Journal of palliative medicine
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Introduction: In 2013, the Vermont legislature passed Act 39: The Patient Choice and Control at End-of-Life Act, which legalized medical aid in dying (MAID) under specific circumstances for terminally ill Vermont residents. In the five years since the law was passed, 52 patients in Vermont have been prescribed medications to hasten death; however, important information regarding the experiences of the patient, caregiver, or physician involved in this process is lacking. Objective: To survey the subspecialty physicians with the greatest contact with these patient populations, to better understand the physicians' attitudes and experiences with Act 39, and to gather more data about the utilization of Act 39 in Vermont. Design: Physicians practicing Hematology/Oncology, Neurology, and/or Palliative Care at the University of Vermont Medical Group and affiliated hospitals in the state of Vermont were invited to participate. ⋯ Seventy-one percent of the participants supported MAID via Act 39; however, many felt that they could use more information and resources to counsel a patient (51.4%) and complete the paperwork and prescription for life-ending medication (37.4%). Conclusion: This is the first study to collect information regarding physicians' attitudes and experiences regarding Act 39 in Vermont. Most respondents supported Act 39, but there is a need and desire for more physician education and resources regarding patient counseling and paperwork.
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Randomized Controlled Trial
Advance Care Planning to Improve End-of-Life Decision-Making Consistency between Older People and Their Surrogates in Taiwan.
Background: Surrogates often do not accurately predict older people's preferences about end-of-life (EOL) care. Few studies have examined the impact of advance care planning (ACP) on EOL decision-making consistency between older people and their surrogates, and these studies have yielded conflicting results. Objectives: To evaluate the effectiveness of ACP in improving EOL decision-making consistency between older people and their surrogates. Design: The intervention in this pre-post quasi-experimental design included an informative video, a brochure about ACP, and a guided discussion about EOL wishes. Setting: Two geriatric wards in a medical center in northern Taiwan. Subjects: One hundred eight participants, as 54 pairs of older people and their surrogates, were randomly assigned to either the experimental or control group. The experimental group received an intervention, while the control group received usual care. Measurements: Life-Support Preferences Questionnaire. Results: The intervention did not improve decision-making consistency between older people and their surrogates. ⋯ This study also found that some older people had difficulty concentrating on the educational brochure or understanding the related terms. Conclusions: Preparation for ACP discussion is needed for older people and their surrogates. Longer-term effects of ACP should be monitored because ACP interventions may have enhanced empathy between older people and their surrogates. Additionally, a culturally sensitive illustrated questionnaire that explains life-support preferences and ACP topics may improve communication between older people and their surrogates.
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Background: Older adults frequently report a preference to "trial" intubation and mechanical ventilation (MV) if faced with life-threatening respiratory failure. Understanding the anticipated outcome of unplanned MV is key to structuring a time-limited trial of treatment. Objective: To characterize the time-to-death (TTD) among adults 65 years of age and older, who undergo emergency intubation and MV. Design: Retrospective cohort study. Setting/Subjects: All patients 65 years of age and older, who underwent emergency department (ED) intubation from 2008 to 2015, from 417 hospitals were included. Measurements: The primary outcome was TTD after emergency intubation. Results: We identified 41,463 ED encounters. The median TTD was three days (interquartile range, IQR, 1-8). ⋯ Bivariate analysis comparing TTD by Charleston Comorbidity Index (CCI) revealed a trend of increasing TTD with increasing CCI score among decedents. Patients with a CCI of 0 had a median TTD of one day (IQR 4), whereas the median TTD among those with a CCI >4 was four days (IQR 9). Conclusions: In a large, nationally representative cohort of older adults undergoing ED intubation, the median time from intubation to death was short; however, the length of time between intubation and death varied considerably by principal diagnosis. This information will help guide providers' prognostication after emergency intubation and enhance serious illness conversations by informing expectations. Tweet: Thirty-five percent of older adults die after ED intubation-most only survive two or three days after intubation.