End-of-life Decision-making Differs Between a Cancer and a Dementia Patient: Influences of the Physician's Background Factors.

BACKGROUND/AIM: Appropriate decision-making is essential for end-of-life (EOL) care without futile therapies. However, these decisions might vary in cases of cancer and other advanced diseases according to physicians' experience, education, and values. This study aimed to compare the decisions in EOL care of advanced cancer and dementia and the factors that influence them in medical students, general practitioners (GPs), and physicians with special competence in palliative medicine (cPM). PATIENTS AND METHODS: A questionnaire presenting patient scenarios concerning different decisions and ethical aspects of EOL care with additional questions on attitudes and background factors was delivered to 500 Finnish GPs, all Finnish physicians with cPM (n=82), and all graduating medical students (n=639) in 2015-2016. Altogether 601 responses were obtained (53%). RESULTS: Palliative care was chosen more often for a patient with advanced prostate cancer (83%) than for a patient with advanced dementia (41%) (both patients males, same age). A suspicion of iatrogenic bleeding in the prostate cancer patient decreased the willingness to choose palliative care, especially among the students. Patient benefit was regarded as an important background factor in decision making by all respondent groups, but physicians' legal protection was not considered as important among the physicians with cPM as it was among the other respondent groups. CONCLUSION: Finnish doctors and students were more likely to choose palliative care options for an advanced prostate cancer patient than for an advanced dementia patient. Decision-making was influenced by respondents' background factors and attitudes. Education on EOL care for different types of advanced and incurable diseases is highly needed.

Physicians' decreased tendency to choose palliative care for patients with advanced dementia between 1999 and 2015.

BACKGROUND: Physicians' decision-making for seriously ill patients with advanced dementia is of high importance, especially as the prevalence of dementia is rising rapidly, and includes many challenging ethical, medical and juridical aspects. We assessed the change in this decision-making over 16 years (from 1999 to 2015) and several background factors influencing physicians' decision. METHODS: A postal survey including a hypothetical patient-scenario representing a patient with an advanced dementia and a life-threatening gastrointestinal bleeding was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. The target groups were general practitioners (GPs), surgeons, internists and oncologists. The respondents were asked to choose between several life-prolonging and palliative care approaches. The influence of physicians' background factors and attitudes on their decision were assessed. RESULTS: The response rate was 56%. A palliative care approach was chosen by 57 and 50% of the physicians in 1999 and 2015, respectively (p = 0.01). This change was statistically significant among GPs (50 vs 40%, p = 0.018) and oncologists (77 vs 56%, p = 0.011). GPs chose a palliative care approach less often than other responders in both years (50 vs. 63% in 1999 and 40 vs. 56% in 2015, p < 0.001). In logistic regression analysis, responding in 2015 and being a GP remained explanatory factors for a lower tendency to choose palliative care. The impact of family's benefit on the decision-making decreased, whereas the influence of the patient's benefit and ethical values as well as the patient's or physician's legal protection increased from 1999 to 2015. CONCLUSIONS: Physicians chose a palliative care approach for a patient with advanced dementia and life-threatening bleeding less often in 2015 than in 1999. Specialty, attitudes and other background factors influenced significantly physician decision-making. Education on the identification and palliative care of the patients with late-stage dementia are needed to make these decisions more consistent.

Has there been a change in the end-of-life decision-making over the past 16 years?

