Terrie Wetle

Discussions About End-of-Life Care in Nursing Homes

OBJECTIVE: To measure the frequency with which nursing home residents and their surrogates discuss with clinicians the residents wishes concerning future treatment and to assess the influence of the Patient Self Determination Act (PSDA) on the frequency and nature of such discussions.

Elder abuse screening and intervention.

Elder abuse and neglect are forms of family violence, a growing societal concern. Estimates suggest that 500,000 to 1.5 million cases of abuse and neglect occur annually in this country. This article describes the nurse practitioners legal liability for reporting suspected cases of elder abuse and neglect. In addition, specific screening guidelines for this problem are outlined. Assessment parameters for evaluating suspected cases of elder abuse are described.

Resident Decision Making and Quality of Life in the Frail Elderly

Publisher Summary This chapter examines the exercise of autonomy, as expressed via decision making by nursing home residents, beginning with a discussion of the growing emphasis on autonomy among competing values. It is followed by a brief look at the expressed preferences of the frail elderly in nursing homes, distinguishing among micro and macro decisions, cohort differences, and the influence of institutional settings on preferences and participation. The potential influence of the sick role on decision-making preferences is also considered, as are the competing values or contributors to quality of life. The chapter highlights a discussion of delegated and forced autonomy. A focus on autonomy of the individual in practical and legal terms is both time and culture bound. It may be a luxury of modern Western economies that the considerations of autonomy are balanced so strongly against the perceptions of the common good. The heterogeneity of experience and preferences of individuals should be considered in efforts to enhance autonomy and resident decision making with a goal of improving the quality of life.

Improving health for elderly people: an international health promotion and disease prevention agenda

Across the world, there are substantial but missed opportunities for promoting health of older persons and extending the health life span. Current approaches to health care rely on late detection and treatment of disease, and some of the most expensive systems of care have population health outcomes that are poor to mediocre. A majority of deaths and disability result from progression of preventable chronic diseases for which human behaviors are major contributing factors. An organized and aggressive agenda in health promotion and disease prevention emerges as an important part of the strategy to both promote health and control costs. After reviewing data on determinants of health and contribution of behavioral factors to morbidity and mortality, this paper presents the evidence for efficacy and effectiveness of specific behavioral and clinical interventions to reduce risk for many of the problems accounting for death and disability among elders. We address tobacco use, lack of exercise, inadequate nutrition, hypertension, delirium, obesity, falls, cancer screening, poor oral health, osteoporosis, immunizations and medication safety. Strategies for implementation of effective interventions present an international challenge.

The oldest old: missed public health opportunities.

The fastest growing segment of our population is the “oldest old,” usually defined as those 85 years and older. In 2005, this group numbered more than 5 million persons, or about 1.7% of the US population, a 40% increase since 1990. Because the oldest old carry a greater burden of disease and disability, they account for a substantial proportion of health care spending, with total annual per capita health care costs of

The US Cancer Moonshot initiative

25691. A higher proportion of health care spending in this population is partially attributable to long-term services—most notably, nursing home care. As our population ages, substantial concerns have been expressed regarding the future ability of the health care system to provide needed care. Much of this analysis, however, has failed to consider the potential impact of public health strategies to promote health and reduce disability among the old and very old in our population. There is promising evidence that rates of disability and functional dependence among older persons have been decreasing over the last 2 decades, and continue to fall. In this issue of the Journal, Murabito et al. provide data from the Framingham study to show a significant decline in disability among community-dwelling elders from the 1970s to the 1990s. Unfortunately, there are important missed public health opportunities to improve the health and function of older populations. Vaccination for influenza is provided to less than 75% of older persons, and even fewer (60%) have ever received a pneumococcal vaccine. Promotion of healthy behaviors is also crucial. The Type II Diabetes Prevention Trial demonstrated that older persons were able to follow diet and exercise regimens, and that these behavior changes resulted in significant success in prevention of type II diabetes. However, despite the fact that physical activity is associated with important health outcomes at all ages, physical activity declines with age. Only 1 in 5 persons aged 45–64 years engages in vigorous physical activity, and this drops to about 1 in 20 for those over the age of 75 years. To achieve the potential of improved health among the oldest old, as a society we would do well to work together to (1) change public perceptions regarding the benefits of promoting health among older persons, (2) encourage elders to engage in healthier behaviors, (3) improve the practices of health providers, (4) stimulate health departments and service agencies to provide health promotion services, and (5) include public health and aging in education of public health professionals. Despite the importance of improving health behaviors across the life span to achieve optimal health and function in old age, a recent survey of schools of public health reported that fewer than 6% of students participated in a public health and aging course. Moreover, the majority of schools lack a comprehensive and integrated curriculum that adequately addresses health issues in the aging. We have the opportunity to do better for our older population and for ourselves as we age. My 93-year-old grandmother illustrated this perfectly. As she showed us around her senior housing, she pointed out the congregate meals site that she visited on Tuesdays and Thursdays. When I asked if she enjoyed the meals, she pulled herself up to her full 4 feet, 10 inches to indignantly declare that she did not go to eat, but to “help serve the old people.”

