PubMed Health⌕ Search

Biomedical subjects

J C Ahronheim

Publications and source records attributed to J C Ahronheim.

At least 19 recordsLinked to original sources
PubMed2001

High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding.

BACKGROUND: The influence of tube feeding on survival in hospitalized patients with advanced dementia is controversial. OBJECTIVE: To assess long-term survival in an inception cohort, incident tube feeding placement during the index hospitalization, and the influence of tube feeding on survival in this group of patients. SUBJECTS AND METHODS: Ninety-nine hospitalized patients with advanced dementia and an available surrogate decision maker were followed up through and after the index hospitalization for mortality and placement of a feeding tube. Other variables measured included advance directive status, presence of a long-term primary care physician, level of involvement of the surrogate decision maker, admitting diagnosis, prior hospitalizations, comorbidities, and diagnosis related group diagnostic category. RESULTS: A new feeding tube was placed in 50% (51/99) of the study patients during the index hospitalization, 31% (31/99) left the hospital without a feeding tube, and 17% (17/99) were admitted with a feeding tube already in place. By stepwise logistic regression analysis, predictors of new feeding tube placement included African American ethnicity (odds ratio, 9.43; 95% confidence interval, 2.1-43.2) and residence in a nursing home (odds ratio, 4.9; 95% confidence interval, 1.02-2.5). Median survival of the 99 patients was 175 days. Eighty-five (85%) survived the index hospitalization, and 28 (28%) were still alive at last follow-up, a range of 1.3 to 4.2 years after enrollment in the study. Tube feeding was not associated with survival (P =.90). An admitting diagnosis of infection was associated with higher mortality (odds ratio, 1.9; 95% confidence interval, 1.01-3.6). CONCLUSIONS: In this cohort of hospitalized patients with advanced dementia, risk of receiving a new feeding tube is high, associated with African American ethnicity, and prior residence in a nursing home, and has no measurable influence on survival. With or without a feeding tube, these patients have a 50% six-month median mortality.

Aged↗
PubMed2001

State practice variations in the use of tube feeding for nursing home residents with severe cognitive impairment.

OBJECTIVE: To describe the differences in prevalence of tube feeding among states and to examine possible factors that could explain practice patterns. DESIGN: Analysis of random samples from an interstate data bank comprised of the Minimum Data Set (MDS), a standardized, federally mandated assessment instrument for nursing home residents. SETTING: Nursing homes in four states participating in a federal demonstration project of case mix payment plus five others with existing MDS data systems. PARTICIPANTS: Individuals 65 years of age and older (N = 57,029), who had very severe cognitive impairment, including total dependence in eating, and who resided in nursing homes during 1994, the most recent year for which uniform data were available. MEASUREMENTS: State-by-state differences in prevalence of tube feeding, controlling for demographic and clinical variables. RESULTS: The prevalence of tube feeding ranged from 7.5% in Maine to 40.1% in Mississippi. Each state had a significantly elevated prevalence of tube feeding compared with Maine, with odds ratios (ORs) ranging from 1.50 to 5.83, P < .001. Specific directives not to provide tube feeding (OR 0.41, P < .001), and white race (OR 0.45, P < .001) were strongly and negatively associated with tube feeding. CONCLUSIONS: Wide regional variations exist in the use of tube feeding of nursing home residents with equivalent impairments. Sociodemographic factors could be important, but more study is needed to determine whether physician characteristics, such as race, attitudes, or knowledge, have an impact and to clarify medical standards for the use of tube feeding in this population.

Advance Directives↗
PubMed2000

Nutrition and hydration in terminally ill patients: an update.

Many health care professionals lack knowledge about artificial nutrition and hydration at the end of life or may hold different attitudes about artificial nutrition and hydration compared with other treatments. Consequently, they may convey inaccurate or misleading information to patients or their surrogate decision makers. An updated understanding about artificial nutrition and hydration in light of prevailing medical evidence is presented.

Attitude of Health Personnel↗
PubMed2000

Palliative care in advanced dementia: a randomized controlled trial and descriptive analysis.

