Impact of Age on Consent in a Geriatric Orthopaedic Trauma Patient Population

Introduction: Persistent misconceptions of frailty and dementia in geriatric patients impact physician-patient communication and leave patients vulnerable to disempowerment. Physicians may inappropriately focus the discussion of treatment options to health care proxies instead of patients. Our study explores the consenting process in a decision-making capable orthogeriatric trauma patient population to determine if there is a relationship between increased patient age and surgical consent by health care proxy. Methods: Patients aged 65 and older who underwent operative orthopaedic fracture fixation between 1 of 2 Level 1 Trauma Centers were retrospectively reviewed. Decision-making capable status was defined as an absence of patient history of cognitive impairment and a negative patient pre-surgical Confusion Assessment Method (CAM) and Mini-Cog Assessment screen. Provider of surgical consent was the main outcome and was determined by signature on the consent form. Results: 510 patients were included, and 276 (54.1%) patients were deemed capable of consent. In 27 (9.8%) of 276 decision-capable patients, physicians obtained consent from health care proxies. 20 of these 27 patients (74.1%) were 80 years of age or older. However, in patients aged 70 to 79, only 7 health care proxies provided consent. (p = 0.07). For every unit increase in age, the log odds of proxy consent increased by .0008 (p < 0.001). Age (p < 0.001), income level (p = 0.03), and physical presence of proxy at consult (p < 0.001) were factors associated with significantly increased utilization of health care proxy provided consent. Language other than English was a significant predictor of proxy-provided consent (p = 0.035). 48 (22%) decision-making incapable patients provided their own surgical consent. Discussion: The positive linear association between age and health care proxy provided consent in cognitively intact geriatric orthopaedic patients indicates that increased patient age impacts the consenting process. Increased physician vigilance and adoption of institutional consenting guidelines can reinforce appropriate respect of geriatric patients’ consenting capacity.

Dying in the Neurointensive Care Unit After Withdrawal of Life-Sustaining Therapy: Associations of Advance Directives and Health-Care Proxies With Timing and Treatment Intensity

Background and Purpose: Critically ill patients require a careful approach for prognosis and decision-making. The German health legislation aims to strengthen the role of advance directives (ADs) and health-care proxies (HCPs). Their impact within a dedicated neurocritical care setting is unknown. This study aimed to assess the practice of withdrawal or withholding of life-sustaining therapy (WOLST) in a German neurointensive care unit (NICU) focusing on whether AD or HCP is associated with timing and treatment intensity. Methods: Data on patients who died after WOLST at a dedicated NICU of a German university hospital, from 2010 to 2013, were retrospectively analyzed. Results: Of 400 deceased patients, 310 (77.5%) died after initiation of WOLST. Among them, 68 (21.9%) were identified to have AD or HCP or both (AD + HCP). WOLST patients with AD, HCP, or AD + HCP were older than those without (median age: 77 vs 72 years, P < .001) but did not show any other distinct baseline features. There was no difference in the specific neurocritical care measures between the groups. Poisson regression analysis showed no significant difference in the probability of time-dependent WOLST initiation between those with and without AD/HCP, after adjusting for age and sex (adjusted incidence rate ratio, 1.10; 95% confidence interval, 0.94-1.28; P = .244). Conclusions: In this single-center study of mainly cerebrovascular NICU patients, AD or HCP was neither associated with an earlier WOLST nor associated with a difference in treatment intensity before WOLST. Further prospective studies should assess the emerging concept of advance care planning in neurocritical care.

Pilot study to evaluate a novel advance-care planning tool to identify informed health care proxies in an oncology palliative care clinic.

136 Background: To increase the probability that cancer patients receive care consistent with their wishes, medical providers require simple, practical, and effective communication tools to initiate and complete meaningful advance care planning (ACP) discussions. Ideally, ACP discussions occur in the non-emergent setting with a selected health care proxy and trusted medical provider and may lead to completion of an advance directive (AD). The primary aim of this study is to determine the proportion of advanced cancer patients who identify an informed health care proxy implementing a novel ACP tool. Methods: In an American Cancer Society funded pilot study, advanced cancer patients were evaluated in an academic oncology palliative care clinic (n=35). Subjects engaged in a 1-hour ACP intervention completed by a licensed clinical social worker utilizing a novel ACP tool developed by the investigators. The ACP tool identifies a health care proxy and defines three key elements an informed health care proxy must know. Details of this ACP conversation were documented in the electronic medical record with the goal of completing an AD. After subject’s death, health care proxies were contacted to determine if end-of-life wishes were honored. Results: 35 subjects (51% woman, 71% Caucasian, 54% married) were enrolled with a mean age ± SD of 57.4 ± 14.1 years with gastrointestinal as the most common primary cancer (13/35). The ACP intervention was completed in 80% in 1-2 clinic visits. After the ACP intervention, 94% of subjects (33/35) identified an informed health care proxy. The most common identified health care proxies were either a spouse (17/35) or child (11/35). 43% of subjects (15/35) completed an AD after the ACP intervention. As of July 2014, 69% (24/35) of subjects had died and 71% of these (17/24) died in a setting consistent with their end-of-life wishes. Mean time to death from ACP intervention was 4.5 ± 3.2 months. 11 subjects remain in surveillance. Conclusions: Results suggest that this novel ACP tool facilitates successful identification of an informed health care proxy. Despite low AD completion, death consistent with end-of-life wishes was achieved in the majority of patients.