Health Care Proxy Research Articles

Integrating palliative care into care of patients with kidney cancer and melanoma.

56 Background: Early palliative care (PC) has been shown to improve quality of life (QOL), enhance quality end-of-life (EOL) care, and reduce costs, yet many cancer centers lack resources to provide outpatient palliative care services. Data is needed to identify the optimal timing and most effective and efficient model for integrating PC into the care of cancer patients. In order to understand what components of PC have the greatest impact on patients, we examined the acceptability of early PC among patients with kidney cancer (RCC) and melanoma (M) and describe the content of PC visits. Methods: In July 2013, the outpatient PC team at Beth Israel Deaconess Medical Center, including physician (MD), social worker (SW) and chaplain (chap) were invited to see patients within a clinic that specializes in seeing patients with advanced RCC and M. All patients completed data on symptom burden using the Edmonton Symptom Assessment Scale, measures of QOL and degree of psycho-social and spiritual support. Referral to PC was based on these metrics and physician discretion. Results: Of the 21 patients seen by PC, 57% had RCC; 76% male; 86% White; 57% married. Mean age was 62 (range: 36-87). At the 1st PC visit: All had locally adv/metastatic disease; 48% were being treated with curative intent; 29% had not yet started treatment; 57% rated pain 0 on 0-10 scale (range: 0-9). First PC visit content: 76% psychosocial support (including building rapport); 67% symptom management; 33% included advance care planning (ACP) and decision-making support. Ninety-one percent were seen >1 by PC; 19% seen by SW or chap; median PC visits: 3. Eighty-one percent completed health care proxy. Additional data on patient outcomes will be presented. Conclusions: Nearly half of patients seen by PC were being treated with curative intent, suggesting acceptability of early PC integration in patients with RCC and M. Symptom management and psychosocial support dominated the early PC visits.

Use of advance directives by South Australians: results from the Health Omnibus Survey Spring 2012.

To determine the prevalence of completion of advance directives (ADs) and wills by South Australians aged 15 years and over. Statewide population-based survey of a single member (aged 15 years and over) of 3055 South Australian households between 4 September and 12 December 2012. Prevalence and sociodemographic determinants of completion of the four recognised legal ADs in South Australia (enduring power of attorney [EPA] for finance, enduring power of guardianship [EPG] for health care/lifestyle, medical power of attorney [MPA] for medical treatment and anticipatory direction for end-of-life care) and wills. Nearly half the 3055 survey participants had not completed any AD document or will. Financial documents were more likely to be completed than health care documents. In multivariate analysis, the odds of not having completed any AD was higher among those aged 15-24 years compared with those aged over 65 years (odds ratio [OR], 55.3; 95% CI, 31.3-97.7) and 25-44 years (OR, 24.9; 95% CI, 17.3-36.1). Similarly, the odds were higher for those born in another country (OR, 2.0; 95% CI, 1.6-2.4); those never married (OR, 3.1; 95% CI, 2.3-4.2) or in de facto relationships (OR, 2.8; 95% CI, 2.1-3.8) or separated/divorced (OR, 1.8; 85% CI, 1.3-2.4) compared with those married; those who left school in Year 12 or before (OR, 1.5; 95% CI, 1.1-1.9) or with a bachelor degree (OR, 1.5; 95% CI, 1.1-2.0) compared with those who had completed a trade/apprenticeship, certificate/diploma; and those in blue collar occupations (OR 1.6; 95% CI, 1.3-2.2) or not employed (OR, 2.2; 95% CI, 1.4-3.6) versus professionals. The odds of not having completed any AD were lower for those living in rural or regional areas (OR, 0.8, 95% CI, 0.6-1.0) compared with the metropolitan area, and for those in the highest income bracket earning more than $80 000 (OR, 0.6; 95% CI, 0.5-0.8) compared with those in the middle bracket earning $40 000-$80 000. Completion rates of ADs among South Australians remain low, with financial instruments more likely to be completed than health care and lifestyle instruments. The odds of not completing ADs were associated with age and socioeconomic characteristics. General practitioners are in a good position to target advance care planning towards relevant patient groups, which would likely improve rates of decision making in future health care.

