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The Journal of Nutrition, Health & Aging Mar 2014The "Do Not Resuscitate" orders (DNR) are defined as advance medical directives to withhold cardiopulmonary resuscitation during cardiac arrest. Age-related... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The "Do Not Resuscitate" orders (DNR) are defined as advance medical directives to withhold cardiopulmonary resuscitation during cardiac arrest. Age-related multimorbidity may influence the DNR decision-making process. Our objective was to perform a systematic review and meta-analysis of published data examining the relationship between DNR orders and multimorbidity in older patients.
METHODS
A systematic Medline and Cochrane literature search limited to human studies published in English and French was conducted on August 2012, with no date limits, using the following Medical Subject Heading terms: "resuscitation orders" OR "do-not-resuscitate" combined with "aged, 80 and over" combined with "comorbidities" OR "chronic diseases".
RESULTS
Of the 65 selected studies, 22 met the selection criteria for inclusion in the qualitative analysis. DNR orders were positively associated with multimorbidity in 21 studies (95%). The meta-analysis included 7 studies with a total of 27,707 participants and 5065 DNR orders. It confirmed that multimorbidity were associated with DNR orders (summary OR = 1.25 [95% CI: 1.19-1.33]). The relationship between DNR orders and multimorbidity differed according to the nature of morbidities; the summary OR for DNR orders was 1.15 (95% CI: 1.07-1.23) for cognitive impairment, OR=2.58 (95% CI: 2.08-3.20) for cancer, OR=1.07 (95% CI: 0.92-1.24) for heart diseases (i.e., coronary heart disease or congestive heart failure), and OR=1.97 (95% CI: 1.61-2.40) for stroke.
CONCLUSIONS
This systematic review and meta-analysis showed that DNR orders are positively associated with multimorbidity, and especially with three morbidities, which are cognitive impairment, cancer and stroke.
Topics: Advance Directives; Age Factors; Aged; Aged, 80 and over; Chronic Disease; Cognition Disorders; Comorbidity; Decision Making; Female; Heart Failure; Humans; Male; Medical Subject Headings; Middle Aged; Neoplasms; Patient Selection; Resuscitation Orders; Stroke
PubMed: 24626763
DOI: 10.1007/s12603-014-0023-5 -
American Journal of Kidney Diseases :... May 2014Recent clinical practice guidelines have highlighted the importance of advance care planning (ACP) for improving end-of-life care for people with chronic kidney disease... (Review)
Review
BACKGROUND
Recent clinical practice guidelines have highlighted the importance of advance care planning (ACP) for improving end-of-life care for people with chronic kidney disease (CKD).
STUDY DESIGN
We conducted a systematic integrative review of the literature to inform future ACP practice and research in CKD, searching electronic databases in April 2013. Synthesis used narrative methods.
SETTING & POPULATION
We focused on adults with a primary diagnosis of CKD in any setting.
SELECTION CRITERIA FOR STUDIES
We included studies of any design, quantitative or qualitative.
INTERVENTIONS
ACP was defined as any formal means taken to ensure that health professionals and family members are aware of patients' wishes for care in the event they become too unwell to speak for themselves.
OUTCOMES
Measures of all kinds were considered of interest.
RESULTS
55 articles met criteria reporting on 51 discrete samples. All patient samples included people with CKD stage 5; 2 also included patients with stage 4. Seven interventions were tested; all were narrowly focused and none was evaluated by comparing wishes for end-of-life care with care received. One intervention demonstrated effects on patient and family outcomes in the form of improved well-being and anxiety following sessions with a peer mentor. Insights from qualitative studies that have not been used to inform interventions include the importance of instilling patient confidence that their advance directives will be enacted and discussing decisions about (dis)continuing dialysis therapy separately from "aggressive" life-sustaining treatments (eg, ventilation).
LIMITATIONS
Although quantitative and qualitative findings were integrated according to best practice, methods for this are in their infancy.
CONCLUSIONS
Research on ACP in patients with CKD is limited, especially intervention studies. Interventions in CKD should attend to barriers and facilitators at the levels of patient, caregiver, health professional, and system. Intervention studies should measure impact on compliance with patient wishes for end-of-life care.
