Heart Failure in Post-Acute and Long-Term Care: Evidence and Strategies to Improve Transitions, Clinical Care, and Quality of Life.

Heart failure (HF) is highly prevalent among older patients in skilled nursing facilities (SNFs). HF outcomes for SNF patients suffer because of many factors, including staff training, lack of physician availability, and failure to implement evidence-based care. AMDA - The Society for Post-Acute and Long-Term Care Medicine has recently updated the Clinical Practice Guidelines for Heart Failure Management in SNFs. This review supplements the Guidelines with a robust focus on best practices for transitional care, symptom management, treatment and monitoring, and palliative care in patients with HF.

Actual and perceived gender differences in the accuracy of surrogate decisions about life-sustaining medical treatment among older spouses.

This study examined the influence of surrogate gender on the accuracy of substituted judgments about the use of life-sustaining treatment in a sample of 249 older adults and their self-selected surrogate decision-makers. Overall, wives were more accurate than husbands at predicting their spouses' treatment wishes. Surrogates' perceptions of their own abilities did not differ by gender but, among patients, husbands had more confidence than wives in their spouses' accuracy as, and comfort being, a surrogate. The results are discussed within the context of broader gender differences in caregiving and highlight the need for more research regarding predictors of surrogate accuracy to assist patients in selecting surrogates who will help protect their end of life wishes.

Answering questions at the point of care: do residents practice EBM or manage information sources?

PURPOSE: To determine the types of information sources that evidence-based medicine (EBM)-trained, family medicine residents use to answer clinical questions at the point of care, to assess whether the sources are evidence-based, and to provide suggestions for more effective information-management strategies in residency training. METHOD: In 2005, trained medical students directly observed (for two half-days per physician) how 25 third-year family medicine residents retrieved information to answer clinical questions arising at the point of care and documented the type and name of each source, the retrieval location, and the estimated time spent consulting the source. An end-of-study questionnaire asked 37 full-time faculty and the participating residents about the best information sources available, subscriptions owned, why they use a personal digital assistant (PDA) to practice medicine, and their experience in preventing medical errors using a PDA. RESULTS: Forty-four percent of questions were answered by attending physicians, 23% by consulting PDAs, and 20% from books. Seventy-two percent of questions were answered within two minutes. Residents rated UptoDate as the best source for evidence-based information, but they used this source only five times. PDAs were used because of ease of use, time factors, and accessibility. All examples of medical errors discovered or prevented with PDA programs were medication related. None of the participants' residencies required the use of a specific medical information resource. CONCLUSIONS: The results support the Agency for Health Care Research and Quality's call for medical system improvements at the point of care. Additionally, it may be necessary to teach residents better information-management skills in addition to EBM skills.

Context changes choices: a prospective study of the effects of hospitalization on life-sustaining treatment preferences.

OBJECTIVE: Policy and law encouraging individuals to document their wishes for life-sustaining medical treatment in advance of serious illness assumes that these wishes are unaffected by changes in health condition. To test this assumption, the authors examine the life-sustaining treatment preferences of a sample of elderly adults prior to, soon after, and several months after a hospitalization experience. SUBJECTS AND METHODS: As part of the Advance Directives, Values Assessment, and Communication Enhancement (ADVANCE) project, 401 individuals older than age 65 participated in 3 annual interviews. A subsample of 88 individuals who were hospitalized for greater than 48 hours during the course of the study participated in an additional "recovery" interview conducted soon after their release from the hospital (M = 14 days postdischarge). At each interview, subjects indicated their desire to receive 4 life-sustaining medical treatments in 4 serious illness scenarios. RESULTS: Treatment preferences showed a significant "hospitalization dip," with subjects reporting less desire to receive life-sustaining treatment at the recovery interview than they did at the annual interview conducted prior to hospitalization, but with desire returning to near prehospitalization levels at the annual interview conducted several months after hospitalization. This dip was more pronounced in preferences for cardiopulmonary resuscitation and artificial nutrition and hydration than in preferences for less invasive treatments. CONCLUSIONS: Preferences for life-sustaining treatment are dependent on the context in which they are made, and thus individuals may express different treatment preferences when they are healthy than when they are ill. These results challenge a key psychological assumption underlying the use of instructional advance directives in end-of-life decision making.

Micromanaging death: process preferences, values, and goals in end-of-life medical decision making.