Infection management and multidrug-resistant organisms in nursing home residents with advanced dementia.

Infection management in advanced dementia has important implications for (1) providing high-quality care to patients near the end of life and (2) minimizing the public health threat posed by the emergence of multidrug-resistant organisms (MDROs). Prospective cohort study of 362 residents with advanced dementia and their health care proxies in 35 Boston area nursing homes for up to 12 months. Data were collected to characterize suspected infections, use of antimicrobial agents (antimicrobials), clinician counseling of proxies about antimicrobials, proxy preference for the goals of care, and colonization with MDROs (methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and multidrug-resistant gram-negative bacteria). Main outcomes were (1) proportion of suspected infections treated with antimicrobials that met minimum clinical criteria to initiate antimicrobial treatment based on consensus guidelines and (2) cumulative incidence of MDRO acquisition among noncolonized residents at baseline. The cohort experienced 496 suspected infections; 72.4% were treated with antimicrobials, most commonly quinolones (39.8%) and third- or fourth-generation cephalosporins (20.6%). At baseline, 94.8% of proxies stated that comfort was the primary goal of care, and 37.8% received counseling from clinicians about antimicrobial use. Minimum clinical criteria supporting antimicrobial treatment initiation were present for 44.0% of treated episodes and were more likely when proxies were counseled about antimicrobial use (adjusted odds ratio, 1.42; 95% CI, 1.08-1.86) and when the infection source was not the urinary tract (referent). Among noncolonized residents at baseline, the cumulative incidence of MDRO acquisition at 1 year was 48%. Acquisition was associated with exposure (>1 day) to quinolones (adjusted hazard ratio [AHR], 1.89; 95% CI, 1.28-2.81) and third- or fourth-generation cephalosporins (AHR, 1.57; 95% CI, 1.04-2.40). Antimicrobials are prescribed for most suspected infections in advanced dementia but often in the absence of minimum clinical criteria to support their use. Colonization with MDROs is extensive in nursing homes and is associated with exposure to quinolones and third- and fourth-generation cephalosporins. A more judicious approach to infection management may reduce unnecessary treatment in these frail patients, who most often have comfort as their primary goal of care, and the public health threat of MDRO emergence.

Palliative Care Intervention in the Intensive Care Unit: Comparing Outcomes among Seriously Ill Asian Patients and those of Other Ethnicities

The literature describing the attitude of Asians toward palliative care in the intensive care unit (ICU) is scarce. The purpose of this study was to compare outcomes of Asians and people of other ethnicities after palliative care intervention in the ICU. A retrospective chart review was conducted of all ICU patients evaluated by palliative care; the outcomes measured were incidence of life-sustaining treatments, institution of advance care directives, and preferences for end-of-life care. The palliative care team evaluated 119 patients (46.2 percent Caucasian, 27.2 percent Asian, and 26.1 percent other ethnicities). There were no differences in demographics or clinical variables. Thirty-six percent of the Asians, 49 percent of the Caucasians, and 28.6 percent of the patients of other ethnicities (p = 0.19) had healthcare proxies. The palliative care team increased advance care directives by more than 40 percent in all groups (p < 0.001). There were no differences in the use of life-sustaining treatments or preferences for comfort measures among ethnic groups. Asians are as likely as people of other ethnicities to decide on advance care directives, life-sustaining treatments, and comfort measures after palliative care evaluation in the ICU.

The Impact of a Tumor Diagnosis on Patients' Attitudes toward Advance Directives

Background: Although advance care planning and the completion of advance directives (ADs) are important tools to avoid unwanted aggressive care once patients have lost their decision-making capacity, only a minority of cancer patients are admitted with completed ADs, and little is known about patients' wishes regarding AD consultations. Methods: For 1 year, every new patient admitted to the hematology/oncology outpatient clinic of the University Hospital Regensburg received a self-administered questionnaire comprising a self-evaluation of AD knowledge and questions about preferences regarding consultation partners and the time of consultation. Disease-related data were collected from medical records. Statistics were calculated with SPSS. Results: Of the 500 questionnaires handed out, 394 (75%) were evaluable and analyzed. Twenty-eight percent of the participants had completed an AD (living will or health care proxy). Ninety-two percent of the participants without ADs had never received a consultation offer from any professional involved. Only 20% perceived a clear relation between cancer and AD consultations. More than 50% of the participants without ADs were in favor of consultations ‘now' or ‘in a few weeks', while more than 40% objected to AD consultations. Conclusions: Oncology patients have a large unmet demand for AD consultations. However, a relevant percentage of these patients object to AD consultations. Structured and early AD consultation offers should be made, and early discussions about indications for aggressive treatment should take place.

