Frailty is independently associated with 1-year mortality for elderly patients with non-ST-segment elevation myocardial infarction.

BACKGROUND: For the large population of elderly patients with cardiovascular disease, it is crucial to identify clinically relevant measures of biological age and their contribution to risk. Frailty is denoting decreased physiological reserves and increased vulnerability. We analysed the manner in which the variable frailty is associated with 1-year outcomes for elderly non-ST-segment elevation myocardial infarction (NSTEMI) patients. METHODS AND RESULTS: Patients aged 75 years or older, with diagnosed NSTEMI were included at three centres, and clinical data including judgment of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale. Of 307 patients, 149 (48.5%) were considered frail. By Cox regression analyses, frailty was found to be independently associated with 1-year mortality after adjusting for cardiovascular risk and comorbid conditions (hazard ratio 4.3, 95% CI 2.4-7.8). The time to the first event was significantly shorter for frail patients than for nonfrail (34 days, 95% CI 10-58, p = 0.005). CONCLUSIONS: Frailty is strongly and independently associated with 1-year mortality. The combined use of frailty and comorbidity may constitute an important risk prediction concept in regard to cardiovascular patients with complex needs.

Frailty is independently associated with short-term outcomes for elderly patients with non-ST-segment elevation myocardial infarction.

BACKGROUND: For the large and growing population of elderly patients with cardiovascular disease, it is important to identify clinically relevant measures of biological age and their contribution to risk. Frailty is an emerging concept in medicine denoting increased vulnerability and decreased physiological reserves. We analyzed the manner in which the variable frailty predicts short-term outcomes for elderly non-ST-segment elevation myocardial infarction patients. METHODS AND RESULTS: Patients aged ≥ 75 years, with diagnosed non-ST-segment elevation myocardial infarction were included at 3 centers, and clinical data including judgment of frailty were collected prospectively. Frailty was defined according to the Canadian Study of Health and Aging Clinical Frailty Scale. The impact of the comorbid conditions on risk was quantified by the coronary artery disease-specific index. Of 307 patients, 149 (48.5%) were considered frail. By multiple logistic regression, frailty was found to be strongly and independently associated with risk for the primary composite outcome (death from any cause, myocardial reinfarction, revascularization due to ischemia, hospitalization for any cause, major bleeding, stroke/transient ischemic attack, and need for dialysis up to 1 month after inclusion) (odds ratio, 2.2; 95% confidence interval, 1.3-3.7), in-hospital mortality (odds ratio, 4.6; 95% confidence interval, 1.3-16.8), and 1-month mortality (odds ratio, 4.7; 95% confidence interval, 1.7-13.0). CONCLUSIONS: Frailty is strongly and independently associated with in-hospital mortality, 1-month mortality, prolonged hospital care, and the primary composite outcome. The combined use of frailty and comorbidity may constitute an ultimate risk prediction concept in regard to cardiovascular patients with complex needs.

A tentative consensus-based model for priority setting: an example from elderly patients with myocardial infarction and multi-morbidity.

BACKGROUND: In most Western countries the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines into focus. However, such guidelines are difficult to use when the evidence base is weak. Priority setting for frail elderly patients with heart disease illustrates this problem. We have outlined a tentative model for priority setting regarding frail elderly heart patients. The model takes cardiovascular risk, frailty, and comorbidity into account. OBJECTIVE: Our aim is to validate the model's components. We want to evaluate the inter-rater reliability of the study experts' rankings regarding each of the model's categories. METHODS: A confidential questionnaire study consisting of 15 authentic and validated cases was conducted to assess the views of purposefully selected cardiology experts (n = 58). They were asked to rank the cases regarding the need for coronary angiography using their individual clinical experience. The response rate was 71%. Responses were analysed with frequencies and descriptive statistics. The inter-rater reliability regarding the experts' rankings of the cases was estimated via an intra-class correlation test (ICC). RESULTS: The cardiologists considered the clinical cases to be realistic. The intra-class correlation (two-way random, consistency, average measure) was 0.978 (95% CI 0.958-0.991), which denotes a very good inter-rater reliability on the group level. The model's components were considered relevant regarding complex cases of non-ST elevation myocardial infarction. Comorbidity was considered to be the most relevant component, frailty the second most relevant, followed by cardiovascular risk. CONCLUSIONS: A framework taking comorbidity, frailty, and cardiovascular risk into account could constitute a foundation for consensus-based guidelines for frail elderly heart patients. From a priority setting perspective, it is reasonable to believe that the framework is applicable to other groups of elderly patients with acute disease and complex needs.

