The patient's role in medical decision making is often not matched to the clinical circumstances: rather than making strong recommendations when there's greater certainty and allowing patients to ...decide when there's greater uncertainty, we should do the opposite.
The importance of shared decision making in health care has been increasingly recognized over the past several decades. Consensus has emerged that of the various types of decisions we make, those that involve choosing among more than one reasonable treatment option should be made through a process in which patients participate: clinicians provide patients with information about all the options and help them to identify their preferences in the context of their values.
But there are many ways in which decision making can be shared between clinicians and patients. Physicians describe processes that range from explaining the clinical situation and . . .
The merits and effectiveness of advance care planning (ACP) continue to be debated a full 30 years after the passage of the Patient Self-Determination Act. This act gave patients the right to create ...advance directives, with the objective of ensuring that the care they received at the end of life was consistent with their preferences and goals. ACP has definitively moved beyond the completion of advance directives to encompass the identification of a healthcare agent and the facilitation of communication among patients, surrogates, and clinicians. Nonetheless, the provision of goal-concordant care remains a primary objective for ACP. This article argues that this cannot and should not be the objective for ACP. Patients' goals change, and the provision of goal-concordant care is sometimes incompatible with other critical determinants of appropriate care. Instead, ACP should focus on the objective of improving caregiver outcomes. Surrogate decision-making by caregivers is associated with an elevated risk of post-traumatic stress disorder and other adverse outcomes, and these outcomes can be improved with ACP. ACP focused on caregivers involves helping caregivers to understand how they can help to shape the final chapter in a patient's life story, preventing caregivers from making promises they cannot keep, and preparing them to use all relevant information at the time decisions need to be made.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Tinetti et al argue that health care must shift its current focus on managing innumerable individual diseases to ensure safe and effective care for adults with multiple chronic conditions. 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.
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.
Objectives
To summarize evidence regarding the health outcomes associated with polypharmacy, defined as number of prescribed medications, in older community‐dwelling persons.
Design
Systematic review ...of MEDLINE (OvidSP 1946 to May, Week 3, 2014).
Setting
Community.
Participants
Observational studies examining health outcomes according to number of prescription medications taken.
Measurements
Association between number of medications and health outcomes. Because of the importance of comorbidity as a potential confounder of the relationship between polypharmacy and health outcomes, articles were assessed regarding the quality of their adjustment for confounding.
Results
Of the 50 studies identified, the majority that were rated good in terms of their adjustment for comorbidity demonstrated relationships between polypharmacy and a range of outcomes, including falls, fall outcomes, fall risk factors, adverse drug events, hospitalization, mortality, and measures of function and cognition. However, a number of these studies failed to demonstrate associations, as did a substantial proportion of studies rated fair or poor.
Conclusion
Data are mixed regarding the relationship between polypharmacy, considered in terms of number of medications, and adverse outcomes in community‐dwelling older persons. Because of the challenge of confounding, randomized controlled trials of medication discontinuation may provide more‐definitive evidence regarding this relationship than observational studies can provide.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Abstract Context Advance care planning (ACP) has focused on documenting life-sustaining treatment preferences in advance directives (ADs). The ADs alone may be insufficient to prepare diverse ...patients and surrogates for complex medical decisions. Objectives To understand what steps best prepare patients and surrogates for decision making. Methods We conducted 13 English/Spanish focus groups with participants from a Veterans Affairs and county hospital and the community. Seven groups included patients ( n = 38), aged ≥65 years, who reported making serious medical decisions. Six separate groups included surrogates ( n = 31), aged ≥18 years, who made decisions for others. Semistructured focus groups asked what activities best prepared the participants for decision making. Two investigators independently coded data and performed thematic content analysis. Disputes were resolved by consensus. Results The mean ± SD patient age was 78 ± 8 years, and 61% were nonwhite. The mean ± SD surrogate age was 57 ± 10 years, and 91% were nonwhite. Qualitative analysis identified four overarching themes about how to best prepare for decision making: 1) identify values based on past experiences and quality of life, 2) choose surrogates wisely and verify that they understand their role, 3) decide whether to grant leeway in surrogate decision making, and 4) inform other family and friends of one's wishes to prevent conflict. Conclusion Beyond ADs, patients and surrogates recommend several additional steps to prepare for medical decision making including using past experiences to identify values, verifying that the surrogate understands their role, deciding whether to grant surrogates leeway, and informing other family and friends of one's wishes. Future ACP interventions should consider incorporating these additional ACP activities.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
OBJECTIVES: To explore whether models of health behavior change can help to inform interventions for advance care planning (ACP).
