Author Insights: Patients Face Too Many Burdensome Care Transitions at the End of Life

Joan M. Teno, MD, of Brown University, and colleagues found that many patients continue to receive aggressive care at the end of life, with on average 3 health care transitions in the last 3 months of life. Image: Joan M. Teno

Joan M. Teno, MD, of Brown University, and colleagues found that many patients continue to receive aggressive care at the end of life, with on average 3 health care transitions in the last 3 months of life. Image: Joan M. Teno

A growing number of older adults in the United States are dying at home, but many continue to face multiple health care transitions to different care sites and receive aggressive inpatient care in their final days, according to a study published in JAMA today.

The majority of individuals report that they would prefer to die at home rather than in a health care facility. There is also evidence suggesting that patients cared for in their homes at the end of life receive higher-quality care—particularly when hospice services are provided—and that such a setting may also ease grief and reduce trauma for loved ones. But most US adults die in some kind of institutional setting. To promote care that is more responsive to patient wishes, some advocates for quality improvement have proposed using the site of death as measure of the quality of care patients receive at the end of life.

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Author Insights: Midlife Fitness May Ease the Burden of Chronic Disease Later in Life

Jarett D. Berry, MD, MS, of the University of Texas Southwestern Medical Center in Dallas, and colleagues found that having high levels of fitness in middle age is associated with avoiding or delaying chronic disease in late life. (Image: UT Southwestern Medical Center)

Being fit in middle life appears protective against developing chronic diseases later in old age and is also associated with living the final 5 years of life with fewer chronic diseases. The findings appear today in the Archives of Internal Medicine.

Researchers from the Cooper Institute and the University of Texas Southwestern Medical Center in Dallas studied 18 670 healthy participants in the Cooper Center Longitudinal Study who lived long enough to receive Medicare coverage (a benefit that typically becomes available at age 65 years) from 1999 through 2009. Fitness in midlife was assessed by a Balke treadmill test. The median age of the study population at the time of enrollment was 49 years, and 21% of them were women. Using Medicare data to determine which participants had certain chronic conditions, the researchers found that for both men and women, those who had been in the highest quintile of fitness in middle age were less likely than those who had been in the lowest quintile of fitness in middle age to have 1 or more chronic conditions. The chronic conditions assessed were congestive heart failure, ischemic heart disease, stroke, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, Alzheimer disease, and colon or lung cancer. Continue reading

Young Survivors of Cancer More Likely to Report Poor Health Later in Life

Survivors of cancer who developed the disease as adolescents or young adults are more likely to smoke and have chronic health conditions than individuals their age with no cancer history, researchers report. (iStockphoto.com/DElight)

Individuals who were diagnosed with cancer as adolescents or young adults are more likely to report having chronic health conditions, having poor mental health, or being disabled than others in their age cohort, according to study findings published today in the journal Cancer. They were also more likely to smoke.

As a consequence of cancer and treatment for cancer, people who were diagnosed with cancer when  aged 15 to 29 years are at increased risk of death compared with others their age and also have an elevated risk of cardiovascular and lung problems. To further explore the long-term heath outcomes of this group, researchers from the US Centers for Disease Control and Prevention analyzed survey responses, collected as part of the Behavioral Risk Factor Surveillance System from 4054 people with a history of cancer in adolescence or young adulthood and 345 592 people with no cancer history. Continue reading

Author Insights: Reducing Restraint Use Takes a Multifaceted Approach

German researchers Sascha Köpke, PhD, of the University of Lübeck, and Gabriele Meyer, PhD, of Witten/Herdecke University, demonstrated that reducing use of physical restraints in nursing homes is possible with an intervention that targets staff, resident, and family member attitudes about such restraints. Image: Anne Junghans (left) Witten/Herdecke University (right)

Changing the attitudes of nurses, family members, and leaders at nursing homes can reduce the use of physical restraints on nursing home residents, according to research findings published today in JAMA.

The use of physical restraints is a common practice in nursing homes in the United States and around the world, despite evidence suggesting that they may have a detrimental effect on the health and well-being of nursing home residents. In Germany, it remains common despite laws that have been passed discouraging the practice. So a team of German researchers tested whether a multicomponent intervention targeting the attitudes of nursing home staff, residents, and family members could help reduce the use of physical restraints in this setting. Continue reading

Author Insights: Remembering the Lost Art of Prognosis

Physicians should provide realism and not allow unchallenged optimistic perceptions to unrealistically cloud patients’ views of their prognoses. (Image: JAMA, ©AMA)

A new study appearing today in the Archives of Internal Medicine adds to the body of evidence that a patient’s hopeful expectations following diagnosis of a disease or condition is associated with clinically important benefits. But Robert Gramling, MD, DSc, and Ronald Epstein, MD, urge physicians to be cautious about excessive optimism.

In an invited commentary in the same issue of the journal, Gramling, an associate professor of family medicine, and Epstein, a professor of family medicine, both at the University of Rochester Medical Center in New York, say that medical training and practice focuses on the arts of diagnosis and treatment while underplaying the art of prognosis. Continue reading