Scientific dishonesty--questionnaire to doctoral students in Sweden.

'Scientific dishonesty' implies the fabrication, falsification or plagiarism in proposing, performing or reviewing research or in reporting research results. A questionnaire was given to postgraduate students at the medical faculties in Sweden who attended a course in research ethics during the academic year 2008/2009 and 58% answered (range 29%-100%). Less than one-third of the respondents wrote that they had heard about scientific dishonesty in the previous 12 months. Pressure, concerning in what order the author should be mentioned, was reported by about 1 in 10 students. We suggest that all departments conducting research should have a written policy about acceptable research behaviour and that all doctoral students should be informed of the content of this policy. Participants in the research groups concerned should also be required to analyse published articles about scientific dishonesty and critically discuss what could be done about unethical conduct.

Elderly people with multi-morbidity and acute coronary syndrome: doctors' views on decision-making.

BACKGROUND: In most Western countries the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines into focus. However, problems exist in areas where the evidence base is weak, e.g. elderly patients with heart disease and multiple co-morbidities. OBJECTIVE: Our aim is to evaluate the views of Swedish cardiologists on decision-making for elderly people with multiple co-morbidities and acute coronary syndrome without ST-elevation (NSTE ACS), and to generate some hypotheses for testing. METHODS: A confidential questionnaire study was conducted to assess the views of cardiologists/internists (n = 370). The response rate was 69%. Responses were analyzed with frequencies and descriptive statistics. When appropriate, differences in proportions were assessed by a chi-square test. A content analysis was used to process the answers to the open-ended questions. RESULTS: 81% of the respondents reported extensive use of national guidelines for care of heart disease in their clinical decision-making. However, when making decisions for multiple-diseased elderly patients, the individual physician's own clinical experience and the patient's views on treatment choice were used to an evidently greater extent than national guidelines. Approximately 50% estimated that they treated multiple-diseased elderly patients with NSTE ACS every day. Preferred measures for improving decision-making were: (a) carrying out treatment studies including elderly patients with multiple co-morbidities, and (b) preparing specific national guidelines for multiple-diseased elderly patients. CONCLUSIONS: In the future, national guidelines for heart disease should be adapted in order to be applicable for elderly patients with multiple co-morbidities.

Would physician-assisted suicide jeopardize trust in the medical services? An empirical study of attitudes among the general public in Sweden.

AIM: To investigate the attitudes among the Swedish population towards physician-assisted suicide, with special regard to the possible effects on trust in the medical services of physician-assisted suicide being allowed. DESIGN: A postal questionnaire about physician-assisted suicide under certain conditions and its possible influence on trust in the medical services was distributed to 1206 randomly selected individuals living in the county of Stockholm. Two reminders were distributed, followed by a short version of the questionnaire containing only the question about the attitude towards physician-assisted suicide. RESULTS: The total response rate was 51%, a short-version reminder adding another 7%. Of all participants, 73% were in favour of physician-assisted suicide, 12% were against, and 15% were undecided. They believed that their trust in the medical services would increase (38%) or not be influenced at all (45%) if physician-assisted suicide were to be allowed. However, 75% of those who were against physician-assisted suicide believed that their trust would decrease. As compared to those reporting high trust in medical services (n = 492), those with low trust (n = 97) stated that their trust would increase, 36% (confidence interval (CI) = 35-37%) vs. 49% (95% CI = 39-59%). Thirty-three per cent (95% CI = 28-38%) of the younger respondents (<50 years), and 43% (95% CI = 37-49%) of the older respondents believed that their trust would increase. CONCLUSIONS: We found no evidence for the assumption that trust in the medical services would be unambiguously jeopardized if physician-assisted suicide were to be legalized. Only among the minority who opposed physician-assisted suicide did a majority of respondents report that their trust would decrease.

Managing consequences and finding hope--experiences of Swedish women and men 4-6 months after myocardial infarction.

Research has focused more on symptoms, risk factors and treatment, than on individuals' experiences of illness and recovery after myocardial infarction (MI). Therefore, the aim of the study was to describe the experiences of present everyday life of women and men 4-6 months after MI and their expectations for the future. Semi-structured interviews were conducted with 20 women and 19 men from January 2000 to November 2001. Data were analysed with content analysis. Two themes, 'Managing consequences of MI' and 'Finding a meaning in what had happened', were generated. The first theme reveals that many of the patients had not established a stable health condition, even if symptoms and emotional distress had diminished over time. They had to manage health problems, lifestyle modifications, emotional reactions and changes in social life. The support from their social network encouraged them to move on. The second theme shows that patients also found positive consequences of what they had gone through, new life values and hopes in the future. The conclusions were that most of the patients moved on and began to regain a balance in everyday life, but some patients still struggled hard to find this balance. Those patients experienced large difficulties with managing their everyday life and felt a lack of support from their social network. Health professionals can be an important resource in helping patients in their adaptation to changes if they are more sensitive to patients' needs of support both in a short- and long-term perspective.