BACKGROUND: Few patients with end-stage dementia are enrolled in hospice care. A palliative care approach would nonetheless seem to be appropriate in various care settings, including the acute care hospital. METHODS: We conducted a randomized controlled trial of palliative care in patients with advanced dementia (Functional Assessment Staging Tool [FAST] stage 6d-7f) who were hospitalized with acute illness. Intervention patients received recommendations by a palliative care team with the goal of enhancing patient comfort; control patients received usual care without these recommendations. RESULTS: Among 99 patients enrolled over 3 years, groups were comparable at baseline in terms of gender, age, race, dementia stage, and advance directive status. Outcomes were similar in terms of mean number of hospitalizations, average length of stay, and mortality. Intervention patients were more likely than control patients to receive a palliative care plan (23% versus 4%; p = 0.008), usually on discharge, and more decisions were made to forgo certain medical treatments but the numbers were small. Fewer patients in the intervention group received intravenous therapy throughout the admission (66% vs. 81%, p = 0.025). Overall, additional interventions included daily phlebotomy for at least half of the admission (41%), systemic antibiotics (75%), and new feeding tubes (44%). Including tubes present at the time of randomization, a total of 69% received long-term enteral feeding. CONCLUSION: It was difficult for a palliative care research team to influence the care of advanced dementia patients in the acute hospital setting. When patients have advanced dementia, there may be unique barriers, including perceived prognostic uncertainty, difficulty assessing comfort level, and perceptions about tube feeding. There must be a reexamination of treatment approaches for this severely impaired group of patients. Further study should attempt to identify patients prior to the need for acute hospitalization so goals can be established when there is less urgency to make life and death decisions.

Journal Article↗
PubMed1999

Pursuit of assisted dying: a pilot study of inquiries made to a national consumer-based organization.

Legal developments in assisted dying have focused on assisted suicide for mentally competent, terminally ill adults. Requests for assisted dying are likely to represent broader concerns, but studies have been limited to surveys of specific patient groups or recollections of physicians. To describe the nature of inquiries by a broad range of persons seeking assisted dying, a retrospective review was performed of confidential client memoranda summarizing telephone inquiries regarding assisted dying to a counseling service of a national, not-for-profit, consumer-based organization. The review evaluated the underlying medical condition prompting the inquiry, evidence of patient's decisional capacity, and relationship of caller to the patient. Of 125 assisted suicide calls, 111 with medical illness were analyzed. Among 111 inquiries, 71 (64%) were made by someone other than the person suffering from the illness ("the patient"); 52 (47%) of these were family members, 14 (13%) were friends, and 5 (7%) were professionals. Cancer accounted for 25% of cases, HIV/AIDS and amyotrophic lateral sclerosis (ALS) for 10 and 9%, respectively, other neurological diseases for 23%, and chronic or other medical conditions for approximately 17%. In an additional 10 cases, there was no medical illness. Within the group of callers inquiring on behalf of others, 18 (25%) stated the patient lacked ability to communicate his or her wishes and 7 (10%) stated there was uncertainty. Inquiries about assisted dying represent a broader range of concerns than represented by legal initiatives. More study is needed to determine if enhanced knowledge about alternatives, such as palliative care, reduces requests for assisted dying.

Adult↗
PubMed1998

Barriers to obtaining consent in dementia research: implications for surrogate decision-making.

OBJECTIVE: To identify barriers to informed consent in research involving subjects with advanced dementia. DESIGN: A randomized controlled clinical trial of palliative care approaches, compared with usual care, in subjects with advanced dementia who are hospitalized. SETTING: A large metropolitan teaching hospital. PARTICIPANTS: All patients older than 65 years of age who have advanced dementia and a Functional Assessment Staging score of 6d to 7f and have been admitted to the hospital. MEASUREMENTS: Surrogates for all eligible subjects were approached for consent to enroll their family members in the trial. Reasons for refusal to enroll in the study were recorded and categorized as either informed refusal (i.e., the surrogate understood the research protocol but declined to give consent for participation) or as a barrier to informed consent (i.e., the surrogates could not participate in the informed consent process or there was no functional surrogate). RESULTS: Forty-nine percent of 146 eligible subjects could not be enrolled in the study. Only four surrogates refused consent for their family members. Of the remaining 68 patients, 41 eligible subjects' surrogates could not be engaged in the informed consent process, and 22 subjects did not have a functional surrogate to consent for research. CONCLUSIONS: Absence of functional surrogate decision-makers is a major barrier to research and clinical decision-making for hospitalized patients with advanced dementia.