Doctors' Decisions When Faced With Contradictory Patient Advance Directives and Health Care Proxy Opinion: A Randomized Vignette-Based Study

ContextSometimes a written advance directive contradicts the opinion of a health care proxy. How this affects doctors' decision making is unknown. ObjectivesTo quantify the influence of contradictory instructions on doctors' decisions. MethodsAll the generalists and internists in French-speaking Switzerland were mailed the questionnaire. Respondents (43.5%) evaluated three vignettes that described medical decisions for incapacitated patients. Each vignette was produced in four versions: one with an advance directive, one with a proxy opinion, one with both, and one with neither (control). In the first vignette, the directive and proxy agreed on the recommendation to forgo a medical intervention; in the second, the advance directive opposed, but the proxy favored the intervention; and in the third, the roles were reversed. Each doctor received one version of each vignette, attributed at random. The outcome variables were the doctor's decision to forgo the medical intervention and the rating of the decision as difficult. ResultsWritten advance directives and proxy opinions significantly influenced doctors' decision making. When both were available and concordant, they reinforced each other (odds ratio [OR] of forgoing intervention 35.7, P < 0.001 compared with no instruction). When the directive and proxy disagreed, the resulting effect was to forgo the intervention (ORs 2.1 and 2.2 for the two discordant vignettes, both P < 0.001). Discordance between instructions was associated with increased odds of doctors rating the decision as difficult (both ORs 2.0, P ≤ 0.001). ConclusionContradictions between advance directives and proxy opinions result in a weak preference for abstention from treatment and increase the difficulty of the decision.

Family structure, experiences with end-of-life decision making, and who asked about advance directives impacts advance directive completion rates.

Advance directives are an important but underutilized resource. Reasons for this underutilization need to be determined. We investigated factors associated with completion of advance directives among inpatients. We conducted prospective, structured interviews on family structure, health care, disease, and end-of-life experiences. We compared those with completed advance directives and those without. We interviewed 130 inpatients in an urban university hospital. We used bivariate analysis and logistic regression to identify characteristics of patients with living wills and health care proxies versus patients without them. Twenty-one percent of patients had a living will and 35% had a health care proxy. Patients with completed living wills were older (p≤0.0046), had more comorbidities (p=0.018), were widowed (p=0.02), and were more often admitted with chronic disease (p=0.009) compared to those without living wills. Patients with health care proxies were older (p<0.001), had religious affiliations (p=0.04), more children (p=0.03), and more often widowed (p≤0.001) than those without health care proxies. Patients were 10.8 times (95% confidence interval [CI] 4.59-25.3), 46.5 times (95% CI 15.1-139.4), and 68.6 times (95% CI 13.0-361.3) more likely to complete a living will when asked by medical staff, legal staff, or family and friends, respectively, than those not asked. Patients with health care proxies were 1.68 times (95% CI 0.81-3.47), 4.34 times (95% CI 1.50-12.6), and 18.0 times (95% CI 2.03-158.8) more likely to have been asked by the same groups. Patients with experience in end-of-life decision-making were 2.54 times more likely to possess a living will (95%CI 1.01-6.42) and 3.53 times more likely to possess a health care proxy (95% CI 1.51-8.25) than those without experiences. Having been asked about advance directives by medical staff, legal staff, or family and friends increases the likelihood that patients will possess an advance directive. Those with prior experience with end-of-life decision-making are more likely to possess an advance directive. Family structure and health care utilization also impacts possession of advance directives.

Single-center, prospective pilot study to evaluate advance care planning implementing the 3 Questions and 3 Elements to identify an informed health care proxy in an outpatient oncology palliative care clinic.