Topics: Advance Care Planning; Humans; Quality Indicators, Health Care; Renal Insufficiency, Chronic; Terminal Care
PubMed: 24434187
DOI: 10.1053/j.ajkd.2013.12.007 -
Journal of the American Geriatrics... May 2012To determine to what extent current practice promotes the goals of individuals who did not designate a surrogate while competent with respect to decision-making during... (Review)
Review
OBJECTIVES
To determine to what extent current practice promotes the goals of individuals who did not designate a surrogate while competent with respect to decision-making during periods of decisional incapacity.
DESIGN
Systematic literature search for studies published in English and listed in PubMed, Scopus, Embase, CINAHL, or PsycINFO. Studies were eligible if they provided quantitative or qualitative empirical data on how adults want treatment decisions to be made for them during periods of incapacity.
SETTING
Primarily United States, with six other countries.
PARTICIPANTS
Fourteen qualitative articles, representing 11 distinct data sets, and 26 quantitative articles, representing 25 distinct data sets, providing data on the views of 22,828 individuals, met the inclusion criteria. Most of the respondents were elderly or seriously ill.
MEASUREMENTS
Quantitative surveys and qualitative interview studies assessing individuals' goals.
RESULTS
The majority wanted close family members to act as their surrogate. The most common reason for preferring family members was the belief that they know which treatments the patient would want. Individuals also wanted to reduce the burden on their families. There was significant variation in the extent to which respondents wanted their surrogates to have leeway when making treatment decisions.
CONCLUSION
Individuals have three primary goals with respect to making treatment decisions for them during periods of incapacity: involve their family, treat them consistently with their own treatment preferences, and reduce the burden on their family. Unfortunately, prior systematic reviews have found that family members often are not able to determine which treatment patients want, and family members frequently experience substantial distress when acting as surrogates. These findings suggest that current practice frequently fails to promote individuals' primary goals for treatment decision-making. Future research should evaluate ways to better promote individuals' goals. In the meantime, clinicians should be aware of these findings and should encourage patients to document their own goals, including their treatment preferences and their preferences regarding how they want decisions to be made for them during periods of decisional incapacity.
Topics: Advance Directives; Aged; Decision Making; Goals; Humans; Third-Party Consent
PubMed: 22469395
DOI: 10.1111/j.1532-5415.2012.03937.x -
Interventions to improve transitional care between nursing homes and hospitals: a systematic review.Journal of the American Geriatrics... Apr 2010Transitions between healthcare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to... (Review)
Review
Transitions between healthcare settings are associated with errors in communication of information and treatment plans for frail older patients, but strategies to improve transitional care are lacking. A systematic review was conducted to identify and evaluate interventions to improve communication of accurate and appropriate medication lists and advance directives for elderly patients who transition between nursing homes and hospitals. MEDLINE, ISI Web, and EBSCO Host (from inception to June 2008) were searched for original, English-language research articles reporting interventions to improve communication of medication lists and advance directives. Five studies ultimately met all inclusion criteria. Two described interventions that enhanced transmission of advance directives, two described interventions that improved communication of medication lists, and one intervention addressed both goals. One study was a randomized controlled trial, whereas the remaining studies used historical or no controls. Study results indicate that a standardized patient transfer form may assist with the communication of advance directives and medication lists and that pharmacist-led review of medication lists may help identify omitted or indicated medications on transfer. Although preliminary evidence supports adoption of these methods to improve transitions between nursing home and hospital, further research is needed to define target populations and outcomes measures for high-quality transitional care.
Topics: Advance Directives; Aged; Checklist; Communication Barriers; Continuity of Patient Care; Drug Therapy; Evidence-Based Practice; Frail Elderly; Hospitals; Humans; Medical Errors; Nursing Homes; Patient Discharge; Patient Transfer; Patient-Centered Care; Research Design; Total Quality Management
PubMed: 20398162
DOI: 10.1111/j.1532-5415.2010.02776.x -
The Cochrane Database of Systematic... Jan 2009An advance directive is a document specifying a person's preferences for treatment, should he or she lose capacity to make such decisions in the future. They have been... (Review)
Review
BACKGROUND
An advance directive is a document specifying a person's preferences for treatment, should he or she lose capacity to make such decisions in the future. They have been used in end-of-life settings to direct care but should be well suited to the mental health setting.