PURPOSE: This study examined patients' and surrogates' attitudes about using advance directives to manage end-of-life medical care. It also explored process preferences, or how patients want decisions to be made. DESIGN AND METHODS: Data come from the third wave of the Advance Directives, Values Assessment, and Communication Enhancement project, a longitudinal study designed to investigate psychological assumptions underlying the use of advance directives. Three-hundred thirty-seven outpatients aged 65 and older and their designated surrogate decision makers completed interviews and questionnaires. RESULTS: Very few individuals wished to document specific medical treatment preferences and mandate that they be followed, without exception, near death. Most desired to express more general preferences, such as values and goals for care, in addition to (or, instead of) specific treatment preferences and to allow surrogate decision makers leeway in decision making. Patient-to-patient variability with regard to process preferences was substantial, as was surrogates' misunderstanding of the patients' process preferences. IMPLICATIONS: Very few individuals may desire the standard approach to advance care planning whereby preferences for specific life-sustaining treatments are documented and these requests are strictly followed near death. Instead, patient autonomy may be better served by emphasizing discussion of process preferences and leeway in decision making.

Longitudinal relationship between elapsed time in the action stages of change and weight loss.

OBJECTIVE: The objective of this study was to examine the longitudinal relationship between the elapsed time in the action and maintenance stages of change for multiple target behaviors and weight loss or gain. RESEARCH METHODS AND PROCEDURES: The research design was a prospective cohort study of overweight and obese primary care patients randomized to an obesity management intervention based on the Transtheoretical Model and a chronic disease paradigm. The target behaviors included increased planned exercise and usual physical activity, decreased dietary fat, increased fruit and vegetable consumption, and increased dietary portion control. The participants were 329 middle-aged men and women with elevated body mass indices recruited from 15 primary care practices in Northeastern Ohio; 28% of the participants were African Americans. The main outcomes were weight loss (5% or more) or weight gain (5% or more) after 18 or 24 months of follow-up. RESULTS: There were significant (p < 0.05) longitudinal relationships between the number of periods (0 to 4) in action or maintenance for each of the five target behaviors, or a composite score taken across the five target behaviors, and weight loss. In all cases, there was a significant (p < 0.05) stepped (graded) relationship between the time in action or maintenance and weight loss (or gain). DISCUSSION: The data support the concept of applying the Transtheoretical Model to the problem of managing obesity in primary care settings. The remaining challenge is to identify those factors that reliably move patients into the action and maintenance stages for long periods.

Stability of older adults' preferences for life-sustaining medical treatment.

The use of instructional advance directives assumes that preferences for life-sustaining medical treatment remain stable over time and across changes in life condition. A sample of 332 older adults recorded their preferences for 4 life-sustaining treatments in 9 illness scenarios. These preferences were elicited again 1 and 2 years after the original interview. Overall, preferences for life-sustaining treatment were moderately stable over time, but stability varied significantly across judgments. Preferences were most stable for illness scenarios that were most and least serious and for decisions to refuse treatment. Age, gender, education, and prior completion of an advance directive were all related to preference stability, and evidence indicated that declines in physical or psychological functioning resulted in decreased interest in life-sustaining treatment.

Predicting elderly outpatients' life-sustaining treatment preferences over time: the majority rules.

BACKGROUND: This study describes longitudinal changes in the composition and accuracy of modal life-sustaining treatment preferences as predictors of patients' treatment preferences. METHOD: Healthy outpatients age 65 and older and their surrogate decision makers recorded preferences for 4 treatments in 9 hypothetical illness scenarios 3 times over a period of 2 years. A statistical prediction model, based on patients' modal preferences, was created using initial responses and updated 2 years later. RESULTS: When reestimating the model at 2 years, 4 of 27 items in the model created using baseline responses no longer reached the threshold for inclusion, but 5 new items did meet criteria. All modal preference changes reflected a trend toward refusing treatment. Both the original and updated models were more accurate in predicting patients' preferences than were surrogates making concurrent predictions. Adding covariates (e.g., gender, age, presence of plans for future medical care) did not alter the model's predictive superiority over surrogates. CONCLUSIONS: Models using modal preferences are useful to patients, surrogates, and physicians when trying to accurately discern end-of-life treatment choices, but the models must be updated periodically.

Fates worse than death: the role of valued life activities in health-state evaluations.

One hundred eight college students (Study 1) and 109 elderly adults (Study 2) rated 28 health impairments for the quality of life perceived to be possible in that state, the extent to which the state was perceived as a fate better or worse than death, and the extent to which the state was perceived to interfere with the ability to engage in the activities each individual valued most in life. States perceived most negatively were those perceived to interfere most with valued life activities. For any given health state, evaluations were more negative the more the state was perceived by individuals as likely to interfere with engagement in their valued life activities. Implications of these results for end-of-life medical decision making in general and the use of advance medical directives in particular are discussed.