TPS9655 Background: Despite the growing cancer therapeutics arsenal, the vast majority of advanced cancer patients will die. Consequently, understanding and communicating their end-of-life (EoL) ca...

Connaissance infirmière de la personne de confiance et des directives anticipées

Le Groupe infirmier en soins palliatifs de Basse-Normandie (GISPBN) a souhaité travailler sur la connaissance qu’avaient les infirmiers des directives anticipées et de la personne de confiance. Un questionnaire a été remis aux infirmiers des établissements publics et privés de Basse-Normandie, exerçant dans les services de médecine, chirurgie, urgences et gériatrie. L’objectif de départ était d’interroger au moins 200 infirmiers dans les trois départements de Basse-Normandie. Cette étude a mis en évidence que les infirmiers connaissent l’obligation de la désignation de la personne de confiance. Ils confondent la personne de confiance et la personne à prévenir et ils ne connaissent pas les directives anticipées. Ce travail fait apparaître comme indispensable la formation des infirmiers à ces dispositifs afin de faciliter l’information aux patients sur leurs droits. “Leonetti's Law” gives French patients the right to draw up advance directives and to designate a health care proxy or “personne de confiance”. However, many questions remain unanswered concerning the role of health care professionals in informing patients of their rights in end of life issues. The Association of palliative care nurses in Basse-Normandie (GISPBN) believed that nurses had insufficient knowledge of these two devices and so were unable to adequately inform patients of their rights. A questionnaire on the subject was devised and distributed among nurses working in medical, surgical, geriatric and trauma departments with the aim of reaching at least 200 nurses in all the departments of the region. The results of this study indicated that nurses tended to consider the designation of a health care proxy as mandatory. There appeared to be a lack of differentiation between naming a health care proxy and naming a personal contact like “next of kin”. A discussion also emerged as to whether or not a health care professional could accept the role of health care proxy. The results concerning advance directives clearly showed a lack of knowledge at all levels. Furthermore, the nurses who responded did not link advance directives to the designation of a health care proxy. It would appear that these devices are not perceived as united by a common concern to safeguard self determination in end of life situations, as promoted by “Leonetti's Law‘”. These results raise the issue of teaching programmes and the importance of placing these subjects in their legal and ethical context, in order to enable nurses to understand the issues at stake and hence better inform patients of their rights.

Healthcare resource use and relapses with fingolimod versus natalizumab for treating multiple sclerosis: a retrospective US claims database analysis

Objective:Healthcare resource utilization in patients with multiple sclerosis (MS) is linked to relapses and disease progression. This retrospective cohort database analysis compared healthcare resource use and proxy measures of relapse outcomes in patients with active disease who switched to fingolimod or natalizumab.Methods:Using administrative claims data from the US PharMetrics Plus database, we identified patients with an MS diagnosis and a claim for fingolimod or natalizumab between 1 October 2010 and 30 June 2012 (index period) who had experienced a relapse (identified using a claims-based algorithm) and used other disease-modifying therapies (DMTs) in the previous year. Patients in the fingolimod and natalizumab cohorts were propensity score matched (1:1). MS-related inpatient stays, corticosteroid use and the proportion of patients experiencing claims-based relapses were assessed in the pre-index and post-index persistence periods. Time to first claims-based relapse in the post-index persistence period was assessed using a Kaplan–Meier curve.Results:The study included 623 unmatched patients (299 and 324 patients in the fingolimod and natalizumab cohorts, respectively) and 370 matched patients (185 in each cohort). In the matched analysis, MS-related inpatient stays and corticosteroid use were similar in the fingolimod and natalizumab cohorts during the post-index persistence period, and were significantly reduced versus the pre-index period (p < 0.01). A similar proportion of patients in the fingolimod and natalizumab cohorts were free from claims-based relapses in the persistence period (68.1% and 68.6%, respectively). There was no significant difference in the likelihood of experiencing a claims-based relapse (p = 0.8696).Limitation:Identification of relapses is based on database claims rather than on clinical assessment.Conclusions:In analyses of patients with MS with a history of relapse and DMT use, fingolimod and natalizumab reduce healthcare resource utilization and have similar effectiveness in a real-world setting.

Practical resource for creating a Catholic living will.