Physician-assisted suicide: a survey of attitudes among Swedish physicians.

AIMS: To investigate the attitudes of Swedish physicians towards physician-assisted suicide. DESIGN: A postal questionnaire on the respondent's opinion of physician-assisted suicide was sent to a randomly selected sample of physicians in Sweden. The respondents were given the opportunity of furnishing arguments of their own and of prioritizing arguments. They were also asked about possible influence on their own and patients' trust in the healthcare system if physician-assisted suicide was to be legally accepted. PARTICIPANTS: 1,200 physicians from six specialties, approximately 200 individuals each in: general practice, geriatrics, internal medicine, oncology, psychiatry and surgery. SETTING: The study was commissioned by the Swedish Medical Society and its logo was printed on questionnaires and envelopes. RESULTS: The total response rate was 74%, ranging between 63%-80% among the specialties. On average 34% were pro physician-assisted suicide, 39% against it and 25% were doubtful; 2% per cent did not respond to the question at all. Psychiatrists were significantly more accepting than oncologists, who were the most restrictive specialty. Older physicians (>50 years) provided a significantly more accepting attitude than younger ones (

Physicians' experiences with end-of-life decision-making: survey in 6 European countries and Australia.

BACKGROUND: In this study we investigated (a) to what extent physicians have experience with performing a range of end-of-life decisions (ELDs), (b) if they have no experience with performing an ELD, would they be willing to do so under certain conditions and (c) which background characteristics are associated with having experience with/or being willing to make such ELDs. METHODS: An anonymous questionnaire was sent to 16,486 physicians from specialities in which death is common: Australia, Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland. RESULTS: The response rate differed between countries (39-68%). The experience of foregoing life-sustaining treatment ranged between 37% and 86%: intensifying the alleviation of pain or other symptoms while taking into account possible hastening of death between 57% and 95%, and experience with deep sedation until death between 12% and 46%. Receiving a request for hastening death differed between 34% and 71%, and intentionally hastening death on the explicit request of a patient between 1% and 56%. CONCLUSION: There are differences between countries in experiences with ELDs, in willingness to perform ELDs and in receiving requests for euthanasia or physician-assisted suicide. Foregoing treatment and intensifying alleviation of pain and symptoms are practiced and accepted by most physicians in all countries. Physicians with training in palliative care are more inclined to perform ELDs, as are those who attend to higher numbers of terminal patients. Thus, this seems not to be only a matter of opportunity, but also a matter of attitude.

End-of-life decision-making in Belgium, Denmark, Sweden and Switzerland: does place of death make a difference?

OBJECTIVE: To examine differences in end-of-life decision-making in patients dying at home, in a hospital or in a care home. DESIGN: A death certificate study: certifying physicians from representative samples of death certificates, taken between June 2001 and February 2002, were sent questionnaires on the end-of-life decision-making preceding the patient's death. SETTING: Four European countries: Belgium (Flanders), Denmark, Sweden, and Switzerland (German-speaking part). MAIN OUTCOME MEASURES: The incidence of and communication in different end-of-life decisions: physician-assisted death, alleviation of pain/symptoms with a possible life-shortening effect, and non-treatment decisions. RESULTS: Response rates ranged from 59% in Belgium to 69% in Switzerland. The total number of deaths studied was 12 492. Among all non-sudden deaths the incidence of several end-of-life decisions varied by place of death. Physician-assisted death occurred relatively more often at home (0.3-5.1%); non-treatment decisions generally occurred more often in hospitals (22.4-41.3%), although they were also frequently taken in care homes in Belgium (26.0%) and Switzerland (43.1%). Continuous deep sedation, in particular without the administration of food and fluids, was more likely to occur in hospitals. At home, end-of-life decisions were usually more often discussed with patients. The incidence of discussion with other caregivers was generally relatively low at home compared with in hospitals or care homes. CONCLUSION: The results suggest the possibility that end-of-life decision-making is related to the care setting where people die. The study results seem to call for the development of good end-of-life care options and end-of-life communication guidelines in all settings.