OBJECTIVES
To examine the effects of advance treatment directives for people with severe mental illness.
SEARCH STRATEGY
We searched the Cochrane Schizophrenia Group's Register (February 2008), the Cochrane Library (Issue 1 2008), BIOSIS (1985 to February 2008), CINAHL (1982 to February 2008), EMBASE (1980 to February 2008), MEDLINE (1966 to February 2008), PsycINFO (1872 to February 2008), as well as SCISEARCH and Google - Internet search engine (February 2008). We inspected relevant references and contacted first authors of included studies.
SELECTION CRITERIA
We included all randomised controlled trials (RCTs), involving adults with severe mental illness, comparing any form of advance directive with standard care for health service and clinical outcomes.
DATA COLLECTION AND ANALYSIS
We extracted data independently. For homogenous dichotomous data we calculated fixed-effect relative risk (RR) and 95% confidence intervals (CI) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD) and their 95% confidence interval again using a fixed-effect model.
MAIN RESULTS
We were able to include two trials involving 321 people with severe mental illnesses. There was no significant difference in hospital admission (n=160, 1 RCT, RR 0.69 0.5 to 1.0), or number of psychiatric outpatient attendances between participants given advanced treatment directives or usual care. Similarly, no significant differences were found for compliance with treatment, self harm or number of arrests. Participants given advanced treatment directives needed less use of social workers time (n=160, 1 RCT, WMD -106.00 CI -156.2 to -55.8) than the usual care group, and violent acts were also lower in the advanced directives group (n=160, 1 RCT, RR 0.27 CI 0.1 to 0.9, NNT 8 CI 6 to 92). The number of people leaving the study early were not different between groups (n=321, 2 RCTs, RR 0.92 CI 0.6 to 1.6).
AUTHORS' CONCLUSIONS
There are too few data available to make definitive recommendations. More intensive forms of advance directive appear to show promise, but currently practice must be guided by evidence other than that derived from randomised trials. More trials are indicated to determine whether higher intensity interventions, such as joint crisis planning, have an effect on outcomes of clinical relevance.
Topics: Adult; Advance Directives; Commitment of Mentally Ill; Humans; Mental Disorders; Patient Admission; Randomized Controlled Trials as Topic
PubMed: 19160260
DOI: 10.1002/14651858.CD005963.pub2 -
Canadian Family Physician Medecin de... Oct 1999To assess whether advance directives influence resource use by hospitalized patients. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To assess whether advance directives influence resource use by hospitalized patients.
DATA SOURCES
A systematic search of computerized medical databases, reference lists from relevant articles, and personal files was conducted to identify studies examining the association between advance directives and resource use.
STUDY SELECTION
Primary studies assessing the effect of advance directives on hospital resource use were selected if they had a clear quantitative measure of hospital resource use, hospitalized patients as a study population, a control group for comparison, and a description of the advance directive being studied. Data on the following topics were abstracted from studies meeting inclusion criteria: study methods and design, resource use, source of financial data, description of advance directive, population size and composition, length of assessment.
SYNTHESIS
Six studies met inclusion criteria. Three retrospective studies showed significant reductions in resource use associated with documentation of advance directives while three prospective studies (two randomized, one not randomized) showed no association between advance directives and reduced resource use. Studies were limited to narrowly defined patient populations in US tertiary care hospitals.
CONCLUSIONS
Little evidence supports the hypothesis that advance directives reduce resource use by hospitalized patients. Some retrospective studies have shown savings, but their conclusions are weakened by shortcomings in study design. Prospective trials, which have better experimental methods, have demonstrated no evidence of cost savings with the use of advance directives.
Topics: Advance Directives; Cost Savings; Health Resources; Hospital Costs; Hospitalization; Humans; Prospective Studies; Research Design
PubMed: 10540700
DOI: No ID Found