Dear Editor, I read with interest the recent issue of the Linacre dedicated to geriatrics and end-of-life care. This is such a timely topic! With the implementation of Obamacare – which is government-run health care funded at the rate of economic inflation, not the more rapidly increasing healthcare inflation – there will be ever-increasing healthcare rationing. This will lead to escalating pressure to withhold life-preserving treatment (including food and water) especially to vulnerable populations including the elderly, the disabled, and the poor. As a result, end-of-life documents are already incredibly important and will become ever moreso. The article by Dr. Morrow articulates several key principles that should be present in an end-of-life document that adheres to Catholic principles – one that recognizes and respects the inherent dignity for human life for its own sake, one that ensure ordinary care and comfort care, and one that is “personalized” by appointing a healthcare proxy who understands and can implement your wishes according to the situation at hand. While there are several end-of-life document templates available, most do not adhere to the principles outlined in Dr. Morrow's article. A practical, easy-to-use resource for developing an end-of-life document that adheres firmly to the principles outlined in Dr. Morrow's article is the Will To Life Project developed by the National Right To Life Committee. From this website, one can download a legally valid document for any of the fifty states. While creating a Catholic end-of-life document can be daunting, this resource provides a practical starting point and a template anyone can complete. For more information, check out: http://www.nrlc.org/medethics/willtolive/.

Alzheimer, dementia and the living will: a proposal.

The world population aged significantly over the twentieth century, leading to an increase in the number of individuals presenting progressive, incapacitating, incurable chronic-degenerative diseases. Advances in medicine to prolong life prompted the establishment of instruments to ensure their self-determination, namely the living will, which allows for an informed person to refuse a type of treatment considered unacceptable according to their set of values. From the knowledge on the progression of Alzheimer disease, it is possible to plan the medical care, even though there is still no treatment available. Irreversible cognitive incapacity underlines the unrelenting loss of autonomy of the demented individual. Such a loss requires the provision of specific and permanent care. Major ethical issues are at stake in the physician–patient–family relationship, even when dementia is still at an early stage. The authors suggest that for an adequate health care planning in Alzheimer disease the living will can be presented to the patient in the early days of their geriatric care, as soon as the clinical, metabolic or even genetic diagnosis is accomplished. They also suggest that the appointment of a health care proxy should be done when the person is still in full enjoyment of his cognitive ability, and that the existence and scope of advance directives should be conveyed to any patient in the early stages of the disease. It follows that ethical guidelines should exist so that neurologists as well as other physicians that deal with these patients should discuss these issues as soon as possible after a diagnosis is reached.

Advance Care Planning and Proxy Decision Making for Patients with Advanced Parkinson Disease

To examine advance care planning practices and proxy decision making by family healthcare proxies for patients with advanced Parkinson disease (PD). Sixty-four spouses and adult children, self-designated as a/the healthcare proxy for advanced patients with PD, participated in a cross-sectional survey study. Sixty patients with PD (95%) had completed a living will, but only 38% had shared the document with a physician. Among three life-support treatments--cardiopulmonary resuscitation (CPR), ventilator, and feeding tube--47% of patients opted for CPR, 16% for ventilator, and 20% for feeding tube. Forty-two percent of proxies did not know patients' preferences for one or more of the three life-support treatments. Only 28% of proxies reported that patients wanted hospice. Patients who shared advance directives with a physician were significantly less likely to choose CPR and a feeding tube and they were more likely to choose hospice. In a hypothetical end-of-life (EOL) scenario, the majority of proxies chose comfort care as the EOL goal of care (53%) and pain and symptom management only as the course of treatment option (72%); these proxy choices for patients, however, were not associated with patients' preferences for life support. Patients' proxies preferred a form of shared decision making with other family members and physicians. Advance care planning is effective when patients, families, and healthcare professionals together consider future needs for EOL care decisions. Further efforts are needed by healthcare professionals to provide evidence-based education about care options and facilitate advanced discussion and shared decision making by the patient and families.