DESIGN: Qualitative cross‐sectional study.
SETTING: Community.
...PARTICIPANTS: Sixty‐three community‐dwelling persons aged 65 and older and 30 caregivers with experience as surrogate decision‐makers.
MEASUREMENTS: In focus groups conducted separately with older persons and caregivers, participants were asked to discuss ways they had planned for future declines in health and why they had or had not engaged in such planning. Transcripts were analyzed using grounded theory.
RESULTS: Four themes illustrated the potential of applying models of health behavior change to improve ACP. (1) Participants demonstrated variable readiness to engage in ACP and could be in different stages of readiness for different components of ACP, including consideration of treatment goals, completion of advance directives, and communication with families and physicians. (2) Participants identified a wide range of benefits of and barriers to ACP. (3) Participants used a variety of processes of change to progress through stages of readiness, and ACP was only one of a broader set of behaviors that participants engaged in to prepare for declines in their health or for death. (4) Experience with healthcare decision‐making for loved ones was a strong influence on perceptions of susceptibility and engagement in ACP.
DISCUSSION: The variability in participants' readiness, barriers and benefits, perceptions of susceptibility, and use of processes to increase readiness for participating in each component of ACP suggests the utility of customized, stage‐specific interventions based on individualized assessments to improve ACP.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background/Objectives
Advance care planning (ACP) traditionally involves asking individuals about their treatment preferences during a brief period of incapacity near the end of life. Because ...dementia leads to prolonged incapacity, with many decisions arising before a terminal event, it has been suggested that dementia‐specific ACP is necessary. We sought to elicit the perspectives of older adults with early cognitive impairment and their caregivers on traditional and dementia‐specific ACP.
Design
Qualitative study with separate focus groups for patients and caregivers.
Setting
Memory disorder clinics.
Participants
Twenty eight persons aged 65+ with mild cognitive impairment or early dementia and 19 caregivers.
Measurements
Understanding of dementia trajectory and types of planning done; how medical decisions would be made in the future; thoughts about these decisions.
Results
No participants had engaged in any written form of dementia‐specific planning. Barriers to dementia‐specific ACP emerged, including lack of knowledge about the expected trajectory of dementia and potential medical decisions, the need to stay focused in the present because of fear of loss of self, disinterest in planning because the patient will not be aware of decisions, and the expectation that involved family members would take care of issues. Some patients had trouble engaging in the discussion. Patients had highly variable views on what the quality of their future life would be and on the leeway their surrogates should have in decision making.
Conclusions
Even among patients with early cognitive impairment seen in specialty clinics and their caregivers, most were unaware of the decisions they could face, and there were many barriers to planning for these decisions. These issues would likely be magnified in more representative populations, and highlight challenges to the use of dementia‐specific advance directive documents.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Older adults are prescribed a growing number of medications. Polypharmacy, commonly considered the receipt of five or more medications, is associated with a range of adverse outcomes. There is a ...debate about the reason(s) why. On one side is the assertion that older persons are being prescribed too many medications, with the number of medications increasing the risk of adverse events. On the other side is the observation that polypharmacy is associated both with overprescribing of inappropriate medications and underprescribing of appropriate medications. This leads to the concept of “inappropriate” vs “appropriate” polypharmacy, with the latter resulting from the prescription of many correct medications to persons with multiple chronic conditions. Few studies have examined the health outcomes associated with adding and/or removing medications to address this debate directly. The criteria used to identify underutilized medications are based on results of randomized controlled trials that may not be generalizable to older adults. Several randomized controlled trials and many more observational studies provide evidence that these criteria overestimate medication benefits and underestimate harms. In addition, evidence suggests that the marginal effects of medications added to an already complex regimen differ from their effects when considered individually. Although in selected circumstances adding medications results in benefit to patients, patients with multimorbidity and frailty/disability have susceptibilities that can decrease the likelihood of medication benefit and increase the likelihood of harms. The identification of appropriate polypharmacy requires more robust criteria to evaluate the net effects of complex medication regimens.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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