Community engagement and the resource centers for minority aging research.

The National Institute on Aging created the Resource Centers for Minority Aging Research (RCMARs) to address infrastructure development intended to reduce health disparities among older adults. The overall goals of the RCMARs are to (a) increase the size of the cadre of researchers conducting research on issues related to minority aging; (b) increase the diversity of researchers conducting research on minority aging; (c) create and test reliable measures for use in older diverse populations; and (d) conduct research on recruitment and retention of community-dwelling older adults for research addressing behavioral, social, and medical issues. Along with this latter goal, the RCMARs developed and maintain academic-community partnerships. To accomplish the recruitment and retention goal, the RCMARs established Community Liaison Working Groups using a collaborative approach to scientific inquiry; this special issue will identify research priorities for moving the science of recruitment and retention forward. In addition, sustainable and efficient methods for fostering long-term partnerships will be identified between community and academia. Evidence-based approaches to the recruitment and retention of diverse elders are explored. We expect this supplement to serve as a catalyst for researchers interested in engaging diverse community-dwelling elders in health-related research. In addition, this supplement should serve as a source of the most contemporary evidence-based approaches to the recruitment and retention of diverse older populations for participation in social, behavioral, and clinical research.

A prospective trial of a new policy eliminating signed consent for do not resuscitate orders.

BACKGROUND: Some institutions require patients and families to give signed consent for Do Not Resuscitate (DNR) orders, especially in New York State. As this may be a barrier to discussions about DNR orders,we changed a signed consent policy to a witnessed verbal consent policy,simplified and modified the DNR order forms, and educated the staff at 1 hospital, comparing the effects with an affiliated hospital where the policy was not changed. DESIGN: Prospective natural experiment with intervention and comparison sites. SUBJECTS AND MEASUREMENTS: Pre- and postintervention, we surveyed house officers' confidence and attitudes, reviewed charts to assess the number of concurrent care concerns (CCCs) addressed per DNR order (e.g., limits on intubation or blood products or need for hospice),and at the intervention hospital, measured the stress levels of surrogates consenting for DNR orders using the Horowitz Impact of Event Scale. We also surveyed staff perceptions about the policy following the change. RESULTS: At the intervention hospital, the percentage of house officers reporting low confidence in their ability to obtain consent for DNR orders declined postintervention (24% to 7%, P=.002), while there was no significant change at the comparison hospital (20% vs 15%, P=.45).Among intervention hospital house officers, there were declines in percent reporting difficulty talking to patients and families about DNR orders, but no significant changes at the comparison hospital.At the intervention hospital, the mean number of CCCs/DNR order Increased (1.0 pre to 4.2 post, P<.001). but did not change significantly(1.2 pre to 1.4 post) at the comparison hospital. The mean total stress score for intervention hospital surrogates declined postintervention(23.6 to 17.3, P=.02), indicating lower stress. House officers(98%), attendings (59%), and nurses (79%} thought the new policy was better for families. CONCLUSIONS: The policy change was well received and associated with improved house officer attitudes, more attention to patients'concurrent care concerns, and decreased surrogate stress. The results suggest that DNR orders can be made simpler and clearer, and raise questions about policies requiring signed consent for DNR orders.

When patients lack capacity: the roles that patients with terminal diagnoses would choose for their physicians and loved ones in making medical decisions.

