Biomedical subjects
Publications and source records attributed to L C Hanson.
A team of caregivers provides health care in nursing homes. This team is led by a nurse and includes a physician, nursing assistants, and other nursing home staff. Given the future demand for palliative care in this setting, the roles of all caregivers need to be supported with meaningful training, improved working conditions, and respect for each caregiver's contribution.
OBJECTIVE: To determine if family members perceive that hospice improves the care of dying nursing home residents during the last 3 months of life. DESIGN: Mailed survey. PARTICIPANTS: Family members for all nursing home hospice enrollees in North Carolina during a 6-month period. MEASUREMENTS: After residents' deaths, family members answered questions about the quality of care for symptoms before and after hospice, the added value of hospice, the effect of hospice on hospitalization, and special services provided by nursing home staff or by hospice staff. RESULTS: A total of 292 (73%) of 398 eligible family members completed surveys. The average age of the nursing home residents who had received hospice was 79.5 years; 50% had cancer and 76% were dependent for self-care. In their last 3 months, 70% of decedents had severe or moderate pain, 56% had severe or moderate dyspnea, and 61% had other symptoms. Quality of care for physical symptoms was rated good or excellent by 64% of family before hospice and 93% after hospice (P<.001). Dying residents' emotional needs included care for moderate or severe depression (47%), anxiety (50%), and loneliness (35%). Quality of care for emotional needs was rated good or excellent by 64% of family before hospice and 90% after hospice (P<.001). Fifty-three percent of respondents believed hospice prevented hospitalizations. Family estimated the median added value of hospice to be $75 per day and described distinct special services provided by hospice and by nursing home staff. CONCLUSIONS: Family members believe that nursing home hospice improves quality of care for symptoms, reduces hospitalizations, and adds value and services for dying nursing home residents.
BACKGROUND: Most dying patients are treated by physicians in community practice, yet studies of terminal care rarely include these physicians. OBJECTIVE: To examine the frequency of life-sustaining treatment use and describe what factors influence physicians' treatment decisions in community-based practices. METHODS: Family members and treating physicians for decedents 65 years and older who died of cancer, congestive heart failure, chronic lung disease, cirrhosis, or stroke completed interviews about end-of-life care in community settings. RESULTS: Eighty percent of eligible family and 68.8% of eligible physicians participated (N = 165). Most physicians were trained in primary care and 85.4% were primary care physicians for the decedents. Physicians typically knew the decedent a year or more (68.9%), and 93.3% treated them for at least 1 month before death. In their last month of life, 2.4% of decedents received cardiopulmonary resuscitation, 5.5% received ventilatory support, and 34.1% received hospice care. Family recalled a discussion of treatment options in 78.2% of deaths. Most discussions (72.1%) took place a month or more before death. Place of death, cancer, and having a living will were independent predictors of less aggressive treatment before death. Physicians believed that advanced planning and good relationships were the major determinants of good decision making. CONCLUSIONS: Community physicians use few life-sustaining treatments for dying patients. Treatment decisions are made in the context of long-term primary care relationships, and living wills influence treatment decisions. The choice to remain in community settings with a familiar physician may influence the dying experience.
PURPOSE: To review clinical interventions designed to change care at the end of life. DATA SOURCES: Published results of clinical trials identified by MEDLINE searches, review of abstracts from meetings, and selected bibliographies. STUDY SELECTION: Studies were included if data were presented on a clinical intervention designed to change medical care at the end of life. Studies done in nonclinical settings or outside the United States were excluded. DATA EXTRACTION: Interventions were classified as targeting patients, physicians, or both and were analyzed by their effect on four common clinical goals: increasing use of patient preferences, decreasing pain and suffering, reducing use of life-sustaining treatments, and reducing costs. Positive and negative trial results were compared for differences in intervention, target group, and strength of study methods. DATA SYNTHESIS: Educational interventions usually increased expression of patient treatment preferences. Success rates were higher when more severely ill patients were targeted and when written materials were combined with repeated discussions in clinical encounters. Educational interventions with physicians led to increased use of patient preferences, but sophisticated educational techniques were needed to motivate physicians to change their behavior. Three studies provided limited evidence that physician education reduced the use of life-sustaining treatments. No clinical intervention had an effect on pain, suffering, or cost of medical care. CONCLUSION: To change care at the end of life, intensive educational interventions for physicians and broad institutional programs seem more promising than advance directives. Future innovations should seek to change physician practices, reduce costs, and improve patient-centered outcomes, such as pain control and satisfaction.
