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Biomedical subjects

L L Emanuel

Publications and source records attributed to L L Emanuel.

At least 19 recordsLinked to original sources
PubMed1997

Can goals of care be used to predict intervention preferences in an advance directive?

BACKGROUND: Some have suggested that advance directives elicit goals of care from patients, instead of or in addition to specific intervention preferences, but little is known about whether goals of care can be used in a meaningful way on documents or whether they can predict preferences for specific interventions. METHODS: Attending physicians (n = 716) at the Massachusetts General Hospital in Boston were surveyed to elicit general goals of care (eg, treat everything or comfort measures only) along with specific preferences for 11 medical, interventions in 6 scenarios. In each scenario, each goal was classified as an adequate predictor of acceptance or rejection of an intervention if its predictive value of the preference for that intervention was at least 80%. RESULTS: Goals varied with scenarios (P < .001) in a predictable manner. The goal treat everything was an adequate predictor of acceptance of each intervention, and comfort was an adequate predictor of rejection for nearly every intervention. Attempt cure adequately predicted acceptance of almost every nonaggressive intervention, but did not predict acceptance of aggressive interventions. Quality of life predicted rejection of aggressive interventions in 3 scenarios, but was not useful in other cases. When goals were predictors of preferences, the mean range of 95% confidence intervals for their predictive values was generally 20% or less. CONCLUSIONS: Goals have a valid role in advance directives, since the goal choices had a logical relationship to scenarios and intervention choices. However, the 2 goals attempt cure and choose quality of life were not predictive in many instances. If these findings hold true for more general populations of patients, then advance directive documents will need to rely on more than these general goal statements if they are to adequately represent patient preferences.

Acute Disease↗
PubMed1997

Preserving community in health care.

There are two prominent trends in health care today: first, increasing demands for accountabilty, and second, increasing provision of care through managed care organizations. These trends promote the question: What form of account-ability is appropriate to managed care plans? Accountability is the process by which a party justifies its actions and policies. Components of accountability include parties that can be held or hold others accountable, domains and content areas being assessed, and procedures of assessment. Traditionally, the professional model of accountability has operated in medical care. In this model, physicians establish the standards of accountability and hold each other accountable through professional organizations. This form of accountability seems outdated and inapplicable to managed care plans. The alternatives are the economic and the political models of accountability. In the economic model, medicine becomes more like a commodity, and "exit" (consumers changing providers for reasons of cost and quality) is the dominant procedure of accountability. In the political model, medicine becomes more like a community good, and "voice" (citizens communicating their views in public forums or on policy committees, or in elections for representatives) is the dominant procedure of accountability. The economic model's advantages affirm American individualism, make minimal demands on consumers, and use a powerful incentive, money. Its disadvantages undermine health care as a nonmarket good, undermine individual autonomy, undermine good medical practice, impose significant demands on consumers to be informed, sustain differentials of power, and use indirect procedures of accountability. The political model's advantages affirm health care as a matter of justice, permit selecting domains other than price and quality for accountability, reinforce good medical practice, and equalize power between patients and physicians. Its disadvantages include inefficiency in decision making, capture by extremists or experts, intractable value conflicts, fragmentation of community, and oppression of minorities. The political model is the model we should endorse. Its disadvantages can be minimized by proper institutional design. In addition, recent research on managed care plans suggests that the political model may be the best for a competitive marketplace because it can ensure that tough allocation decisions are addressed and improve health through changes in nonmedical aspects of community life.

Advisory Committees↗
PubMed1996

What is accountability in health care?

Accountability has become a major issue in health care. Accountability entails the procedures and processes by which one party justifies and takes responsibility for its activities. The concept of accountability contains three essential components: 1) the loci of accountability--health care consists of at least 11 different parties that can be held accountable or hold others accountable; 2) the domains of accountability--in health care, parties can be held accountable for as many as six activities: professional competence, legal and ethical conduct, financial performance, adequacy of access, public health promotion, and community benefit; and 3) the procedures of accountability, including formal and informal procedures for evaluating compliance with domains and for disseminating the evaluation and responses by the accountable parties. Different models of accountability stress different domains, evaluative criteria, loci, and procedures. We characterize and compare three dominant models of accountability: 1) the professional model, in which the individual physician and patient participate in shared decision making and physicians are held accountable to professional colleagues and to patients; 2) the economic model, in which the market is brought to bear in health care and accountability is mediated through consumer choice of providers; and 3) the political model, in which physicians and patients interact as citizen-members within a community and in which physicians are accountable to a governing board elected from the members of the community, such as the board of a managed care plan. We argue that no single model of accountability is appropriate to health care. Instead, we advocate a stratified model of accountability in which the professional model guides the physician-patient relationship, the political model operates within managed care plans and other integrated health delivery networks, and the economic and political models operate in the relations between managed care plans and other groups such as employers, government, and professional associations.

