Methodological review: measured and reported congruence between preferred and actual place of death.

Congruence between preferred and actual place of death is an important palliative care outcome reported in the literature. We examined methods of measuring and reporting congruence to highlight variations impairing cross-study comparisons. Medline, PsychInfo, CINAHL, and Web of Science were systematically searched for clinical research studies examining patient preference and congruence as an outcome. Data were extracted into a matrix, including purpose, reported congruence, and method for eliciting preference. Studies were graded for quality. Using tables of preferred versus actual places of death, an overall congruence (total met preferences out of total preferences) and a kappa statistic of agreement were determined for each study. Twelve studies were identified. Percentage of congruence was reported using four different definitions. Ten studies provided a table or partial table of preferred versus actual deaths for each place. Three studies provided kappa statistics. No study achieved better than moderate agreement when analysed using kappa statistics. A study which elicited ideal preference reported the lowest agreement, while longitudinal studies reporting final preferred place of death yielded the highest agreement (moderate agreement). Two other studies of select populations also yielded moderate agreement. There is marked variation in methods of eliciting and reporting congruence, even among studies focused on congruence as an outcome. Cross-study comparison would be enhanced by the use of similar questions to elicit preference, tables of preferred versus actual places of death, and kappa statistics of agreement.

Surrogate decision makers' attitudes towards tube feeding in the nursing home.

In the nursing home, a widely accepted medical practice is to recommend the initiation of long term tube feeding in residents with eating difficulties. However, frequently the nursing home resident has dementia, lacks decision-making capacity, and has no advance directives to guide the physician and the family member(s). Therefore, the family member or another surrogate decision maker has to make the difficult decision of whether or not to consent to the placement of a feeding tube. We surveyed 50 English speaking surrogates of nursing home residents who were on a feeding tube for at least 6 months. Each surrogate was contacted by telephone and was administered a 16-item structured questionnaire. Statistical analyses included frequency distributions, and the Wilcoxon signed rank test for two related samples. Most surrogates rated the residents' quality of life as poor or extremely poor. Yet, 78% of the surrogates perceived tube feeding to be beneficial, 62% would repeat their initial decision to initiate tube feeding, and 68% would not consider removal of the feeding tube. Their leading concerns were medical complications, tube feeding's impact on each resident's quality of life, and adequacy of nursing care. The surrogates were satisfied with their initial decision for the placement of a feeding tube despite their perception that there was no improvement in the quality of life of the residents. The surrogates may have viewed tube feeding as a life prolonging measure.

Elderly persons' last six months of life: findings from the Hospitalized Elderly Longitudinal Project.

BACKGROUND: Few studies describe the end of life in very old people. OBJECTIVES: To characterize the last 6 months of life and dying in patients 80 years and older by describing demographic characteristics, functional state and quality of life, symptoms, preferences, use of life-sustaining treatments, satisfaction with care, and family burden. DESIGN: A retrospective analysis for patients enrolled in a prospective cohort study. SETTING: Four teaching hospitals who participated in the Hospitalized Elderly Longitudinal Project (HELP). SUBJECTS: 417 patients who died within 1 year of their enrollment hospitalization. MEASUREMENTS: Chart reviews and interview data with patients and surrogates at several points in time. We constructed four observational time windows backward in time beginning with the patients' death. RESULTS: Before hospitalization, two out of three patients reported fair quality of life, and patients averaged 2.4 impairments in activities of daily living. Seventy percent preferred comfort care on the third day of hospitalization. During the last month of life, three of five patients interviewed in the hospital and four of five interviewed out of the hospital preferred not to be resuscitated. At the time of death, four of five patients had a do not resuscitate (DNR) order and two of five had an order to withhold a ventilator. During the last month of life, one out of four patients reported severe pain. CONCLUSIONS: Patients reported increasing functional impairments and limited quality of life. The majority preferred comfort care. The number of patients in severe pain was substantial. Before death, the majority had measures in place to limit aggressive care.

Dying with acute respiratory failure or multiple organ system failure with sepsis.