OBJECTIVE: To describe family perceptions of care at the end of life. METHODS: In a representative sample of older people who died from chronic diseases, family members were interviewed about satisfaction with treatment intensity, decision-making, and symptom relief in the last month of life, and gave suggestions to improve care. RESULTS: Interviews were completed with 461 family members, 80% of those contacted. They reported that 9% of decedents received CPR, 11% ventilator support, and 24% intensive care during their last month of life. Family members could not recall a discussion of treatment decisions in 23% of cases. Presence or absence of a living will did not affect the likelihood of no discussion (22% vs 24%, P = .85). Family informants desired more treatment to sustain life in 8% of deaths. They or the decedent wanted treatments doctors did not recommend in 6% of deaths but refused recommended therapies in 18% of deaths. They believed more care to relieve pain or other symptoms was indicated in 18% of deaths. Asked to make positive or negative comments about any aspect of terminal care, 91% of comments on hospice were positive. Nursing home care received the smallest proportion of positive comments (51%). Family members recommendations to improve end of life care emphasized better communication (44%), greater access to physicians' time (17%), and better pain management (10%). CONCLUSION: Bereaved family members are generally satisfied with life-sustaining treatment decisions. Their primary concerns are failures in communication and pain control. Discussions that focus on specific treatment decisions may not satisfy the real needs of dying patients and their families.
BACKGROUND: Knowing more about who uses living wills may help explain their limited acceptance. METHODS: We analyzed the 1986 National Mortality Followback Survey, a random sample of all US deaths linked to a survey about decedents' use of living wills, their social and health status, and their use of medical services. Decedents with and without living wills were compared for differences in social and health characteristics and use of medical services. RESULTS: There were 16,678 decedents; 9.8% had a living will. Rates of use were higher for decedents who were white (10.7%), were female (11.0%), had private insurance (13.8%), had incomes of $22,000 or more (14.5%), or had college educations (18.7%). The use of living wills was lower among blacks (2.7%), Medicaid recipients (6.3%), those with incomes of less than $5,000 (7.5%), or those with less than 8 years of education (4.0%). Health was also related to use of living wills. Functionally independent persons were unlikely to have a living will (5.5%); use increased with dependency. Cognitive impairment made it less likely that a decedent had a living will (6.7%). Persons who died of cancer (16.4%) or pulmonary disease (11.4%) were more likely to have one. All demographic and health characteristics remained significant in multivariate analyses. Controlling for health status, decedents with living wills used more physician visits (five to nine vs two to four, P < .001) and hospital days (37 vs 30, P < .001). Although more likely to use hospices (19.5% vs 8.4%, P < .001) and half as likely to receive cardiopulmonary resuscitation or ventilatory support, they were still 20% more likely to die in the hospital. CONCLUSIONS: Patients who are black, poorly educated, underinsured, or cognitively impaired are least likely to prepare a living will. Decedents with living wills forgo specific treatments, but remain intensive users of routine medical services.
BACKGROUND: Physician specialty training is associated with variations in the use of medical treatment for specific diseases. OBJECTIVE: To examine whether physicians' specialties predict differences in willingness to use life-sustaining treatments. METHODS: One hundred fifty-eight physicians (response rate, 85%) who cared for 378 hospitalized patients with end-stage congestive heart failure, chronic obstructive pulmonary disease, malignant neoplasms, or hepatic cirrhosis were interviewed to assess their thresholds for use of specific life-sustaining treatments. Their patients were then followed up to determine whether decisions were made to use or withhold cardiopulmonary resuscitation, ventilator support, or intensive care. Physicians' attitudes, their stated thresholds for treatment use, and their use of these treatments in daily practice were compared by specialty group. RESULTS: Physicians recommended cardiopulmonary resuscitation and ventilator support for patients with end-stage congestive heart failure or chronic obstructive pulmonary disease if the chance for survival was at lease 48%, but they required a predicted survival of at least 74% for patients with cancer. For a patient with end-stage congestive heart failure or chronic obstructive pulmonary disease, cardiologists were consistently more willing than other physicians to use life-sustaining treatments. In practice, decisions to use or withhold such treatments were made for 151 patients with end-stage diseases. Compared with other physicians, cardiologists were least likely to issue orders to withhold treatment and most likely to use life-sustaining treatments for patients they treated. Oncologists rarely used such treatments and issued orders to withhold these treatments much more often. CONCLUSION: Physician specialty is associated with differences in willingness to use, and in actual use of, life-sustaining treatments.