Delivery of Health Care, Integrated↗
PubMed1996

A professional response to demands for accountability: practical recommendations regarding ethical aspects of patient care. Working Group on Accountability.

Forceful new demands for accountability in medicine are arising from many interested parties. To maintain professional standards, physicians need to establish which demands are desirable and which are not. We adopt a model of stratified accountability that includes three major components: the accountable parties, the subject matter, and the processes for accountability. To begin describing the model, we focus on physicians and health care institutions. We focus on the ethical dimensions of medical practice, both because the difficulty of measuring such behaviors makes this a test case for accountability and because of the importance of ethical standards in maintaining patient trust. We first identify eight widely endorsed content areas for accountability in ethical conduct: medical decision making, confidentiality, fiduciary obligations (including conflicts of interest), responsibilities arising from patient vulnerability, personal standards, equity among patients, cultural representation, and procedures for resolving dilemmas. We then identify the currently most valid and reliable methods for assessing conduct: surveys among all involved parties, testing methods used for accreditation, limited audits, publication of policy, and careful use of report cards. A prototypical survey and report card are illustrated. However, we also note the need for improved accountability assessment methods. We next identify mechanisms for taking responsibility: sharing information, exchanging perspectives, making adjustments, and enforcing standards when necessary. Finally, because this report only begins to describe a small part of the accountability model, we urge explicit identification and development of professional standards for accountability in the many other areas of medicine.

Clinical Competence↗
PubMed1995

Advance directives: do they work?

Advance directives have been widely endorsed, and empiric work has taken place that can aid clinicians in the appropriate use of validated documents. This report reviews philosophic and methodologic issues and offers practical illustrations. Despite the evidence that advance directives can work, there are serious barriers to their actual use. Therefore, these barriers are evaluated and potential solutions suggested.

Advance Directive Adherence↗
PubMed1994

Advance directives. Stability of patients' treatment choices.

BACKGROUND: Advance directives are intended to extend patient autonomy into periods of mental incompetence. However, for advance directives to fulfill this objective, patients' choices must be reasonably consistent over time. Thus, we assessed the stability of the advance treatment decisions of patients and members of the public. METHODS: In a prospective cohort study of 495 outpatients and 102 members of the public, we studied the stability of scenario- and treatment-specific choices. Subjects completed an advance directive, which included four illness scenarios with 11 treatment choices in each, as part of a questionnaire. A second interview was completed by 296 patients and 78 members of the public after 6 to 12 months; 154 patients completed a third interview after a further 6 to 12 months. We assessed stability by comparing each choice between interviews. RESULTS: Stability of choices was moderately high among patients (pooled kappa = 0.39) and members of the public (pooled kappa = 0.48). Stability improved with repeat interview (pooled kappa = 0.47 among patients). Patients who had discussions with their physicians showed more improvement (kappa = 0.57) than others. Patients had a wide range of personal stability levels (0% to 100%), but individuals starting out stable rarely became less so (93% of the patients with 85% to 100% stability maintained this level of stability on the third interview). Hospitalized patients showed no significant difference in stability at the second interview, but their stability was not improved at the third interview. CONCLUSIONS: Our findings generally support the use of advance directives. Most people made moderately stable decisions when using scenario- and treatment-specific directives, and stability improved after they reviewed the decisions, especially among those who had discussions with their physicians. Recent hospitalization did not decrease stability, although it appeared to reduce the improvement that others achieved with repeat interview. These findings suggest that advance directives can be relied on 1 to 2 years after completion to reflect a patient's choices.

Adult↗
PubMed1994

Advance directives: can patients' stated treatment choices be used to infer unstated choices?