OBJECTIVES: Physicians' decision-making in end-of-life (EOL) care includes many medical, ethical and juridical aspects. We studied the changes of these decisions over time and factors influencing them. METHODS: A postal survey including two hypothetical patient scenarios was sent to 1258 Finnish physicians in 2015 and to 1182 in 1999. The attitudes, values and background factors of the physicians were also enquired. RESULTS: The response rate was 56%. The physicians' decisions to choose palliative approaches over active or intensive care increased from 1999 to 2015 when a terminally ill prostate cancer patient had probable iatrogenic gastrointestinal bleeding (53% vs 59%, p=0.014) and waited to meet his son (46% vs 60%, p<0.001) or a minister (53% vs 71%, p<0.001). Training in EOL care independently increased palliative approaches. Patient's benefit (96% vs 99%, p=0.001), ethical values (83% vs 93%, p<0.001) and patient's (68% vs 86%, p<0.001) or physician's (44% vs 63%, p<0.001) legal protection were considered more influential to the decisions in 2015, while the family's benefit was regarded as less influential to the decisions than it was in 1999 (37% vs 25%, p<0.001). Physicians were more willing to give a hospice voucher for an advanced breast cancer patient in 2015 (34% vs 58%, p<0.001). CONCLUSIONS: Our findings may reflect the transition to a stronger emphasis on patient-centred care and a stronger tendency to avoid futile therapies that have only short-term goals. The results highlight that education in all aspects of EOL care should be incorporated into the post-graduate training of medical specialties that take care of dying patients.

Does Decision-making in End-of-life Care Differ Between Graduating Medical Students and Experienced Physicians?

BACKGROUND/AIM: Appropriate decision-making in end-of-life (EOL) care is essential for both junior and senior physicians. The aim of this study was to compare the decision-making and attitudes of medical students with those of experienced general practitioners (GP) regarding EOL-care. MATERIALS AND METHODS: A questionnaire presenting three cancer patient scenarios concerning decisions and ethical aspects of EOL-care was offered to 500 Finnish GPs and 639 graduating medical students in 2015-2016. RESULTS: Responses were received from 222 (47%) GPs and 402 (63%) students. The GPs withdrew antibiotics (p<0.001) and nasogastric tubes (p=0.007) and withheld resuscitation (p<0.001), blood transfusions (p=0.002) and pleural drainage (p<0.001) more often than did the students. The students considered euthanasia and assisted suicide less reprehensible (p<0.001 in both) than did the GPs. CONCLUSION: Medical students were more unwilling to withhold and withdraw therapies in EOL-care than were the GPs, but the students considered euthanasia less reprehensible. Medical education should include aspects of decision-making in EOL-care.

Changes in attitudes towards hastened death among Finnish physicians over the past sixteen years.

BACKGROUND: The ethics of hastened death are complex. Studies on physicians' opinions about assisted dying (euthanasia or assisted suicide) exist, but changes in physicians' attitudes towards hastened death in clinical decision-making and the background factors explaining this remain unclear. The aim of this study was to explore the changes in these attitudes among Finnish physicians. METHODS: A questionnaire including hypothetical patient scenarios was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. Two scenarios of patients with advanced cancer were presented: one requesting an increase in his morphine dose to a potentially lethal level and another suffering a cardiac arrest. Physicians' attitudes towards assisted death, life values and other background factors were queried as well. The response rate was 56%. RESULTS: The morphine dose was increased by 25% and 34% of the physicians in 1999 and 2015, respectively (p < 0.001). Oncologists approved the increase most infrequently without a significant change between the study years (15% vs. 17%, p = 0.689). Oncological specialty, faith in God, female gender and younger age were independent factors associated with the reluctance to increase the morphine dose. Euthanasia, but not assisted suicide, was considered less reprehensible in 2015 (p = 0.008). In both years, most physicians (84%) withheld cardiopulmonary resuscitation. CONCLUSION: Finnish physicians accepted the risk of hastening death more often in 2015 than in 1999. The physicians' specialty and many other background factors influenced this acceptance. They also regarded euthanasia as less reprehensible now than they did 16 years ago.

The importance of iliac fixation in prevention of stent graft migration.