Current approaches to end-of-life decision making are widely considered inadequate. We explored these complexities by examining how patients with terminal diagnoses would choose to involve their physicians and loved ones in making medical decisions, assuming they were able and unable to participate. Cross-sectional interviews of 130 patients recently diagnosed with fatal conditions were conducted. Patients were recruited from two academic medical centers using a modification of the Decision Control Preferences Scale, ranging from independent decision making to decision making that relies upon others. Patients were asked how they would balance their own wishes relative to the input of physician and loved ones in making medical decisions, and to weigh the input of loved ones relative to physician. Most patients (52%), assuming they had the capacity, would opt to share decision making with their physicians, but 15% would defer to their physicians and 34% would make decisions independently. Similarly, 44% would share decision making with their loved ones, but fewer (6%) would defer to their loved ones. Thirty-nine percent would rely upon their physicians' judgments about what would be best for them rather than their own wishes if they became unconscious, compared with 15% who would do so if they were conscious (P < 0.001). Nonetheless, patients were more likely to weigh their loved ones' input more heavily than their physicians' input if they were unconscious (33%) than if they were conscious (7%, P = 0.05). Race, religion, gender, diagnosis, and health status were largely unassociated with patients' decision control preferences. Patients with terminal diagnoses report a wide diversity of decision control preferences, but most would opt to share decision making with their physicians and loved ones. If unable to decide for themselves, they shift toward greater reliance on physician input relative to their own wishes but would weigh loved ones' input more heavily than physician input. Deciding for patients who cannot speak for themselves may be more complex than has previously been reflected in law, policy, or clinical ethics.

The quality of care plans for patients with do-not-resuscitate orders.

BACKGROUND: Care plans for patients with do-not-resuscitate (DNR) orders often fail to define limits other than cardiopulmonary resuscitation and fail to address other patient care needs. We studied the explicitness and comprehensiveness of care plans for patients with DNR orders and what factors were associated with this aspect of the quality of their care. METHODS: A cross-sectional study was conducted at Georgetown University Medical Center (GUMC), Washington, DC, and St Vincent Catholic Medical Centers (SVCMC), St Vincent's Hospital-Manhattan, New York, NY. Participants included 189 consecutive medical inpatients with DNR orders. RESULTS: A previously validated medical chart review technique termed concurrent care concerns (CCCs) measured whether 11 possible patient care needs had been addressed within 2 days of the DNR order. Reasons for the DNR order were documented in only 55% of cases, and a consent conversation was documented in only 69%. The mean number of total CCCs per DNR order was 1.55 (1.84 at GUMC and 1.29 at SVCMC; (P =.007). In a multivariate logistic regression analysis of low (or=2) CCCs, patients with malignancy (P =.002), higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (P =.007), and a documented consent conversation (P =.009) and those at Georgetown (P =.005) were more likely to have high attention to CCCs. Patients with dementia were the least likely to have high attention to CCCs. CONCLUSIONS: Documented consent conversations and care plans for patients with DNR orders are less than ideal. Care plans differ in quality by diagnosis, institution, and whether or not a consent conversation is documented. These observations might help to guide interventions that aim to improve the care of patients with DNR orders.

Factors associated with the time nurses spend at the bedsides of seriously ill patients with poor prognoses.

BACKGROUND: Little is known about the time health professionals spend with inpatients that are close to the end of life. SUBJECTS AND METHODS: We asked day-shift nurses to use a standardized log sheet to record how much time they spent in various categories of activity for 146 seriously ill medical inpatients with poor prognoses at 2 teaching hospitals. RESULTS: The mean patient age was 68, and the mean APACHE-III physiology score 28; 59% were white, 56% were women, 41% had cancer or HIV, and 81% had do not resuscitate (DNR) orders. The mean amount of time nurses spent with patients per 12-hour day shift was 53 min. In bivariate analyses, sex, religion, diagnosis and insurance status were not associated with nursing bedside time. In an ANOVA model, patients with DNR orders received more time than those without DNR orders (56 vs. 39 min, P = 0.04), and white patients received more bedside time than nonwhites (57 vs. 46 min, P = 0.01), even after controlling for severity of illness and DNR status. Among the 47 mentally alert patients who could be interviewed, symptom severity, quality of care, and satisfaction ratings were not associated with nursing bedside time. CONCLUSIONS: In this population, nurses spent less time with nonwhite patients and more time with patients with DNR orders. That patients with DNR orders received more time may be reassuring. However, further investigation will be required to confirm these results, to understand why nonwhite patients appear to have received less bedside nursing time, and to investigate further the relationship between time, satisfaction, and quality of care.