Advance directives have been widely endorsed as a method to match medical interventions to patients' preferences. However, applying advance directives to unspecified future decisions may be problematic. We wondered how well scenario-based treatment choices in advance directives can be used to infer other choices specified by the same patients. We asked 495 out-patients from the Massachusetts General Hospital to state 11 treatment choices in each of four illness scenarios. We calculated likelihood ratios (LRs) to see how well one choice could predict another. Predictions within a given scenario were strong and followed a pattern that reflected the invasiveness of the treatment. Thus, decline of antibiotics predicted decline of major surgery, in the same scenario (LR 36.0-108.3). Requests for major surgery strongly predicted requests for antibiotics (LR 90.4-244.1). Requests for major surgery and decline of antibiotics were the two most predictive preferences; more traditionally considered decisions about cardiopulmonary resuscitation and mechanical ventilation ranged from the third to ninth most predictive among the 11 interventions. Predictions between scenarios were weaker, but still potentially useful, and followed a pattern that reflected the prognoses of the scenarios. Declining treatment in the best prognosis scenario (coma-with-a-chance) predicted declining the same treatment in other scenarios with LRs of 2.5-6.1. Requests for treatment in the worst prognosis scenario (dementia-with-terminal-illness) predicted the same request in the other scenarios with LRs of 5.2-30.5. These data suggest that patients' advance scenario-based treatment choices can provide potentially useful information to apply to unspecified decisions if inferences follow considerations of prognosis and treatment invasiveness. For maximal predictive power, treatment directives should use a range of illness scenarios and include choices, among several others, on antibiotic use and major surgery.

Adult↗
PubMed1993

How well is the Patient Self-Determination Act working?: an early assessment.

OBJECTIVES: To assess the association between implementation of the Patient Self-Determination Act (PSDA) and (1) the use of formal, written advance directives, (2) the use of informal advance care arrangements, and (3) discussions between patients and their physicians and proxies an advance care planning and end-of-life treatment preferences. DESIGN: A time-sequence study in which patients discharged from acute care hospitals 1 month before the implementation of the PSDA and 5 months after implementation of the PSDA were interviewed. SETTING: Two medical school-affiliated, major teaching hospitals with more than 500 beds and 3 nonteaching community hospitals with fewer than 400 beds in eastern Massachusetts. PATIENTS: A total of 579 adult patients were interviewed: 258 patients discharged before the implementation of the PSDA (pre-PSDA) and 321 patients discharged 5 months after implementation of the PSDA (post-PSDA). MEASUREMENTS: Patients were asked about their formal, written or informal advance care planning arrangements, about the frequency of inquiries and information provided on advance care planning by the hospitals, and about their discussions of advance care planning and end-of-life treatment preferences with physicians and their proxies. RESULTS: In the pre-PSDA cohort, 60.9% of the patients had some kind of advance care planning, whereas in the post-PSDA cohort, 72.6% did (p = 0.01). However, there was not a significant increase in the proportion of patients who had advance care planning "in a written document" (19.8% of the pre-PSDA cohort compared with 25.5% of the post-PSDA cohort, p = 0.11). The increase in written advance care planning was concentrated in the community, nonteaching hospitals (10.7% pre-PSDA versus 23.7% post-PSDA). Overall, 41.4% of patients recalled inquiries or information about advance care planning during their hospitalization. Implementation of the PSDA was not associated with a significant change in the proportion of patients who discussed advance care planning or end-of-life issues with their physicians (13.6% pre-PSDA versus 17.1% post-PSDA, p = 0.25). However, there was an increase in the proportion of patients with poorer health who spoke with their physicians (15.4% pre-PSDA versus 24.8% post-PSDA). Implementation of the PSDA was associated with an increase in the proportion of patients who had general discussions with proxies about end-of-life issues (61.8% pre-PSDA versus 73.0% post-PSDA, p = 0.024). However, 33.6% of pre-PSDA and 33.2% of post-PSDA patients had detailed discussions with their proxy about specific interventions such as mechanical ventilation or artificial nutrition. Patients with formal proxies had detailed discussions significantly more frequently than other patients (50.0% versus 26.8%, p < 0.0001). CONCLUSIONS: The PSDA was associated with significant effects on general advance care planning issues, increasing the proportion of patients who had (1) some kind of advance care arrangements and (2) general discussions of end-of-life issues with their proxies. However, the PSDA did not appear associated with significant increases (1) in the use of formal, written advance care documents, (2) in the frequency of discussions between patients and their physicians on advance care documents or end-of-life issues, or (3) in the frequency of discussions about specific treatment preferences between patients and their proxies.

Adolescent↗
PubMed1992

Advance directives.

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Advance Directives↗