BACKGROUND: The dying experience of patients with acute respiratory failure (ARF) or multiple organ system failure with sepsis (MOSF) has not been described. OBJECTIVES: To describe patients dying from ARF or MOSF, including demographic characteristics, baseline function and quality of life, symptoms, preferences, use of life-sustaining treatments, satisfaction with care, and family burden. DESIGN: A multicenter prospective study. SETTING: Five US teaching hospitals, in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). PARTICIPANTS: A total of 1295 adults who died during hospitalization for ARF or MOSF. MEASUREMENTS: Chart reviews and interviews with patients and surrogates. RESULTS: SUPPORT enrolled 2956 patients with ARF or MOSF, and 44% died during enrollment hospitalization. Quality of life before hospitalization was reported as fair by 87% of patients. The mean number of impairments in their baseline activities of daily living was 1.6. At the time of death, 79% had a DNR order and 31% had an order to withhold ventilator support. The average time from the DNR order to death was 2 days. Dying patients spent an average of 9 days on a ventilator. Surrogates indicated that one out of four patients died with severe pain and one out of three with severe confusion. Families of 42% of the patients who died reported one or more substantial burden. CONCLUSIONS: Patients in this study reported substantial functional impairments and reduced quality of life. Limitations to aggressive treatments were usually implemented only when death was imminent. Family impact and physical and emotional suffering were substantial.

Nasal challenge with histamine decreases nonspecific bronchial reactivity in workers exposed to respiratory irritants.

BACKGROUND: A link ("naso-bronchial reflex") between nasal and bronchial reactivity seems to exist. The effect of nonspecific nasal challenge (standing for the exposure to irritative stimuli at the workplace) on lung function indices and nonspecific bronchial reactivity is not known. METHODS: In 80 healthy workers (age: 36.0 +/- 8.6 years) continuously exposed to acceptable levels of different respiratory irritants (for more than 2 years) nasal challenge was performed by spraying doubling concentrations of histamine (0.0625-16.0 mg/mL, doses of histamine: 7.8 micrograms-2.08 mg) into each nostril. Before and immediately after nasal challenge spirometry and the bronchoprovocation test with histamine (0.5-128 mg/mL) was performed. RESULTS: Although nasal challenge with histamine had not reduced airway caliber (before nasal challenge vs. following nasal challenge: FEV1 3.8 +/- 0.8 vs. 3.7 +/- 0.8 L, and MEF50 4.3 +/- 1.4 vs. 4.3 +/- 1.4 L/s, mean +/- SD, respectively), it had significantly reduced nonspecific bronchial reactivity in 30.2% of the irritant-exposed subjects. CONCLUSIONS: Nasal challenge with histamine decreases nonspecific bronchial reactivity in workers occupationally exposed to respiratory irritants. Thus, a methodological implication would be that these two tests should not be performed consecutively in less than 2 hr in the same subjects.

Non-specific nasal and bronchial reactivity are not correlated in non-asthmatic subjects occupationally exposed to irritants and in healthy subjects.

BACKGROUND: Non-specific nasal and bronchial reactivity are frequently correlated in disease (rhinitis and asthma). It is not known whether such a correlation exists in subjects exposed to irritants and in healthy subjects. In order to test the hypothesis that a correlation between non-specific nasal and bronchial reactivity exists in non-asthmatic subjects, two groups of subjects were studied: 110 workers occupationally exposed to respiratory irritants, and 86 non-exposed healthy controls. METHODS: Allergy, non-specific nasal, and non-specific bronchial reactivity were tested, and smoking habits were categorized in each subject. RESULTS: Respiratory irritants cause a substantial increase in nasal and bronchial reactivity when compared with the group of healthy, non-exposed subjects (33.6% nasal hyperreactors and 20.0% bronchial hyperreactors vs. 4.7% nasal hyperreactors and 2.3% bronchial hyperreactors, respectively). But, occupational exposure to respiratory irritants does not induce a correlation between non-specific nasal and bronchial reactivity frequently found in asthmatic and rhinitic subjects. CONCLUSIONS: We found no correlation between non-specific nasal and bronchial reactivity either in subjects occupationally exposed to respiratory irritants or in the group of healthy subjects. This lack of correlation in both studied groups seems to be a feature of non-diseased airways. Smoking as an additional factor does not increase nasal and bronchial reactivity either in workers exposed to irritants or in healthy subjects. Smoking also does not strengthen the correlation between upper and lower airways' reactivity in both groups.

Modified method of nonspecific nasal provocation with histamine for routine use.