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The purpose of the study was to examine risk factors for nosocomial pneumonia in the surgical and medical/respiratory intensive care unit (ICU) populations. In a public teaching hospital, all cases of nosocomial pneumonia in the surgical and medical/respiratory ICUs (n = 20, respectively) were identified by prospective surveillance during a 5-yr period from 1987-1991. Each group of ICU cases was compared with 40 ICU control patients who did not acquire pneumonia, and analyzed for 25 potential risk factors. Surgical ICU patients were found to have consistently higher rates of nosocomial pneumonia than medical ICU patients (RR = 2.2). The strongest predictor for nosocomial pneumonia in both the surgical and medical/respiratory ICU groups was found to be prolonged mechanical ventilation (> 1 d) resulting in a 12-fold increase in risk over nonventilated patients. APACHE III score was found to be predictive of nosocomial pneumonia in the surgical ICU population, but not in the medical/respiratory ICU population. We conclude that certain groups deserve special attention for infection control intervention. Surgical ICU patients with high APACHE scores and receiving prolonged mechanical ventilation may be at the greatest risk of acquiring nosocomial pneumonia of all hospitalized patients.
Mitochondrial intermediate peptidase (MIP) is a component of the mitochondrial protein import machinery required for maturation of nuclear-encoded precursor proteins targeted to the mitochondrial matrix or inner membrane. We previously characterized this enzyme in rat (RMIP) and Saccharomyces cerevisiae (YMIP) and showed that MIP activity is essential for mitochondrial function in yeast. We have now defined the structure of a new MIP homologue (SMIP) from the basidiomycete fungus Schizophyllum commune. SMIP includes 4 exons of 523, 486, 660, and 629 bp separated by 3 short introns. The predicted SMIP, YMIP, and RMIP sequences share 31-37% identity and 54-57% similarity over 700 amino acids. When SMIP and RMIP were expressed in a yeast mip1 delta mutant, they were both able to rescue the respiratory-deficient phenotype caused by genetic inactivation of YMIP, indicating that the function of this enzyme is conserved in eukaryotes. Moreover, the MIP sequences show 20-24% identity and 40-47% similarity to a family of oligopeptidases from bacteria, yeast, and mammals. MIP and these proteins are characterized by a highly conserved motif, F-H-E-X-G-H-(X)2-H-(X)12-G-(X)5-D-(X)2-E-X-P-S-(X)3-E-X, centered around a zinc-binding site and appear to represent a new family of genes associated with proteolytic processing in the mitochondrial and cytosolic compartments.
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PURPOSE: To study the relationship of patient incompetence to decisions to withhold life-sustaining treatments. DESIGN AND PATIENTS: This prospective cohort study consisted of 311 inpatients with end-stage congestive heart failure, chronic obstructive pulmonary disease, cancer, and cirrhosis. METHODS: Daily assessments were used to classify patients as incompetent if they had depressed consciousness, major psychiatric disease, or cognitive impairment throughout their hospital stay. Treatment decisions were assessed by observation and medical record review. RESULTS: Forty-eight (15%) patients were incompetent: 33 had depressed consciousness, 11 failed cognitive screens, and 4 had major psychoses. Incompetent patients were more severely ill (APACHE II score 14.9 versus 12.6, P < or = 0.05) and more commonly had cancer (73% versus 44%, P < or = 0.05). Decisions were made to withhold cardiopulmonary resuscitation (CPR) for 71% of incompetent patients, but for only 21% of competent patients (P < or = 0.001). Decisions to withhold other treatments were also more common for incompetent patients (42% versus 16%, P < or = 0.001). After controlling for differences in severity of illness, diagnosis, race, and insurance status, patient incompetence remained strongly associated with a decision to withhold CPR (odds ratio 4.0, 95% confidence interval 1.8 to 8.9) and with decisions to withhold other treatments (odds ratio 2.4, 95% confidence interval 1.1 to 5.3). Decisions for incompetent patients were made by physicians with family surrogates 79% of the time. No decision was based on a written advanced directive. Patient preference was the rationale for 41% of decisions to withhold CPR from incompetent patients. Major conflict occurred in only 1% of all cases where a decision was made to withhold treatment. CONCLUSIONS: Despite current legal and ethical debate, incompetent patients are far more likely than competent patients to have life-sustaining treatment withheld. Most decisions are made by a consensus of physicians and family surrogates, and major conflicts rarely occur.
The infection status of 91 infants born to mothers with human immunodeficiency virus (HIV) infection was determined. Twenty-eight (31%) infants had confirmed HIV infection and 63 (69%) had seroreverted to HIV and lack evidence of infection. During the first 6 months of life HIV culture had a sensitivity and specificity for diagnosis of HIV infection of 80 and 100%, respectively. False negative HIV cultures were observed in only 7 of 35 specimens, 6 from among the 12 infected infants tested at birth. The sensitivity and specificity of polymerase chain reaction (PCR) detection of HIV were 95 and 93% respectively. A single false negative PCR test result was observed among the 19 tests performed on specimens from HIV-infected infants. False positive PCR test results were observed occasionally throughout the first 6 months of life. Detection of HIV-specific IgA antibody lacked diagnostic sensitivity; positive test results were observed in only 53% of specimens obtained from infected infants. Culture and PCR detection offer excellent sensitivity and specificity for diagnosis of HIV infection during the first 6 months of life; however, false-negative HIV cultures sometimes are observed, particularly during the newborn period, and either false negative or false positive PCR test results may be noted occasionally. For purposes of clinical decision-making, any positive test result should be confirmed with a second HIV culture or PCR test performed on a separate blood specimen.