Future Society’s Outlook Toward Aging, Illness, and Health Care of the Aged

Correspondence avoid surgery in rapidly progressive or chemo-insensitive disease. 4 Genotyping of pancreatic tumours via fine needle aspiration could influence the clinical management of pancreatic cancer. Fine-needle aspiration sequencing was used to identify subgroups of patients with specific actionable mutations related to resectable or locally advanced tumours. 5 In patients with radiologically resectable or borderline resectable tumours, preoperative fine-needle aspiration sequencing could distinguish between patients with a genetic pattern associated with micrometastatic tumours, who should undergo neoadjuvant therapy, and those with a truly localised disease that would be amenable to a surgery-first strategy. Michele Reni has served as a consultant for or on the advisory boards of Celgene, Boehringer-Ingelheim, Lilly, Genentech, Baxalta, Novocure, Astra-Zeneca, Pfizer, and Merck-Serono, and has received honoraria from Celgene. Massimo Falconi has received honoraria from Celgene, Ipsen and Novartis. The other authors declare no competing interests. *Stefano Crippa, Michele Reni, Gianpaolo Balzano, Claudio Doglioni, Massimo Falconi crippa1.stefano@hsr.it Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy (SC, GB, MF); Medical Oncology Department, IRCCS San Raffaele Hospital , Milan, Italy (MR); Department of Pathology, IRCCS San Raffaele Hospital , Milan, Italy (CD); Clinical and Translational Research Program on Pancreatic Cancer, IRCCS San Raffaele Hospital, Milan, Italy (SC, MR, GB, CD, MF) e178 Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24 Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefit of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103: 179–91. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer 2011; Sohal DP, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst 2014; 106: dju011 Valero V, Saunders TJ, He J, et al. Reliable detection of somatic mutations in fine needle aspirates of pancreatic cancer with next-generation sequencing: implications for surgical management. Ann Surg 2016; Author’s reply Stefano Crippa and colleagues, in responding to our manuscript, 1 agree that increasing the radicality of surgery for pancreatic ductal adenocarcinoma, including synchronous vein resection, is suspect. Indeed, a recent meta-analysis 2 indicates that synchronous vein resection, as reported, increases mortality and decreases survival. Crippa and colleagues put forward two interesting ideas that warrant further discussion. The first is that the surgery-first approach for pancreatic ductal adenocarcinoma might ultimately be retired, given that pancreatic ductal adenocarcinoma is usually systemic at presentation, local treatments have little effect, and neoadjuvant therapy has possible benefits. For now, the absence of high-level evidence for neoadjuvant therapy leaves largely theoretical benefits; namely that neoadjuvant therapy will reveal the biology (ie, those patients that can progress on neoadjuvant therapy will avoid futile surgery), or alter the biology (ie, those patients that are downstaged will become resectable). The preliminary results of the ALLIANCE trial 3 damages the lustre of these purported benefits with no improvement in the number of resections (10 [50%] of 20 patients who completed all preoperative therapy), and no rescue of aggressive tumour biology. This leads to the second idea, in which Crippa and colleagues suggest a biological (rather than radiological) basis for selecting patients for neoadjuvant therapy with a view to reduce the number of synchronous vein resections. Endoscopic ultrasonography- guided genotyping is a possible way to select subgroups of patients with heterogenous pancreatic ductal adenocarcinoma 4 who will benefit from neoadjuvant therapy. In support of this method, Hruban and colleagues 5 suggested that an intact SMAD4/DPC4 gene might be used to select surgery because there is lesser risk of distant metastases for this genotype. 6 In the future, we hope to more accurately select a subgroup of patients in whom a surgery-first approach, and even synchronous vein resection, is justified, but it is much more likely that precision neoadjuvant therapy will ultimately result in less radical surgery and the introduction of non-surgical techniques to support the response to neoadjuvant therapy. We declare no competing interests. Savio G Barreto, *John A Windsor j.windsor@auckland.ac.nz Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India (SGB); Hepatobiliary Pancreatic and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand (JAW) Barreto S, Windsor J. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24. Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; Varadhachary G, Fleming J, Crane C, et al. Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma. Proc Am Soc Clin Oncol 2015; 33 (suppl 3): abstr 362. Killock D. Pancreatic cancer: a problem quartered—new subtypes, new solutions? Nat Rev Clin Oncol 2016; 13: 201. Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009; The US Cancer Moonshot initiative We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to www.thelancet.com/oncology Vol 17 May 2016

Age as a Risk Factor for Inadequate Treatment

In the past 30 years, the societal view of aging and health care of the elderly has changed dramatically. Not only have the enactments of Medicare and Medicaid illuminated the public role in health care delivery, but changing demographics and technology have added to increased demand for service and aggregate cost of care. These factors, combined with growing concerns regarding family responsibility, intergenerational relationships, and quality of health services, have called into sharp focus societal values and individual attitudes influencing care of the aged.