Longitudinal prevalence and correlates of elder mistreatment among older adults receiving home visiting nursing.

The objectives of this study were to identify elder mistreatment (EM) prevalence among a cohort of older adults receiving visiting nurse care in their homes, determine EM subtypes, and identify factors associated with EM. EM data were collected by nurses during monthly home visits for up to 24 months. It took the nurses a mean of 10.5 visits to discern EM. Fifty-four (7.4%) of 724 patients were identified as mistreated, of which 33 had enough information to subtype the EM. Of these 33, 27 were victims of neglect, 16 of psychological abuse, and 10 of financial exploitation, and 17 suffered more than one type. Among the entire sample, 11 variables were positively correlated with EM presence. Nurses visiting older adults in their homes should be aware that their patients are, as a group, vulnerable to EM, and that the factors identified here may be specific markers of greater risk.

Patient experiences of autonomy and coercion while receiving legal leverage in forensic assertive community treatment.

Legal leverage is broadly defined as the use of legal authority to promote treatment adherence. It is widely utilized within mental health courts, drug courts, mandated outpatient treatment programs, and other intervention strategies for individuals with mental illness or chemical dependency who have contact with the criminal justice system. Nonetheless, the ethics of using legal authority to promote treatment adherence remains a hotly debated issue within public and professional circles alike. While critics characterize legal leverage as a coercive form of social control that undermines personal autonomy, advocates contend that it supports autonomy because treatment strategies using legal leverage are designed to promote health and independence. Despite the controversy, there is little evidence regarding the impact of legal leverage on patient autonomy as experienced and expressed by patients themselves. This report presents findings from a qualitative study involving six focus groups with severely mentally ill outpatients who received legal leverage through three forensic assertive community treatment (FACT) programs in Northeastern, Midwestern, and West Coast cities. Findings are discussed in the context of the self-determination theory of human motivation, and practical implications for the use of legal leverage are considered.

Development and initial evaluation of a treatment decision dashboard.

BACKGROUND: For many healthcare decisions, multiple alternatives are available with different combinations of advantages and disadvantages across several important dimensions. The complexity of current healthcare decisions thus presents a significant barrier to informed decision making, a key element of patient-centered care.Interactive decision dashboards were developed to facilitate decision making in Management, a field marked by similarly complicated choices. These dashboards utilize data visualization techniques to reduce the cognitive effort needed to evaluate decision alternatives and a non-linear flow of information that enables users to review information in a self-directed fashion. Theoretically, both of these features should facilitate informed decision making by increasing user engagement with and understanding of the decision at hand. We sought to determine if the interactive decision dashboard format can be successfully adapted to create a clinically realistic prototype patient decision aid suitable for further evaluation and refinement. METHODS: We created a computerized, interactive clinical decision dashboard and performed a pilot test of its clinical feasibility and acceptability using a multi-method analysis. The dashboard summarized information about the effectiveness, risks of side effects and drug-drug interactions, out-of-pocket costs, and ease of use of nine analgesic treatment options for knee osteoarthritis. Outcome evaluations included observations of how study participants utilized the dashboard, questionnaires to assess usability, acceptability, and decisional conflict, and an open-ended qualitative analysis. RESULTS: The study sample consisted of 25 volunteers - 7 men and 18 women - with an average age of 51 years. The mean time spent interacting with the dashboard was 4.6 minutes. Mean evaluation scores on scales ranging from 1 (low) to 7 (high) were: mechanical ease of use 6.1, cognitive ease of use 6.2, emotional difficulty 2.7, decision-aiding effectiveness 5.9, clarification of values 6.5, reduction in decisional uncertainty 6.1, and provision of decision-related information 6.0. Qualitative findings were similarly positive. CONCLUSIONS: Interactive decision dashboards can be adapted for clinical use and have the potential to foster informed decision making. Additional research is warranted to more rigorously test the effectiveness and efficiency of patient decision dashboards for supporting informed decision making and other aspects of patient-centered care, including shared decision making.

The value of "life at any cost": talk about stopping kidney dialysis.