OBJECTIVE: Secure proximal fixation of endografts to the infrarenal aortic neck is known to be important in the short- and long-term success of endovascular aneurysm repair. We sought to determine the relative importance of distal iliac fixation in preventing endograft migration and adverse clinical events after endovascular aneurysm repair. METHODS: We reviewed the outcome of 173 patients treated from 1996 to 2003 at Stanford University Medical Center with an externally supported stent graft. Quantitative image analysis of the postimplantation computed tomography scan was performed to determine the proximal aortic and distal iliac fixation lengths and the proximity the distal end of the stent graft to the iliac bifurcation. Subsequent follow-up computed tomography scans were reviewed for evidence of stent graft migration. Patients were grouped according to good (>15 mm), intermediate, or bad (<10 mm) aortic fixation and good (iliac fixation length > or =25 mm and iliac limbs <10 mm from iliac bifurcation), intermediate, or bad (<25-mm fixation length) iliac fixation. RESULTS: Stent graft migration of 10 mm or more was seen in 17 patients (10%) during the 23 +/- 19-month follow-up period. Patients with no migration had a greater iliac fixation length (30 +/- 12 mm) than those with migration (22 +/- 8 mm; P = .01), and the distal ends of the iliac limbs were closer to the iliac bifurcation (15 +/- 12 mm) than in patients with migration (25 +/- 10 mm; P < .001). Patients with no migration also had a greater proximal aortic fixation length (23 +/- 12 mm) than migration patients (13 +/- 7 mm; P = .001). There were no migrations among patients with good iliac fixation whether aortic fixation was good, intermediate, or bad (0/63; 0%). Among patients with bad/intermediate iliac and good aortic fixation, there were 5 (9%) of 58 patients had migrations. Patients with both bad/intermediate iliac and bad/intermediate aortic fixation had the highest migration rate (12/52; 23%). Cox proportional hazards regression modeling revealed that the significant factors predicting migration were poor proximity of the distal end of the iliac limbs to the iliac bifurcation (odds ratio 17.2; P = .01) and aortic fixation length (odds ratio 2.0; p = 0.007 for each centimeter). Iliac extender modules were placed in 9 patients with bad iliac fixation and migration, with no further migration during a mean follow-up of 12 months. Patients with good iliac and aortic fixation and no endoleak on the initial postprocedure computed tomography scan (n = 43) had no migrations, secondary procedures, or adverse clinical events over a 2-year follow-up period. CONCLUSIONS: Iliac fixation, along with proximal aortic fixation, is an important factor in preventing the migration of stent grafts that have longitudinal columnar support. Patients with good iliac fixation did not experience migration even in the presence of suboptimal proximal aortic fixation. Close proximity of the distal end of the stent graft to the iliac bifurcation seems to provide stability against migration.

Diabetes as an independent risk factor for early postoperative complications in critical limb ischemia.

OBJECTIVE: The purpose of this study was to evaluate the significance of diabetes mellitus as a risk factor for postoperative major morbidity and mortality after surgery for critical lower limb ischemia (CLI). SUBJECTS: A national vascular registry (Finnvasc)-based survey included 5709 operations for CLI from 1991 through 1999. Of these operations, 2508 (44%) were performed on diabetics. Tissue loss was the indication for surgery in 77% of diabetics and in 52% of nondiabetics. The proportion of femorodistal bypasses was 43% in diabetics and 24% in nondiabetics, whereas the proportion of reconstructions for aortofemoral arterial occlusive disease was 16% in diabetics and 34% in nondiabetics. RESULTS: Thirty-day mortality was 4.5% in diabetics and 3.4% in nondiabetics ( P = .05). The rate for early below-knee amputation was 6.5% in diabetics and 3.3% in nondiabetics ( P < .001). Independent factors for postoperative death were aortofemoral reconstruction (odds ratio [OR], 4.0), preoperative cardiac risk factor (OR, 3.1), primary surgery (OR, 2.0), renal insufficiency (OR, 1.9), urgent surgery (OR, 1.7), and age (OR, 1.3). Diabetes was an independent risk factor for postoperative below-knee amputation (OR, 1.7), cardiac complications (OR, 1.5), and superficial wound infection (OR, 1.3). There was an inverse association between diabetes and acute graft occlusion (OR, 0.8). Independent risk factors for early postoperative mortality in diabetes were aortofemoral reconstruction (OR, 2.5), urgent surgery (OR, 2.0), male gender (OR, 2.0), renal insufficiency (OR, 1.9), cardiac risk factor (OR, 1.7), and age (OR, 1.4). In nondiabetics independent risk factors for early postoperative mortality were aortofemoral reconstruction (OR, 4.5), cardiac risk factor (OR, 3.6), primary surgery (OR, 2.6), and extra-anatomic bypass (OR, 2.3). CONCLUSIONS: Diabetes was not an independent risk factor for early postoperative mortality in CLI as there was an increased morbidity in diabetics associated with old age, male gender, known coronary artery disease, and renal insufficiency, as well as urgent surgery. As diabetics have increased proclivity for these factors, special attention needs to be paid to their preoperative assessments.

