Despite considerable progress in advance directives research, it is time to review the research critically and ask potentially uncomfortable questions. For example, What criteria do we use to decide which questions to research? Do we need to conduct more basic research about preference formulation and decisionmaking to ensure further progress? How should the research to date inform future projects? Much of the research pertaining to advance directives has not been very helpful in developing and promoting effective and clinically applicable advance care planning. Several problems may account for this: 1. The research methods often determine the research questions and limit their significance. 2. The research questions and the significance of the results are often constrained by the time frame (frequently geared to the convenience of a fellowship) and sampling of study participants. 3. The research often lacks the insights and sensitivity gained by having an interdisciplinary team of investigators. 4. The research often ignores the central questions about valid representation and communication of patient values, attitudes, and preferences into future circumstances of mental incapacity. 5. Competition for research monies and the logistical difficulties of maintaining effective communication among investigators in different parts of the country inhibit collaboration and efficient pursuit of an organized and orderly research agenda. Purpose of Advance Directives Advance directives were promoted initially to: (1) extend the right of self-determination in health care decisionmaking enjoyed by competent patients to people who become mentally incapacitated; (2) approximate the goal of shared and informed decisionmaking even when mentally incapacitated; and (3) help patients and proxy decisionmakers (speaking on behalf of mentally incapacitated patients) avoid unwanted and non-beneficial death-prolonging treatment or physical states considered to be without dignity.[1] To evaluate whether directives acccomplish these objectives is a area for first-order research. The primary outcomes for this basic research would focus on questions such as, Do instructional advance directives enable mentally incapacitated patients to receive or forgo treatment to the same degree as competent patients? Do proxy advance directives ensure proxy participation in decision-making to a degree that is comparable to that of competent patients? A full evaluation of these outcomes would require a critical examination of the natural history of preference formulation and communication, and ultimate decisionmaking. Important questions include@ Do advance care forms and discussions provide sufficient information for valid representation of preferences? Does the written record communicate meaningful preferences that are applicable to future clinical situations? and, Does availability of advance directives inhibit communication with patients before the onset of mental incapacity? These questions seem more germane than questions about the effects of advance directives on perceived satisfaction with care and health care costs, or clinicians, adherence to the preferences expressed in advance directives. There is also the need to ascertain whether the original objectives for advance directives match the desires of the individuals they were intended to benefit Many patients desire advance directives to ward off untoward outcomes of medical technology. With these individuals it may be desirable simply to elicit general goals of care under certain circumstances. Other patients may want to provide more detailed information, such as treatment preferences. Still others may find both of these alternatives to be too complicated, preferring to designate a proxy decisionmaker. One central question is whether the underlying structure of advance directives matches a particular patient's preferred method of representation. …
This paper analyzes the phenomenon of suffering and its relationship to medical practice by focusing on the paradigmatic work of Eric Cassell. First, it explains Cassell's influential model of suffering. Second, it surveys various critiques of Cassell. Next it outlines the authors' concerns with Cassell's model: it is aggressive, obscure, and fails to capture important features of the suffering experience. Finally, the authors propose a conceptual framework to help clarify the distinctive nature of subjective patient suffering. This framework contains two necessary conditions: (1) a loss of a person's sense of self, and (2) a negative affective experience. The authors suggest how this framework can be used in the medical encounter to promote clinician-patient communication and the relief of suffering.
OBJECTIVES: Patient involvement in decision‐making has been advocated to improve the quality of life at the end of life. Although the size of the oldest segment of the population is growing, with greater numbers of older adults facing the end of life, little is known about their preferences for the end of life. This study aimed to explore the attitudes of older adults with medical illness about the end of life, and to investigate whether current values could be extended to end‐of‐life preferences. DESIGN: Descriptive study with interviews using open‐ and closed‐ended questions. SETTING: Patients attending two university‐affiliated geriatric clinics were interviewed in a private conference room near the clinic they attended or in their homes. PARTICIPANTS: Sixteen older men and women identified by their physicians as having nonterminal heart disease or cancer. MEASUREMENTS: The interview contained open‐ended questions such as: “What are the most important things in your life right now?” and “What would you consider a good/bad death?” The interview also contained closed‐ended questions about symptoms, quality of life, and health status. Additional questions elicited preferences for the end of life, such as location of death and the presence of others. The open‐ended questions were tape‐recorded, transcribed, and analyzed using qualitative methods. The closed‐ended questions were analyzed using descriptive statistics. RESULTS: Patients with heart disease and cancer provided similar responses. Participants' views about good deaths, bad deaths, and end‐of‐life scenarios were heterogeneous. Each participant voiced a unique combination of themes in describing good and bad deaths. Because each participant described a multifaceted view of a good death, for instance, no theme was mentioned by even half of the participants. Participants provided differing explanations for why given themes contributed to good deaths. Currently valued aspects of life were not easily translated into end‐of‐life preferences. For example, although the majority of participants identified their family as being important, many gave reasons why they did not want their family members present when they died. CONCLUSIONS: Because of the heterogeneity of views and the difficulty in inferring end‐of‐life preferences from current values, older adults should be asked not only questions about general values, but also specific questions about their end‐of‐life choices and the reasons for these choices. A thorough understanding of an individual's end‐of‐life preferences may help health professionals working with older adults develop patient‐centered care plans for the end of life.