With the trend toward an older, sicker dialysis population in the USA, discussions of ethical issues surrounding dialysis have shifted from concerns about access to and availability of the therapy, to growing unease about non-initiation and treatment discontinuation. Recent studies report treatment withdrawal as the leading cause of death among elderly dialysis patients. Yet, the actual activities that move patients toward stopping treatment often remain obscure, even to clinicians and patients themselves. This paper explores that paradox, drawing on anthropological research among patients over age 70, their families, and clinicians in two California renal dialysis units. It concludes that many older patients sacrifice a sense of choice about dialysis in the present to maintain "choice" as both value and possibility for the future. Even so, patients desire more information and communication, provided earlier in their illness, about prognosis, how long they can expect to be on dialysis, and what the impact of the treatment will be on their daily lives. That, with time, there is a transition to be made from dialysis as "treatment" to end of life care could be better explained and managed to alleviate patients' confusion and unneeded isolation.

Clinical life: expectation and the double edge of medical promise.

This article introduces the concept of clinical life to capture a form of life produced in the pursuit and wake of medically achieved longevity. Relying on the retrospective accounts of 28 individuals over age 70 who have undergone cardiac bypass surgery, angioplasty or a stent procedure, as well as interviews with their families and with clinicians, we examine three features of clinical life. First, patients do not distinguish between clinical possibility and clinical promise, and thus assume that life can and will be improved by medical intervention in late life. Rather than anticipating a range of potential treatment outcomes, patients therefore expect the best-case scenario: that medical procedures will reverse aging, disease and the march of time. Second, patients then assess the value of their post-procedure lives in accordance with that expectation. Norms regarding what life 'should be like' at particular ages are continually recalibrated to the horizon of what is clinically possible. And third, the price of living longer entails a double-edged relationship with the clinic--it generates opportunities for bodily restoration and increased self-worth but also creates ambivalence about the value of life. This latter feature of clinical life is rarely publicly acknowledged in an environment that emphasizes medical promise.

Old age, life extension, and the character of medical choice.

OBJECTIVES: This qualitative, ethnographic study explores the character and extent of medical choice for life-extending procedures on older adults. It examines the sociomedical features of treatment that shape health care provider understandings of the nature of choice, and it illustrates the effects of treatment patterns on patients' perspectives of their options for life extension. METHODS: By using participant observation in outpatient clinics and face-to-face interviews, we spoke with a convenience sample of 38 health professionals and 132 patients aged 70 or older who had undergone life-extending medical procedures. We asked providers and patients open-ended questions about their understandings of medical choice for cardiac procedures, dialysis, and kidney transplant. RESULTS: Neither patients nor health professionals made choices about the start or continuation of life-extending interventions that were uninformed by the routine pathways of treatment; the pressures of the technological imperative; or the growing normalization, ease, and safety of treating ever older patients. We found a difference among cardiac, dialysis, and transplant procedures regarding the locus of responsibility for maintaining and extending life. DISCUSSION: Provider and patient practices together reveal how the standard use of medical procedures at ever older ages trumps patient-initiated decision making.

Risk, life extension and the pursuit of medical possibility.

With increasing frequency, the oldest members of US society are undergoing medical interventions aimed at prolonging life. Using cardiac care as a case study, this paper explores how a discourse of risk infuses and legitimates high-tech clinical treatments in late life. In particular, we examine how the diminishing risks associated with biomedical procedures produce a sense of medical possibility regarding life extension, and push the definition of "old age" into a receding future. Simultaneously, physicians, patients and families come to understand the management and reduction of future cardiac risks to be germane for individuals even near the end of life. Driven by the logic and language of risk, decisions to intervene are experienced as incremental and largely unremarkable, and the pursuit of an open-ended future via biomedical means is perceived as an ethical imperative, trumping deliberation or discussion of the utility of intervention and the ultimate ends being pursued. For practitioners and patients alike, the engagement of risk, the preservation of hope it facilitates and the routinisation of intervention it produces all contribute to the emerging mandate to treat at ever-older ages.

Policy and prevention as competing imperatives in US Navy life and medicine.