Is physical activity influenced by urinary incontinence?

OBJECTIVE: To evaluate physical activity among urinary incontinent women seeking treatment and to assess the change of physical activity after treatment. DESIGN: Part of a prospective observational intervention study to examine the factors influencing the severity of urinary incontinence. SETTING: Tampere University Hospital-referral unit. POPULATION: Eighty-two urinary incontinent women were evaluated in the baseline and 69 (84%) one year (mean 13 months, range 6-21) after treatment. METHODS: Physical activity was measured by self-report questionnaire and electronic motion sensor: Caltrac accelerometer worn by women for one week. The diagnosis and severity of urinary incontinence was estimated on the basis of urodynamics, pad test, diary and incontinence-specific quality of life measures. Treatment outcome was assessed according to objective parameters and patients satisfaction. MAIN OUTCOME MEASURES: Physical activity at work, leisure and sport expressed in MET (metabolic unit) and kilocalories, change in physical activity after treatment. RESULTS: Twenty-one (25.6%) of all women reported exercise of more than three times per week. Incontinent women with the highest leisure time activity > or =6 MET (n= 23, above 75th centile) were younger; they had less body mass index and greater urine leakage than others. One year after treatment, there was no change in any parameters of physical activities. Also exercise habits among women who were completely dry (n= 37) after treatment were not changed. CONCLUSION: Urinary incontinent women who seek treatment are as physically active as the normal population. Even after successful incontinence treatment, exercise habits do not change.

Do objective urodynamic or clinical findings determine impact of urinary incontinence or its treatment on quality of life?

OBJECTIVES: To correlate the clinical and urodynamic parameters with two measures of incontinence-specific quality of life (QOL), to describe the changes in those measures after treatment, and to explore the factors determining these changes. METHODS: A total of 82 incontinent women (mean age 52 years, range 28 to 80) underwent urodynamics testing and a 48-hour pad test. They also completed the frequency/volume chart, estimated the degree of bother from urinary incontinence using the visual analog scale (VAS), and completed a validated QOL instrument--the Urinary Incontinence Severity Score (UISS). Sixty-nine women were re-evaluated 13 months (range 6 to 21) after treatment. RESULTS: A greater degree of disability from urinary incontinence as measured by the VAS correlated with a lower maximal urethral closure pressure (r = -0.29, P <0.01), greater detrusor pressure (r = 0.30, P <0.05), and amount of urine leakage (r = 0.46, P <0.001). The UISS correlated poorly with the urodynamic and frequency/volume chart findings. A greater amount of urine leakage was the best predictor of QOL impairment as measured by the UISS (beta 0.25; P = 0.034). The change in urine leakage best predicted the change in the UISS (beta 0.30; P = 0.024) and the change in the VAS (beta 0.48; P = 0.001). CONCLUSIONS: The response to the question "How bothered are you by incontinence at this moment?" best reflects the severity of urinary incontinence measured objectively. Urodynamic parameters correlated poorly with incontinence-specific QOL measure. Of the clinical objective measures of the severity of urinary incontinence, the amount of leakage in the pad test was the best, although modest, predictor of QOL impairment. The change in urine leakage best predicted the change in QOL scores and VAS 1 year after beginning treatment.

Attitudes to terminal patients' unorthodox therapy: Finnish doctors' responses to a case scenario.

