Proxies' perceptions about dementia guide care decisions
Patients with advanced dementia were less likely to undergo interventions of questionable benefit near the end of life if their families and caregivers understood the patients' prognoses and likely complications, a recent study found.
Researchers followed 323 residents of nursing homes with advanced dementia and their health care proxies for 18 months. By the end of the study period, 54.8% of patients died and many experienced complications, including pneumonia (41.1%), febrile episodes (52.6%) and eating problems (85.8%). Almost 41% of residents underwent interventions such as hospitalization or tube feeding during the last three months of life, but interventions were much less likely among patients whose proxies had an understanding of the prognosis and expected complications of dementia (adjusted odds ratio, 0.12; 95% CI, 0.04 to 0.37). The results appeared in the Oct. 15 New England Journal of Medicine.
The findings can be used to inform families that infections and eating problems should be expected in patients with advanced dementia and that they often signal that the end of life is near, the authors said. The study also underscores that while these complications may precede death, dementia is the underlying cause.
Knowing that certain complications are associated with high rates of death within six months gives families and caregivers time to discuss the goals of care and potential hospice referral, said an accompanying editorial. The findings highlight that advanced dementia is a terminal illness that requires palliative care, the editorial continued, and that patients with advanced dementia do not need to have another serious illness to qualify for hospice care.
Discussions of the issues raised in the study by providers and families have the potential to modify the perceptions of health care proxies and affect their decisions about the use of interventions and hospice care, the editorial said.
Web site helps in assessing influenza, managing patient care
The American Medical Association is providing a comprehensive patient flu health-assessment Web site to help patients determine the severity of their flu symptoms and share their information with their physicians.
The Web site also provides a set of online tools designed by physicians for physicians to monitor their patients' symptoms, make better health care decisions and efficiently manage their practice patient flow, according to a news release.
The site can help patients assess their own flu symptoms and offer guidance on whether they should seek care. There is also a choice for pregnant women to evaluate their need for a flu vaccination and for all patients to monitor any vaccine-related symptoms. The site can also generate a doctor's note when it is safe to return to work or school.
AMAfluhelp.org is the first application on a portal designed to support quality of care initiatives to link patients, physicians and other caregivers together. The portal offers applications to support patient/physician communication, minimize redundant testing and allow for continuous monitoring of patients with complex health conditions.
Meanwhile, the CDC warned doctors not to rely on flu tests to decide whether to treat sick patients with antiviral drugs.
Anne Schuchat, FACP, the CDC's director of immunization and respiratory disease, said in the October 20 New York Times that the tests are often wrong because the nasal swab isn't done right, or the results take too long to get back. “If you have a person who is severely ill or a person with risk factors like pregnancy, asthma, diabetes, children under 2, and you suspect flu, we recommend any antiviral medicines be given promptly,” she said.
More funding for reducing HAIs
A national project to reduce health care-associated infections (HAIs) will receive $17 million in additional funding, the Department of Health and Human Services announced in October.
The Keystone Project, an effort to reduce central-line bloodstream infections, will receive $8 million of the funds. The program involves a checklist of evidence-based safety practices; staff training and other tools for preventing infections that can be implemented in hospital units; standard and consistent measurement of infection rates; and tools to improve teamwork among doctors, nurses and hospital leaders. The project, which was started by Johns Hopkins University in Baltimore and the Michigan Health & Hospital Association, expanded to 10 states in 2008 and now operates in all 50 states.
The new funding will expand the effort to more hospitals, extend it to other settings in addition to ICUs, and broaden the focus to address other types of infections, including catheter-associated urinary tract infections and bloodstream infections in hemodialysis patients.
The remaining $9 million will be applied to projects focusing on a number of HAI-related goals, including
- reducing Clostridium difficile infections through a regional hospital collaborative,
- reducing the overuse of antibiotics by primary care clinicians treating patients in ambulatory and long-term care settings,
- evaluating two ways to eliminate MRSA in ICUs,
- improving measurement of infection risk after surgery,
- identifying national-, regional- and state-level rates of HAIs that are acquired in the acute care setting,
- standardizing antibiotic use in long-term care settings (two projects), and
- implementing teamwork principles for front-line health care clinicians.
A complete list of institutions funded by the $17 million in resources is online.