Aged↗
PubMed1998

Pain and discomfort associated with common hospital procedures and experiences.

To determine whether reliable and valid rankings of pain and discomfort resulting from hospital procedures encountered by advanced dementia patients could be developed from interviews with cognitively intact adults, rankings of pain and discomfort resulting from 16 common procedures were obtained from two samples of hospitalized, nondemented adults using ten- (N = 100) and five- (N = 35) point numeric rating scales (NRS). Reliability was assessed by having 30 additional subjects complete ten-point NRS representing the ten most frequent procedures in a re-arranged order. By repeated measure analysis of variance, the scales discriminated between procedures (F = 35.1, P < 0.001). Subjects could discriminate between pain and discomfort (F = 21.6, P < 0.001). The five-point NRS exhibited better subject discrimination between experiences. Reliability was also acceptable. A five-point NRS produced reliable and valid pain and discomfort rankings for 16 common hospital procedures and experiences. These rankings should prove useful in reducing suffering and can serve as surrogates for quantifying pain and discomfort in dementia patients.

Adult↗
PubMed1997

End-of-life issues for very elderly women: incurable and terminal illness.

Important demographic realities may have an impact on a woman's end-of-life options. The vast majority of Americans age 85 and older are women, and they are much more likely than their male counterparts to be widowed, live alone, live below the poverty line, or die in a nursing home. Although pain is not inevitable among the terminally ill, it is vastly undertreated, and elderly women are at heightened risk for undertreatment. Pain and other physical and psychological symptoms should be treated aggressively, according to well-delineated principles of palliative care, including avoiding painful, unwanted treatments that only serve to prolong the dying process. Patients have the right to refuse unwanted treatment, even if this would result in death, and patients who lack decisional capacity can refuse these treatments through an authorized surrogate decision maker. Formal, written advance directives are particularly important for older women, who may be the group least likely to desire life-sustaining treatment. Dying patients also have the right to receive adequate analgesia or sedation for intractable symptoms, even if it might hasten death. Societal and legal consensus has been reached that forgoing treatment and receiving adequate symptom control are permissible, while significant moral and legal debate over the permissibility of euthanasia and assisted suicide continues.

Advance Directives↗
PubMed1996

Treatment of the dying in the acute care hospital. Advanced dementia and metastatic cancer.

BACKGROUND: Most Americans die in the acute care hospital, where aggressive, life-prolonging interventions are readily performed. Although patients with incurable illness might prefer palliative care, perceived differences in prognosis by physicians may influence the type of care provided. Patients with advanced cancer and advanced dementia represent 2 extremes in the use of hospice services and may also be treated differently in the acute care hospital. We tested this hypothesis and quantitated the use of nonpalliative interventions in hospitalized, incurably ill patients. METHODS: Charts of elderly patients with advanced dementia or metastatic solid tumor malignancy who died during a 13-month period in a tertiary care acute teaching hospital were reviewed. Main outcome measures included the number of patients receiving invasive of noninvasive (but complex) diagnostic tests, invasive nonpalliative treatments, cardiopulmonary resuscitation, systemic antibiotics, and do-not-resuscitate orders. RESULTS: Charts of 164 patients (80 with dementia and 84 with cancer) were reviewed. Overall, 47% received invasive nonpalliative treatments. Controlling for age, sex, length of stay, and insurance status, the groups were equally likely to receive nonpalliative treatments (P = .75), but patients with dementia were more likely to receive new feeding tubes (P = .02). Cardiopulmonary resuscitation was attempted for 24% of each group. Patients with cancer more often received invasive (41% vs 13%; P = .002) and complex noninvasive diagnostic tests (49% vs 23%; P = .02). Overall, 88% received antibiotics, often empirically, but, controlling for neutropenia and invasive tests and treatments, patients with dementia were significantly more likely to receive antibiotics for an identifiable infection (P = .004). CONCLUSIONS: Incurably ill patients often receive nonpalliative interventions at the end of life. Patients with cancer receive more diagnostic tests, but patients with dementia receive more enteral tube feeding. Patients commonly receive systemic antibiotics, often empirically. Cardiopulmonary resuscitation is equally applied, but is out of proportion to expected survival.