We carried out a postal survey of a sample of Finnish doctors ( n=1182) concerning their attitudes and ethical decisions in end-of-life care. A scenario was presented in which a patient with terminal cancer wished to obtain unorthodox treatment. Factors possibly influencing decision making such as general attitudes, life values and demographics were investigated. The response rate was 62%. The patient's plan to use unorthodox treatment was accepted by 54% of doctors. Gender or speciality did not influence the decision, but doctor's age was a significant factor ( P=0.0005). Doctors aged 35-49 years were more accepting; younger and older ones less accepting. Doctors who had clinical experience in terminal care were more compliant to the patient's plan ( P=0.034). A stepwise logistic regression analysis was used to create a model for explaining not accepting versus accepting the treatment with the background variables. Altogether eight independent significant variables were included in the final model of explaining a doctor's choice in the presented scenario. According to the model the patient's wish was more frequently accepted if the doctor was middle-aged, had clinical experience in terminal care, valued a high standard of living, considered terminal care satisfying, was less critical of health economics, considered advance directives helpful, had a high fear-of-death index score, and valued professional status less.

Severe depression determines quality of life in urinary incontinent women.

AIMS: The purpose of this study was to assess depression and anxiety in urinary incontinent women and to investigate factors influencing their self-perception of urinary incontinence severity. METHODS: In this prospective study, 82 incontinent women estimated the severity of urinary incontinence using a visual analogue scale and completed a validated quality of life instrument: urinary incontinence severity score. Psychiatrists evaluated depression and anxiety using a structured interview of Hamilton Depression and Hamilton Anxiety Scales. Patients were classified on the basis of history and urodynamic evaluation into two diagnostic groups: stress urinary incontinence (n = 57) and idiopatic urge incontinence with or without stress incontinence (n = 25). RESULTS: Major depression occurred in 44.0% of women with idiopatic urge (+/- stress) incontinence and in 17.5% women with stress incontinence (odds ratio (OR 3.69), 95% confidence interval (95% CI 1.30-10.49)). Twenty two patients had severe incontinence defined as Urinary Incontinence Severity Score > or =14 points (upper quartile) and 23 patients defined as visual analogue scale > or =9 (upper quartile). In logistic regression analysis, major depression (OR 5.57; 95% CI 1.19-26.11), urge incontinence diagnosis (OR 23.13; 95% CI 1.90-282.11), parity (OR 2.33; 95% CI 1.16-4.60) and high Urgency Score (OR 1.94; 95% CI 1.32-2.85) predicted Urinary Incontinence Severity Score above the upper quartile. Only the pad-test (OR 1.01; 95% CI 1.00-1.02) predicted visual analogue scale above upper quartile. CONCLUSIONS: Major depression correlates with reduced incontinence specific quality of life. This data also suggests an association between depression and idiopatic urge incontinence.

Relation of cytokines to vasodilation after coronary artery bypass grafting.

Hemodynamic instability is frequent after coronary surgery. The present study tested the hypothesis that inflammation, as determined by circulating cytokine levels, may contribute to the difficulty of controlling arterial blood pressure after coronary artery bypass grafting. A group of 44 male patients undergoing elective coronary artery bypass grafting with cardiopulmonary bypass were studied. Plasma levels of tumor necrosis factor-alpha, interleukin-6 (IL-6), IL-8, and IL-10 were measured before anesthesia induction, 5 minutes and 1 hour after reperfusion to the myocardium, and 2 and 18 hours after arriving in the intensive care unit (ICU). The 29 patients who did not need a vasopressor (norepinephrine) during their ICU stay were designated group I. They were compared to group II, which consisted of 15 patients who required a pressor agent in the ICU. Although no significant differences between groups were found regarding their hemodynamic variables, IL-6 and IL-8 levels were higher in the patients who used a pressor agent in the ICU. The norepinephrine dosage used in the ICU correlated with plasma IL-8 levels 2 hours after arriving in the ICU (r = 0.56, p = 0.031). Circulating IL-6 levels in group II were significantly higher than those in group I 2 hours after arriving in the ICU (126.5 +/- 90.5 vs. 66.5 +/- 48.2 pg/ml; p < 0.05). The mean IL-8 levels were higher in group II at 5 minutes (34.9 +/- 25.7 vs. 17.3 +/- 11.3 pg/ml) and 1 hour (38.6 +/- 30.5 vs. 22.4 +/- 16.7 pg/ml) after reperfusion, and 2 hours (33.0 +/- 21.6 vs. 22.8 +/- 16.7 pg/ml) after arriving in the ICU (p = 0.036). Postoperative vasodilation was associated with increased circulating IL-8 levels. Strategies that modulate cytokine responses may improve hemodynamic stability after coronary artery bypass grafting.