An improved method for assessment of nonspecific nasal reactivity (NNR) was evaluated to validate it, and determine a criterion for nasal hyperreactivity. The efficacies of four different parameters to indicate nasal patency in assessment of the level of NNR were compared in 60 healthy subjects and 65 patients with allergic rhinitis (37 in the period of pronounced symptoms and 28 in the symptom-free period). Histamine/diphosphate was sprayed into both nostrils every three minutes in doubling concentrations (0.03125 to 32 mg/mL); during 90 seconds, sneezes were counted and symptom score was assessed; thereafter nasal inspiratory peak flow (NIPF), total nasal airway resistance (NART), nasal forced expiratory volume in one second (N-FEV1) and nasal midexpiratory flow rate (N-MEF25/75) were measured. Nasal inspiratory peak flow meter (Youlten, "Airmed") was used to measure NIPF. A spirometer (Pneumoscreen II, "Jaeger") with a face mask attached was used to measure NART, N-FEV1, and N-MEF25/75. The test of NNR was terminated when a significant change of values (as determined by a pilot study) occurred: NIPF, -30%; NART, +75%; N-FEV1, -20%; and N-MEF25/75, -25%. Our results indicate a significantly higher NNR (PCNART of patients = 0.77 mg/mL versus PCNART of healthy subjects = 4.5 mg/mL; P < .00001) period of pronounced symptoms than in healthy subjects or in rhinitic patients when symptom free. A criterion, that takes age into account, is set for separation of normoreactivity from hyperreactivity.(ABSTRACT TRUNCATED AT 250 WORDS)

Nonspecific nasal responsiveness in workers occupationally exposed to respiratory irritants.

The aim of the study was to establish the level of the nonspecific nasal responsiveness in a group of workers (N = 84) occupationally exposed to respiratory irritants, and to compare it with its level in healthy subjects (N = 60). Another goal was to study the effect of occupational exposure to irritants, smoking, and atopy on nonspecific nasal responsiveness. The modified method of nonspecific nasal provocation with histamine developed by van Wijk and Dieges (Clin Allerg 17:563-570, 1987) was used. The method was performed by spraying doubling concentrations of histamine (0.03-32 mg/mL), starting with saline, in a cumulative manner into each nostril. The reaction was measured by total nasal resistance ("opening" interruption technique). The result of the test was expressed as provocation concentration of histamine that caused > or = 75% rise of total nasal resistance compared to its value measured after saline. We found a significantly higher percentage of nasal hyperreactors and a significantly greater nonspecific nasal responsiveness among 65 exposed workers (chi 2 = 78.6; p < 0.001, t = -5.48; p < 0.001, respectively) than in the group of healthy subjects. A significantly (t = 4.25; p < 0.001) increased nonspecific nasal responsiveness was observed during exposure when compared to nonspecific nasal responsiveness assessed after 2 weeks out of exposure, when tested in 19 patients. Higher smoking rate as measured by smoking category (number of cigarettes multiplied with years of smoking) was associated with the lower levels of nonspecific nasal responsiveness. Also, we failed to confirm a relation between atopy and nonspecific nasal responsiveness in a group of workers exposed to irritants.

[Bronchial reactivity after provocation of the nasal mucosa with histamine]. / Stanje reaktivnosti bronha nakon podrazivanja nosne sluznice histaminom.

Data on the relationship between nasal and bronchial reactivities are scarce. This study aimed at investigating a possible influence of the nasal provocation test on bronchial reactivity. Three groups of eleven subjects each were examined: patients suffering from allergic rhinitis with no clinical evidence of asthma, workers exposed to respiratory irritants complaining of occupational rhinitis and asthma, and healthy subjects. Non-specific bronchoprovocation was performed before and after nasal challenge with histamine. The bronchial challenge with histamine solutions (0.125 mg/ml and 128 mg/ml) was performed by the five-breath cumulative method (Chai H. et al. J Allergy Clin Immunol 1975;56:323-7). Non-specific nasal provocation was performed by spraying doubling concentrations of histamine (0.125 mg/ml-32 mg/ml) into both nostrils at three-minute intervals. The reaction was monitored by measurement of nasal inspiratory peak flow, nasal resistance, and nasal spirometry. The level of non-specific nasal reactivity was significantly lower in patients with allergic rhinitis than in the other two groups. The bronchial reactivity of the "rhinitis" group and of those occupationally exposed to irritants was significantly lower than among healthy subjects. An immediate and significant decrease in bronchial reactivity could be observed after nasal challenge in the group of healthy subjects as well as in workers exposed to irritants, but there was no significant change in bronchial reactivity among patients suffering from allergic rhinitis.