Advance Directives↗
PubMed1996

Nutrition and hydration in the terminal patient.

Artificial nutrition and hydration (ANH) may be provided parenterally or enterally. Hydration alone can be provided intravenously (vein) or subcutaneously (hypodermocylsis). This article explores the medical myths surrounding ANH, especially the enteral route ("tube feeding"), and discusses alternative approaches.

Deglutition Disorders↗
PubMed1992

Impact of do-not-resuscitate legislation on the use of cardiopulmonary resuscitation in three teaching hospitals.

Under New York State's unique do-not-resuscitate law, patients admitted to a hospital are assumed to consent to cardiopulmonary resuscitation unless a do-not-resuscitate order has been written in accordance with specific stipulations. This study was undertaken to determine if the law would significantly change the use of cardiopulmonary resuscitation. The charts of 952 patients who died on the medical services of Bellevue, New York University, and New York Veterans hospitals during the 12-month periods before and after the law went into effect were reviewed. The proportion of patients undergoing cardiopulmonary resuscitation was determined. To take into account the effects of potential confounders (ie, hospital, sex, race or ethnic group, age, diagnosis), a multiple logistic regression analysis was performed. The relative risk for cardiopulmonary resuscitation was found to be 0.81, (95% confidence interval: 0.59-1.10) after the law as compared with before, which was not statistically significant. Although patients with chronic or potentially reversible illness were much more likely than those with hopeless illness to undergo cardiopulmonary resuscitation (relative risk of 7.08 [3.23-15.54] and 12.89 [8.71-19.07], respectively), the data failed to show that the law had an impact on the use of cardiopulmonary resuscitation in any of the disease categories. Total use of formal do-not-resuscitate orders increased from 32.7% to 83.9% (p less than .0001), although at Bellevue, where documentation was high before the law, no further increase occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Refusal of tube feeding as seen from a patient advocacy organization: a comparison with landmark court cases.

OBJECTIVE: To determine how closely high court decisions regarding tube feeding are a reflection of the situations that occur in the general population. DESIGN: A retrospective review was conducted of memos recording inquiries made to the Society for the Right to Die (SRD), a patient advocacy organization. Characteristics of clients were compared to characteristics of individuals considered in landmark "right-to-die tube feeding cases during the same period of time. RESULTS: Information from 116 memos of inquiries made from 1985 through mid-1990 was compared to 20 court cases, and significant differences were identified. The average age of the SRD clients was 77.6 (+/- 18.4) years compared to 55.1 (+/- 22.8) years for the court cases (P less than 0.001). Of the clients, 79% were 70 years of age or older and 28% were 90 or older; in contrast, 7 (35%) of subjects in the court cases were 70 years of age or older, and none was over 90 (P less than 0.001). In addition, whereas 14 (70%) of the court cases dealt with individuals in a persistent vegetative state, only 17 (15%) of SRD clients carried that diagnosis (P less than 0.001), with the remainder suffering from dementia, various stages of coma, or a variety of other debilitating disorders. The sex distribution, year of inquiry or year of court decision, and geographic distribution were similar. Some states were overrepresented in both groups. CONCLUSION: High court cases may inadequately reflect the majority of situations that arise on a day-to-day basis. Elderly individuals, in particular those who are not in a persistent vegetative state, are significantly underrepresented.

Aged↗
PubMed1988

Hyperthyroid chorea in an elderly woman associated with sole elevation of T3.

A 72-year-old woman presented with chorea, mild tachycardia, and elevation of T3RIA. T4 was not elevated until the third determination. Chorea resolved with treatment of hyperthyroidism. This case represents the first case of T3 hyperthyroid chorea and the oldest patient with hyperthyroid chorea described in the literature. It demonstrates yet another subtle way in which thyroid disease can present in the elderly.

Aged↗