Prevalence of advanced directives in the geriatric population with in long-term care facilities in the United States

Advanced directives, such as Living Wills and Do Not Resuscitate (DNR) orders, provide the ability to identify, respect, and implement an individual's wishes for medical care during serious illness or end-of-life care. The aim of this study was to evaluate the prevalence of advanced directives amongst the residents of long-term care facilities in the United States. A total of 527 cases were extracted from 2018 National Study of Long-Term Care Providers, which was collected by the National Center for Health Statistics through the surveys of residential care communities and adult day services centers. Advanced directive rates were higher in patients 90 years of age and above as compared to other age groups. Nursing home residents were more likely to have advanced directives than other long term care facilities. There was no significant difference among males and females in the rate of advanced directives. Nursing home and Hospice residents had more advanced directives compared to other facilities. The Black population had the highest rate of advanced directive preparedness. Overall, the finding of this study revealed that there was a significant difference in the preparedness of DNR orders and Living Wills by patient demographics and the type of long-term care facility. Offering advanced directive services at public health/social services facilities can enhance the rate of advanced directive preparedness. Advanced directives ease the stress and anxiety of patients, family, and friends during difficult times.

Who Should Make Medical Decisions When a Patient Lacks an Advance Directive?

Patients admitted to the hospital with neurological problems are sometimes incapacitated and unable to make end-of-life decisions. In these instances, without an advanced directive from the patient, clinicians and family members must make critical medical decisions without input from the patient. This paper looks at two cases - one child and one adult – in which neuroprognosis was uncertain, and physician and family members’ beliefs on end-of-life care clash. We provide insight into these disagreements and reflect on how best to manage them. We argue that when considering withdrawing treatment, respecting autonomy is of paramount importance, while decision-making about continuing life-sustaining treatment requires clinicians to ensure surrogates are adequately educated about the principle of beneficence.

COVID-19 pandemic causing medical and public health ethical dilemmas: A case report and review of literature

The COVID-19 pandemic presented myriad of unprecedented and daunting ethical dilemmas to healthcare workers, patients, their families, and the public health. Here we present a case of a 42-years-old Hispanic female with underlying hematological malignancy that developed severe SARS-COV-2 infection amidst the pandemic. This case illustrates some remarkable ethical dilemmas during pandemic times, including the lack of advanced directive planning, the repercussions of restricting family visits, and what ethics in crisis and moral injury entails. Identifying the ethical challenges emerging from the pandemic will assist physicians and other providers in making proper decisions and maintaining the best standard of care.

Factors associated with optimal patient outcomes after operative repair of isolated hip fractures in the elderly

BackgroundIncreased time to operative intervention is associated with a greater risk of mortality and complications in adults with a hip fracture. This study sought to determine factors associated with timeliness of operation in elderly patients presenting with an isolated hip fracture and the influence of surgical delay on outcomes.MethodsTrauma quality collaborative data (July 2016 to June 2019) were analyzed. Inclusion criteria were patients ≥65 years with an injury mechanism of fall, Abbreviated Injury Scale (AIS) 2005 diagnosis of hip fracture, and AIS extremity ≤3. Exclusion criteria included AIS in other body regions >1 and non-operative management. We examined the association of demographic, hospital, injury presentation, and comorbidity factors on a surgical delay >48 hours and patient outcomes using multivariable regression analysis.Results10 182 patients fit our study criteria out of 212 620 patients. Mean age was 82.7±8.6 years and 68.7% were female. Delay in operation >48 hours occurred in 965 (9.5%) of patients. Factors that significantly increased mortality or discharge to hospice were increased age, male gender, emergency department hypotension, functionally dependent health status (FDHS), advanced directive, liver disease, angina, and congestive heart failure (CHF). Delay >48 hours was associated with increased mortality or discharge to hospice (OR 1.52; 95% CI 1.13 to 2.06; p<0.01). Trauma center verification level, admission service, and hip fracture volume were not associated with mortality or discharge to hospice. Factors associated with operative delay >48 hours were male gender, FDHS, CHF, chronic renal failure, and advanced directive. Admission to the orthopedic surgery service was associated with less incidence of delay >48 hours (OR 0.43; 95% CI 0.29 to 0.64; p<0.001).DiscussionHospital verification level, admission service, and patient volume did not impact the outcome of mortality/discharge to hospice. Delay to operation >48 hours was associated with increased mortality. The only measured modifiable characteristic that reduced delay to operative intervention was admission to the orthopedic surgery service.Level of evidenceIII.