Voluntarily Stopping Eating and Drinking by Proxy: A Long Term Care Dilemma

In providing Patient Centered Care, the ethical principle of autonomy often helps to guide the treatment plan. The principle of non-maleficence also plays a vital role. In dementia care, the activated healthcare agent often speaks “on behalf” of the patient, but even then there's a limit to such authority. Within biomedical ethical literature, voluntary stopping eating and drinking has been a defensible decision for patients who maintain decision-making capacity and wish to exert their autonomy. However, it remains unclear whether a health care proxy may also make this decision on behalf of a patient with dementia, attempting to enforce such autonomy by proxy would be appropriate, or whether this would be an overreach.

Abstract W MP7: Predictors and Implications of Capacity to Provide Informed Consent for Acute Ischemic Stroke Treatment Trials

Background and objectives: Enrollment into AIS trials has always been limited by the ability of the patient to give informed consent or the availability of a Legally Authorized Representative (LAR) in decision making capacity on behalf of the patient. In this analysis we try to identify the factors contributing to an acute ischemic stroke (AIS) patient’s inability to give informed consent. We hypothesized that clinical features and demographics would differ between those patients with and without capacity to consent. Methods: This analysis includes patients who enrolled into the coordinating center of the prospective, randomized ARTSS-2 clinical trial (Argatroban + TPA for acute ischemic stroke) and also screen failures due to inability to consent. Data is collected prospectively in the study screening log. The data collected included age, gender, race, NIHSS, lesion location, ER arrival time and mode of consent (self-consent, LAR-consent and unable to consent). Results: Between 12/11 and 06/13, a total of 33 acute ischemic stroke patients received IV-tPA and were eligible for the ARTSS-2 study. While 19 were enrolled, 14/33 (42.4%) were otherwise eligible, but not enrolled due to inability to self-consent and no LAR present. Patients not enrolled due to lack of capacity to consent and without LAR present tended to have higher median NIHSS scores and greater proportions of drowsiness and aphasia compared to the other groups (see table). Conclusion: Approximately 2 in 5 AIS patients are not eligible for AIS clinical trials based solely on their lack of capacity for informed consent. It is remains ethically imperative that current clinical trials as well as future study designs address this disregarded group of patients who deserve the right to be able to participate in research. Addressing this group of patients through exception from informed consent (EFIC) will both extend research to all stroke patients, but also greatly enhance AIS research.

Abstract T P293: Determinants of Early Withdrawal of Care in Patients Who Die During Index Hospitalization for Acute Ischemic Stroke

Introduction: CMS recently announced plans to report risk-standardized stroke mortality. Decisions to withdraw medical care after acute ischemic stroke are based on numerous factors, not just the severity of the incident stroke. Withdrawal of care decisions have the potential to confound these adjusted mortality rates. We investigated factors associated with early withdrawal of care in patients hospitalized with AIS. Methods: We used our institutional GWTG database (1474 consecutive stroke inpatients from 12/2009 - 12/2012) to identify 176 consecutive in-hospital mortalities; of these, 100 patients were transitioned to comfort care during hospitalization. Chart review was performed on these 100 patients to identify factors associated with early (&lt; 5 days) withdrawal of care. Results: Seventy-eight patients (78%) had early withdrawal of care. Table 1 shows the comparison of patients with early (&lt;5 days) versus late (≥ 5 days) withdrawal of care decisions. As shown, Early-CMO patients were younger, and less often were Hispanic, had a college level or higher education, and annual income &gt;$100,000. They had more often expressed a DNR request, had placed limits on life sustaining measures prior to admission or had a known health care proxy (84% vs. 68%). They had pre-existing comorbidities of prior MI, atrial fibrillation, cancer and dementia. They had slightly higher NIHSS scores, and lower rates of thrombolysis. Early-CMO patients had lower rates of post-stroke pneumonia. Conclusion: Several non-clinical variables appear to be associated with early withdrawal of care decisions and contribute substantially to in-hospital stroke mortality. Many of these factors are non-modifiable, and the association with pneumonia may be confounded by the reduced opportunity to develop pneumonia in cases of very early death. Given the vigorous debate about preventable stroke mortality and public reporting, these data suggest the need for more complex mortality risk models.