On the face of it, US Navy sexual health initiatives face a challenge similar to those on college and university campuses: how to prepare individuals coming into adulthood for both the positive and less positive health consequences of sexual intimacy. However, rules unique to military settings that forbid relationships between certain categories of personnel and that delimit the appropriate context and content of sexual expression have special implications for Navy safer sex programmes. Guided by in-depth interviews with 58 Navy officers and enlisted members, this paper examines how official policies regulating sexual behaviour sometimes hinder the effective prevention and medical management of sexually transmitted infections and unplanned pregnancies. Two findings in particular are worthy of note: first, perceptions of sexual risk are often displaced from concerns about health to concerns about 'getting caught' for violating Navy rules; and second, official prevention efforts do not adequately reflect the realities of sexual life (especially on deployments). Current US Navy rules governing sex may therefore have the inadvertent effects of contributing to sexual health risk and of preventing the occurrence not of sex, but of safer sex.

Aged bodies and kinship matters: The ethical field of kidney transplant.

The number of kidneys transplanted to people over age 70, both from living and cadaver donors, has increased steadily in the past two decades in the United States. Live kidney donation, on the rise for all age groups, opens up new dimensions of intergenerational relationship and medical responsibility when the transfer of organs is from younger to older people. There is little public knowledge or discussion of this phenomenon, in which the site of ethical judgment and activism about longevity and mortality is one's regard for the body of another and the substance of the body itself is ground for moral consideration about how kinship is "done." The clinic, patient, and patient's family together shape a bond between biological identity and human worth, a demand for an old age marked by somatic pliability and renewability, and a claim of responsibility that merges the "right to live" and "making live." Live kidney transplantation joins genetic, reproductive, and pharmacological forms of social participation as one more technique linking ethics to intervention and the understanding of the arc of human life to clinical opportunity and consumption. Significant in this example is the medicocultural scripting of transplant choice that becomes a high-stakes obligation in which the long-term impacts on generational relations cannot be foreseen.

"Is there life on dialysis?": time and aging in a clinically sustained existence.

Increasingly, in the United States, lives are being extended at ever-older ages through the implementation of routine medical procedures such as renal dialysis. This paper discusses the lives and experiences of a number of individuals 70 years of age and older at two dialysis units in California. It considers what kind of life it is that is being sustained and prolonged in these units, the meanings of the time gained through (and lost to) dialysis for older people, and the relationship of "normal" life outside the units to an exceptional state on the inside that some patients see as not-quite-life. Highlighting the unique dimensions of gerontological time on chronic life support, the article offers a phenomenology of the end of life as that end is drawn out, deferred by technological means, and effaced by the ethos and experiential course of dialysis treatment.

Family perceptions of prognosis, silence, and the "suddenness" of death.

Studies of end-of-life communication and care have emphasized physician-patient conversations, often to the exclusion of family members' discussions and interactions with providers, or with patients themselves. Relatively little is known therefore about families' experiences of end-of-life care in the hospital, or the concrete meanings and practices through which families conceive and define communication. Yet increasingly, family members are asked to serve as surrogates and thereby to participate in the facilitation of decisions for medical procedures and the withdrawal of treatments. It is thus worthwhile to consider their perceptions and involvement in hospitalization at the end of life. This paper offers a descriptive account of families' assessments of communication at life's end in the hospital--focusing in particular on their understandings of and conversations about prognosis and its implications. It reflects on the burdens of responsibility and regret posed to families by the ways communication is both conceived and evaded by different players in the hospital setting.

Revisiting the biomedicalization of aging: clinical trends and ethical challenges.

Developments in the realms of medical innovation and geriatric clinical intervention impact our understanding of the nature of late life, the possibilities for health in advanced age, medical decision making, and family responsibility in ways that could not have been predicted 15 years ago. This essay begins to map new forms of biomedicalization in the U.S. and to underscore their emergence in a new ethical field. We suggest that a new kind of ethical knowledge is emerging through "routine" clinical care, and we offer examples from the following interventions: cardiac procedures, kidney dialysis, and kidney transplant. This new ethical knowledge is characterized by the difficulty of saying "no" to life-extending interventions, regardless of age. We explore the intensification of the biomedicalization of old age through a discussion of three features of the new ethical field: (a) the ways in which routine medical care overshadows choice; (b) the transformation of the technological imperative to a moral imperative; and (c) the coupling of hope with the normalization and routinization of life-extending interventions. We argue that societal expectations about longevity and standard medical care come together today in a shifting ethics of normalcy, with unexplored socio-cultural ramifications.