interventions necessary to adhere to every applicable measure. Uncertain benefit and potential harm of numerous simultaneous treatments, worsening of a single disease by treatment of a coexisting one, and treatment burden arising from following several disease guidelines are the well-documented challenges of clinical decision making for patients with multiple chronic conditions.3,4 To ensure safe and effective care for adults with multiple chronic conditions, particularly the millions of baby boomers entering their years of declining health and increasing health service use, health care must shift its current focus on managing innumerable individual diseases. To align with the clinical reality of multimorbidity, care should evolve from a disease orientation to a patient goal orientation, focused on maximizing the health goals of individual patients with unique sets of risks, conditions, and priorities. Patient goal–oriented health care involves ascertaining a patient’s health outcome priorities and goals, identifying the diseases and other modifiable factors impeding these goals, calculating and communicating the likely effect of alternative treatments on these goals, and guiding shared decision making informed by this information.4

Frailty and hospitalization of long-term stay nursing home residents.

OBJECTIVE: To determine the relationship between characteristics of older, long‐term stay nursing home patients and hospitalization.

Views of Older Adults on Patient Participation in Medication-related Decision Making

AbstractBACKGROUND: Medication decision making is complex, particularly for older patients with multiple conditions for whom benefits may be uncertain and health priorities may be variable. While patient input would seem important in the face of this uncertainty and variability, little is known about older patients’ views of involvement in medication decision making. OBJECTIVE: To explore the views of older adults regarding participation in medication decision making. DESIGN: Qualitative study. PARTICIPANTS: Fifty-one persons at least 65 years old who consumed at least one medication were recruited from 3 senior centers and 4 physicians’ offices. APPROACH: One-on-one interviews were conducted to uncover participants’ perceptions of medication-related decision making through semistructured, open-ended questions. Themes were compared according to the constant comparative method of analysis. RESULTS: The predominant theme that emerged was the variability in perceptions concerning whether it was possible or desirable for patients to participate in prescribing decisions. For some participants, involvement was limited to sharing information. Physician and system factors that were felt to facilitate or impede patient participation included communication skills, the expanding number of medications available, multiple physicians prescribing for the same patient, and a focus on treating numbers. Perceived lack of knowledge, low self-efficacy, and fear were the patient factors mentioned. Both the presence and absence of trust in the prescribing physician were seen as alternatively impeding and enhancing patient participation. Only 1 participant explicitly mentioned patient preference, a cornerstone of shared decision making. CONCLUSIONS: While evolution to greater patient involvement in medication decision making may be possible, and desirable to some older patients, findings suggest that the transition will be challenging.

Health Outcome Prioritization as a Tool for Decision Making Among Older Persons With Multiple Chronic Conditions

Older persons with multiple chronic conditions are at substantial risk for unintended adverse outcomes, such as medication adverse events. Less severe adverse events are commonly referred to as “side effects,” implying that they are secondary to disease-specific benefits. However, patients consider these adverse events to be important outcomes in their own right.1 Such findings suggest that all possible benefits and harms resulting from different treatment options be considered as competing outcomes, among which older persons with multiple chronic conditions face trade-offs. When treatments involve trade-offs, the best option depends upon patients’ preferences. The challenge for older persons with multiple conditions is that these trade-offs encompass both many different specific diseases and non disease-specific health domains.2 One approach to this challenge is to consider treatment in terms of its effects on a set of universal, cross-disease outcomes and to use older persons’ prioritization of these outcomes as an assessment of preferences. These outcomes, examples of which include length of life, physical and cognitive function, and symptoms, include basic domains recognized to be the key components of health.3 The goal of this study was to explore the use of a simple to tool to elicit older persons’ health outcome priorities.

Health Outcomes Associated with Polypharmacy in Community‐Dwelling Older Adults: A Systematic Review

To summarize evidence regarding the health outcomes associated with polypharmacy, defined as number of prescribed medications, in older community‐dwelling persons.

Short-Term Functional Outcomes of Long-Term Care Residents with Pneumonia Treated with and without Hospital Transfer

OBJECTIVE: To determine 2‐month mortality and functional status outcomes after resolution of pneumonia in older long‐term care facility (LTCF) patients treated with and without hospital transfer.

Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients with pneumonia.

OBJECTIVE: To determine factors associated with the decision to treat elderly long-term care patients with pneumonia in the hospital vs in the long-term care facility (LTCF) and factors associated with patient outcomes.DESIGN: Retrospective cohort study.SETTING: Hebrew Rehabilitation Center for Aged.PATIENTS: Nursing home residents who had an episode of pneumonia, defined as a new respiratory sign or symptom and a new infiltrate.MEASUREMENTS AND MAIN RESULTS: The majority of the 316 pneumonia episodes (78%) were managed in the LTCF, most (77%) with oral antibiotics. Both patient-related factors, such as elevated respiratory rate, and non-patient-related factors, such as evening evaluation, were associated with hospitalization. No patient who had a do-not-hospitalize (DNH) order was hospitalized. Equal proportions of patients given LTCF therapy (87%) and hospital therapy (88%) survived. Elevated respiratory rate was associated with dying from pneumonia in the LTCF but not in the hospital. Dependent functional status was associated with dying from pneumonia in both sites.CONCLUSIONS: Many episodes of pneumonia can be managed in the LTCF with oral antibiotics. Because, in the absence of DNH orders, both patient-related and non-patient-related factors are associated with hospital transfer, discussion regarding preferences for hospitalization should occur prior to the development of an acute illness. A high respiratory rate may be a good marker for those LTCF patients requiring hospitalization. Dependent functional status may be a good marker for those LTCF patients unlikely to benefit from hospital transfer.

Unmet desire for caregiver-patient communication and increased caregiver burden.

Objectives: To examine the adequacy of caregiver‐patient communication in serious illness and its relationship to caregiver burden.

Inconsistency Over Time in the Preferences of Older Persons with Advanced Illness for Life-Sustaining Treatment

OBJECTIVES: To determine whether preferences for future attempts at life‐sustaining treatment change over time in a consistent and predictable manner.