Cognitive impairment in systemic lupus erythematosus and neuropsychiatric systemic lupus erythematosus: a population-based neuropsychological study.

We present a cross-sectional, population-based neuropsychological study of systemic lupus erythematosus (SLE) patients identified within Tampere University Hospital district, Finland with 440,000 inhabitants. Patients with definite SLE in the age range of 16-65 years (n = 46) and matched controls (n = 46) underwent neurological examination and comprehensive neuropsychological testing. On the basis of medical examination, the SLE patients were divided into neuropsychiatric (NP+; n = 15) and nonneuropsychiatric (NP-; n = 31) cases. The neuropsychological test results revealed more prevalent cognitive impairment in the NP+ patients, indicating that this subgroup mostly accounts for neuropsychological changes in SLE. Most characteristic changes in NP+ were observed in domains of memory, psychomotor speed, and complex attention. This suggests nonspecific CNS involvement, which is in line with neurological manifestations of the disease.

General practitioners' attitudes and ethical decisions in end-of-life care after a year of interactive Internet-based training.

BACKGROUND: Personal characteristics affect physicians' end-of-life decisions. Education in palliative care (PC) faces a challenge in influencing doctors' attitudes and decision making in PC. A one-year Internet-mediated education project was arranged for general practitioners in Finland to provide postgraduate education in PC. METHODS: A questionnaire was sent before and after the project to the education group (EG, n = 79) and a control group (CG, n = 100). Treatment decisions for presented scenarios and attitudes toward PC were elicited. RESULTS: EG doctors had previously participated in postgraduate training in PC more often than had CG doctors (93% vs 29%). For a young terminal cancer patient, EG doctors chose CPR less often than did CG doctors (7% vs 33%, p = 0.004); 30% of EG doctors would have continued antibiotic treatment in the case of a terminal cancer patient, vs 55% of CG doctors (p = 0.023). EG doctors more often agreed with the statement "Terminal care is satisfying" (p < 0.001). Treatment decisions or attitudes did not change significantly in either group during the year, the EG doctors were more satisfied with their work after the project. CONCLUSION: There are substantial differences in decision making between those who have experience and special interest in the subject and those who do not. To achieve the goals of education in PC, the most difficult target group, the "silent majority" of doctors, should be reached.

Regional differences in the use of a vascular surgical service and incidence of amputations in a well-defined geographical area.

OBJECTIVE: To evaluate regional differences in the use of a vascular surgical service in the treatment of critical lower limb ischaemia and incidence of amputation in the 1990s in a well-defined geographical area. DESIGN: Retrospective study. SETTING: One university and five county hospitals, Finland. SUBJECTS: All referrals to the university hospital vascular surgical unit for chronic critical lower limb ischaemia and the number of major amputations in the region. MAIN OUTCOME MEASURES: Numbers of new vascular surgical consultations and amputations in 11 municipalities. Correlation between numbers of consultations and amputations. RESULTS: Between the subregions the age-standardised incidence of new vascular surgical consultations in the 15-85 year old population varied from 52.4 to 104.7/10(5) and the incidence of amputation from 10.2 to 24.8/10(5). There was an inverse correlation between the numbers of consultations and amputations. The most significant inverse correlation was between consultations and below knee amputations in diabetic patients (r = -0.70). For above knee amputations there was no correlation (r = -0.21). CONCLUSION: An active referral policy leads to reduced amputation rates.