OBJECTIVE: To identify predictors of 6-month mortality known before emergent admission to intensive care (IC) and to describe obstacles to the use of patient preferences in emergency triage decisions. DESIGN: Historical cohort. SETTING: A 600-bed university hospital. PATIENTS: 263 consecutive patients triaged in the emergency room to receive intensive care. MEASUREMENTS AND MAIN RESULTS: Medical records were abstracted for age, performance status, and chronic disease severity as predictors of 6-month survival. Acute Physiology Score (APS) in the emergency room was used as a measure of acute illness severity. Deaths during the 6 months following IC admission were determined from record review and death certificate data. Obstacles to communication of patient treatment preferences at the time of triage were described. Six-month mortality was 19 percent, and increased with increasing APS, age > or = 80 (43%), poor performance status (56%), and severe chronic disease (33%) (P < or = 0.01). In multivariate analysis, APS, age > or = 80 and performance status were independent predictors of 6-month mortality. Only APS predicted mortality in hospital. The most common obstacles to use of patient preferences in triage decisions were absence of documented advance directives (95%) and the brief duration of acute illness (72%). Mental status changes were very common in the emergency room for nonsurvivors (61%), but chronic cognitive impairment was rare (3%). CONCLUSIONS: Patients with poor performance status or very advanced age have increased mortality within 6 months of emergent triage to IC. Mental status changes, absence of advance directives, and time constraints are common barriers to communication of patient preferences at the time of triage. Primary care physicians need to elicit and record patients' preferences before the time of emergent decisions about IC.
PURPOSE: Elderly patients have a disproportionate incidence of nosocomial pneumonia (NP) and a higher mortality rate, yet few studies have focused on this high-risk population. We undertook a study to examine risk factors for NP in elderly inpatients and to describe how these patients differ from younger patients with NP. METHODS: In a public teaching hospital, all cases of NP in patients aged 65+ were ascertained by prospective surveillance during a 2-year period (n = 59). These elderly cases were compared with 59 cases of NP in patients aged 25 to 50 to describe differences in risk factors and outcomes. Elderly cases were then matched to elderly control subjects who were admitted to the same hospital service but did not develop NP. Data were collected on known risk factors and on the potential risk factors of poor nutrition, neuromuscular disease, and dementia. Significant differences in risk factors were analyzed using univariate and multivariate comparisons of cases and controls. RESULTS: Elderly patients had twice the incidence of NP (RR = 2.1) as younger patients. Onset of infection was earlier for young than for older cases (6 versus 11 days, p less than or equal to 0.02), but mortality following NP was equal for the two age groups (42% versus 44%). No significant differences in risk factors were found for old and young cases, although older cases tended to have higher rates of poor nutrition, neuromuscular disease, and aspiration preceding their pneumonias. Comparison of elderly cases and elderly controls revealed significantly increased frequencies of poor nutrition, neuromuscular disease, pharyngeal colonization, aspiration, depressed level of alertness, intubation, intensive care unit admission, nasogastric tube use, and antacid use among cases. Cases were more severely ill on admission and had more pre-existing risk factors (2.8 versus 1.3, p less than or equal to 0.001) and more in-hospital risk factors (4.7 versus 1.6, p less than or equal to 0.001). Logistic regression analysis revealed low albumin, diagnosis of neuromuscular disease, and tracheal intubation to be strong independent predictors of risk for NP among elderly inpatients. CONCLUSIONS: We conclude that the specific risk factors of poor nutrition, neuromuscular disease, and tracheal intubation may prove useful to target future clinical interventions to prevent NP in the elderly.
Advanced age has been proposed as one criterion for limiting the use of life-sustaining medical treatment, but very little is known about current practices. We retrospectively studied utilization rates of intensive care (IC) and cardiopulmonary resuscitation (CPR) in admissions to a university hospital over 1 year (n = 9,998), to test whether these treatments are used more selectively for elderly patients. Overall utilization rates did not vary by age. However, among 524 terminal admissions, IC was used for 63% of patients age 35-74 but for only 50% of patients 75 and older (P less than 0.01). Among elderly patients, nursing home residence, diagnosis of advanced malignancy, severe chronic illness, and older age were independent predictors of withholding IC prior to death. Despite more selective use, survival rates were lower for elderly than for younger patients receiving IC (88% vs 78%, P less than 0.001). CPR showed similar but non-significant trends. Intensive care is being used less frequently prior to death for elderly patients, based on diagnosis and functional status as well as chronologic age.
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