OBJECTIVES: To determine the relationship between leptin and unintentional weight loss in older adults. DESIGN: Prospective cohort study over 2 years. SETTING: University‐affiliated Veterans Affairs Medical Center. PARTICIPANTS: The subjects were 105 community‐dwelling male veterans aged 65 and older who had participated in a prospective cohort study on nutrition and health conducted at the Veterans Affairs Puget Sound Health Care System from 1986 to 1989. MEASUREMENTS: Anthropometric data and fasting blood specimens were collected at baseline and annually for the subsequent 2 years. Stored blood specimens were analyzed for leptin, insulin, glucose, C‐reactive protein, sex hormone binding globulin, and testosterone levels. RESULTS: Over 2 years, 75 men were weight stable (weight loss <4% of baseline) and 30 men had unintentional weight loss (weight loss>4% of baseline). The baseline body mass index (BMI) and leptin levels for the two groups were not statistically different. Positive correlations existed between leptin level and BMI at each time point for weight‐stable and weight‐loss subjects. Furthermore, a significant relationship existed between changes in leptin and changes in BMI over 1 year in multiple regression analysis ( r = .436, P < .001 after the first year; and r = .630, P = .027 after the second year). CONCLUSIONS: Like in younger adults, plasma leptin levels remained proportional to BMI, and changes in BMI were accurately reflected by changes in leptin levels in older individuals. Fasting leptin levels did not predict involuntary weight loss over 2 years of follow‐up.
This article reports on a project to identify and describe systematically problems encountered in providing health care to elderly veterans. A modified Delphi approach was used to survey a wide range of health professionals. A typology of problems was developed in Stage 1 of the Delphi. Problems represented by the typology were then rated by importance in Stage 2. Analysis of Stage 2 data indicates that the typology is conceptually sound. As such, it is a useful tool for describing problems and guiding future research.
...I would suggest that the major objectives of studying the Hippocratic Oath or other pertinent oaths and codes are fourfold. First, studying oaths and codes pertaining to medical conduct and standards enables students to learn about historical changes and cultural influences. Second, choosing an oath or developing one for recitation at graduation enables students to engage in conceptual and moral reasoning. Third, the deliberations and discussions involving students enable them to practice interactional, communication skills about highly charged issues. Fourth, the identified limitations of the Hippocratic Oath or other pertinent oaths and codes enable students to appreciate the value of the broader principles that support medical ethics... The remainder of this commentary is divided into two parts. In the first part, recommendations for an educational program are presented. In the second part, recommendations for future research in this area are offered.
OBJECTIVES : To describe the incidence, anthropometric parameters, and clinical significance of weight loss in older outpatients. DESIGN : Four‐year prospective cohort study. SETTING : University‐affiliated Veterans Affairs Medical Center. PATIENTS : Two hundred forty‐seven community‐dwelling male veterans 65 years of age or older. MEASUREMENTS : Anthropometrics (weight, height, skinfolds, and circumferences), health status measures (Sickness Impact Profile scores, health care utilization, self‐reported ratings of health), and bloodwork (cholesterol, albumin, others) were obtained at baseline and followed annually for 2 years. Outcome measures (hospitalization, nursing home placement, and mortality rates) were followed for a minimum of 2 years after any identified weight change. MAIN RESULTS : The mean annual percentage weight change for the study population was −0.5% (SD: ± 4.0%; range: −17% to +25%). Four percent annual weight loss was determined to be the optimal cutpoint for defining clinically important involuntary weight loss using ROC curve analysis. The annual incidence of this degree of involuntary weight loss was 13.1%. At baseline, involuntary weight losers were similar to nonweight losers in age (73.9 ± 7.9 vs 73.3 ± 6.7 years), body mass index (26.8 ± 3.9 vs 26.9 ± 4.1 kg/m 2 ), and all other anthropometric, health status, and laboratory measures. Relative to nonweight losers, involuntary weight losers had significantly ( P ≤ .05) greater decrements in central skinfold and circumference measures (subscapular skinfolds, −2.9 vs −0.4 mm; suprailiac skinfolds, −4.2 vs −0.2 mm; and waist to hip ratio, −.01 vs + .00). Both groups had significant decreases in their triceps skinfolds (an estimate of peripheral subcutaneous fat), whereas arm muscle area and albumin levels did not decline significantly in either group. Over a 2‐year follow‐up period, mortality rates were substantially higher (RR = 2.43; 95% CI = 1.34–4.41) among involuntary weight losers (28%) than among nonweight losers (11%). Of interest, a similar increase in 2‐year mortality (36%) was also observed among subjects with voluntary weight loss (by dieting). Survival analyses adjusting for differences between weight losers and nonweight losers in baseline age, BMI, tobacco use, and other health status and laboratory measures yielded similar results. CONCLUSIONS : These results indicate that involuntary weight loss occurred frequently (13.1% annual incidence) in this population of older veteran outpatients. When involuntary weight loss occurred, the predominant anthropometric changes were decrements in measures of centrally distributed fat (trunkal skinfolds and circumferences). Finally, involuntary weight loss greater than 4% of body weight appears to be clinically important as an independent predictor of increased mortality.
