Advance directives for truth disclosure.

INTRODUCTION: Although most patients wish to be fully informed about bad news such as a diagnosis of cancer, a significant minority prefer no or minimal information. We examined the value of asking patients about their disclosure preferences at the outset of hospitalization. METHODS: Consecutive patients admitted to a respiratory and a geriatric unit were asked whether and how they would wish to be told of cancer or Alzheimer disease. RESULTS: Of the 207 patients interviewed, 174 (84%) wanted to be told about cancer or dementia; the proportion who would wish to be told did not differ between older patients (89 of 108 patients; 82%) and younger patients (85 of 99 patients; 86%; p = 0.34). Thirty patients (15%) sought reassurance during or after the interview, and 13 patients (6%) reported that they had been bothered by the questions. Of the 207 patients, cancer or dementia was diagnosed in 23 patients (11%). Preferences for disclosure or nondisclosure were honored for 20 patients (87%). CONCLUSIONS: Seeking preferences regarding truth disclosure at the outset of hospitalization is helpful and feasible in everyday practice, and the results can be used by clinicians to improve communication with patients and families in accordance with patients' own wishes.

Use of serial Mini-Mental State Examinations to diagnose and monitor delirium in elderly hospital patients.

OBJECTIVES: To determine the responsiveness of serial Mini-Mental State Examinations (MMSEs) for the diagnosis and monitoring of delirium in elderly hospital patients. DESIGN: Prospective study. SETTING: University teaching hospital. PARTICIPANTS: One hundred sixty-five people admitted to an acute geriatric service. MEASUREMENTS: Subjects were assessed using the MMSE and the Confusion Assessment Method on hospital Days 1 and 6. Changes in scores were compared between patients who remained free of delirium (n=124) and those who by Day 6 had developed delirium (n=14) or had resolution of delirium present on admission (n=22). RESULTS: A number of measures of responsiveness confirmed that serial MMSE scores were responsive to resolution and to development of delirium. A fall of 2 or more points on the MMSE was the best determinant for detecting development of delirium (93% sensitivity, 90% specificity, positive likelihood ratio (LR)=8.9 (95% confidence interval (CI)=5.2-15.1) and negative LR=0.08 95% CI=0.01-0.53)). A rise of 3 or more points was the best determinant for detecting resolution of delirium (77% sensitivity, 75% specificity, positive LR=3.1 (95% CI=2.1-4.5) and negative LR=0.30 (95% CI=0.14-0.66)). CONCLUSION: The MMSE is responsive to short-term changes in cognitive function in elderly patients. Serial MMSE tests should be helpful in monitoring the development and resolution of delirium in this population.