Provider and patient insights into the cancer care journey.

e14019 Background: Research regarding primary care physicians’ (PCPs) involvement in the cancer treatment journey is limited. When a patient is first diagnosed with cancer, navigating healthcare can be confusing without the proper guidance. We conducted this study to understand a PCP’s involvement in the cancer care journey and how to optimize a patient’s journey through healthcare once diagnosed with cancer. Methods: We conducted a cross-sectional survey of 53 PCPs who have practiced over two years and have had at least one patient referred to an oncologist in the past year. We asked PCPs their method of oncologist referral, utilization of an oncologist selection tool that directs patients to high-quality and low-cost oncologists, and when an advanced directive should be established. We conducted a second survey with 112 current and previous cancer patients over the age of 25 who had received chemotherapy. We asked participants to reflect upon their oncologist’s referral, utilization of an oncologist selection tool that identifies high-quality and low-cost providers, participation in clinical trials, and guidance in creating an advanced directive during their cancer care journey. We conducted both surveys through online survey panels in June 2019. Results: PCPs tend to refer patients to oncologists that are part of their health system (67.9%) and who they know through networking (39.6%). While the majority of PCPs (79.2%) were not currently utilizing an oncology selection tool, the majority (77.3%) expressed a willingness to use such a tool for their newly diagnosed cancer patients. The majority of PCPs (69.8%) believe that cancer diagnosis is the best time to talk about establishing an advance directive, which should be initiated by the patient’s PCP (64.2%) or oncologist (56.6%). Patients ranked a PCP referral (52.7%) as “very important” when selecting an oncologist. One-third of patients used an oncology selection tool; 65.2% responded that a tool to understand true quality and cost of an oncologist would be “somewhat important” or “very important.” Most (71.4%) patients reported that it would be “somewhat important” or “very important” to participate in a clinical trial even though none participated in one. Most patients (54.5%) had an advance directive, although most (54.1%) had completed one before their cancer diagnosis. Conclusions: These results present a compelling rationale for developing a data-driven oncologist selection tool, optimize clinical trial involvement and expand the portion of patients who have an advanced directive at the start of their cancer care.

LO16: Predictors of appropriate hospitalization in elderly patients

Introduction: Admission decisions in older patients are often difficult. Our objectives were to identify clinical predictors of appropriate admission for older patients who attend the emergency department (ED). Methods: Administrative data were gathered on all Calgary ED patients &gt;75 years old who were treated during 2017. We considered the following events indicative of appropriate admission: an index hospitalization lasting &gt;72 hours, the need for ICU or CCU care, and 30-day death or readmission. Multivariable logistic regression was used to determine the association of the following potential predictors with appropriate admission: age, sex, EMS arrival, ILI symptoms, living situation (independent, homecare dependency or facility), acuity level, chief complaint, vital signs, need for IV fluid bolus ( &gt;1Li), serum sodium, potassium, creatinine, hemoglobin, and advanced directive care level (comfort, medical, resuscitation, unspecified). Results: We studied 38866 older patients who were 55.9% female with a mean age of 84. Most (69%) lived independently, with 17% in a facility and 14% homecare dependent. Overall, 16,992 (43.7%) were admitted at their index visit and 17,340 had an outcome event, including index hospitalization &gt;72 hours (N = 13,623, 35%), ICU care (352, 0.9%), CCU care (447, 1.2%), or 30-day death (2,241, 5.8%) or readmission (3,964 10.2%). Patients with appropriate admission events were more likely to have an advanced directive (80.7% v. 7.8%), triage hypoxia (30.5% v. 9.2%), EMS arrival (73% v. 48%), facility or homecare dependency (50% v. 15%), or to have a complaint of dyspnea (20.4% v. 8.6%), weakness (9.1% v. 3.8%) or altered mentation (8.8% v. 2.8%). Multivariable modeling showed that the strongest predictors of appropriate admission (adjusted odds ratio) were any advanced directive (OR = 30), need for IV bolus (OR = 1.67), homecare dependency (OR = 1.65), triage hypoxia (OR = 1.63), and a chief complaint of altered mentation (OR = 1.72), weakness (OR = 1.52) or dyspnea (OR = 1.25). Conclusion: The presence of an advanced care directive is strongly associated with appropriate admission in older ED patients. Other significant determinants include homecare dependency, EMS arrival, hypoxia or dyspnea, IV bolus and weakness or altered mentation. Age, sex, acuity, vital signs and laboratory findings were weak predictors.