Specialist respiratory physicians' attitudes to and practice of advance care planning in COPD. A pilot study

Advance care planning (ACP) is increasingly recognised as important in chronic obstructive pulmonary disease (COPD). Specialist respiratory physicians (RPs) are crucial in enabling ACP in patients with COPD. Accordingly, understanding their practice and attitudes regarding ACP is important. We developed and piloted a survey to assess RPs practices, attitudes and educational needs in ACP. The response rate was 41% (17/41). The instrument was brief and acceptable to participants. Among respondents, 13% reported they had discussed ACP with "most" of their patients; 31% with "about half"; 50% with "a few" and 6% with "none or almost none". Although 57% of respondents preferred outpatient discussions, most discussions occurred as inpatients. Diagnosis, purpose of treatment and incurability of COPD were reported as commonly discussed but the appointment of a health care proxy, the patients' values and goals, and palliative care options were rarely addressed. Reported barriers to ACP included: difficulty prognosticating; time constraints; and perceived patient reticence. Facilitators included increasing patient frailty and patient willingness to discuss. Most respondents reported receiving some formal training in ACP and refined skills by observing colleagues. Many were interested in further educational opportunities. This pilot found the new instrument was acceptable. Findings suggest that ACP discussions are infrequent with the majority occurring in the inpatient setting, with key elements omitted. Participants generally had favourable attitudes to ACP and recognised for the need for ongoing training. These early findings require further investigation.

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Introduction: Listeria monocytogenes is an uncommon cause of illness in the general population within the community. However it is an important pathogen among special groups such as the extremes of age, that is the neonates and the elderly, pregnant patients, and immunocompromised individuals. It is typically a food-borne organism, with clinical manifestations ranging from a febrile gastroenteritis to an invasive disease with bacteremia and meningitis. Unless recognized and treated, Listeria infections can result to significant illness and death. It is important to recognize that there is a high risk of infection among those who forgo safe food preparation, consumption, and storage. These characterisctics are often seen among individuals who suffer from compulsive hoarding, called "hoarders." We present a case of an 88-year-old-male, with no known medical illness and no medical follow-up for many years, who was brought in to the emergency department (ED) by emergency medical services (EMS), after he was found unresponsive at home. His neighbor had not seen him for two days and had called EMS. He was otherwise described as an active person, pleasant and appropriate, always at work in his yard and inside his home. In the ED, he was somnolent, normotensive, tachycardic, tachypneic, and febrile with a temperature of 104F. His exam was significant for neck stiffness, without trunk nor limb rigidity. His Glasgow Coma Scale was 5 (E1V1M3). He was intubated for airway protection and mechanically ventilated. A head CT was negative for acute pathology. His chest xray, urinalysis and toxicology screen were unrevealing. Due to concerns of a CNS infection, he was started on Ceftriaxone, Vancomycin and Ampicillin. He was admitted to the intensive care unit where a lumbar puncture was immediately done. Cerebral spinal fluid (CSF) was clear and analysis revealed 640 WBCs with 94% segmenters, 305 RBCs, CSF total protein of 407 mg/dl and CSF glucose of 5 mg/dl. Findings were consistent with bacterial CNS infection. His CSF gram stain and blood cultures revealed gram positive rods, which later was identified as listeria monocytogenes. Ampicillin was continued with plans to treat for four weeks. His neighbor had visited him in the ICU and reported that upon inspection of his house, she found an abundance of pre-made packed meals, meant to be frozen and microwaved prior to consumption. They were unsafely stored in a chiller and the patient was not heating them prior to consumption. The patient's mental status had not improved. He would open his eyes spontaneously, withdraw extremities to pain, however was unable to follow commands. He was extubated on his tenth ICU day and was eventually transferred to the floors. His course was complicated by aspiration and further alterations in mental status. Due to his poor prognosis and severe neurologic injury, comfort measures were initiated by his health care proxy. He passed soon thereafter. It is important to recognize the health hazards associated with compulsive hoarding due to unsafe practices in food storage, handling and consumption. In this case, Listeria infection may have been avoided and prevented. It is important to recognize the risk of this infection among hoarders and immediate treatment with Ampicillin is warranted if CNS infection is suspected.

The Ethical Intersection of Elder Law and Elder Care Practices

Clinical geriatricians and other healthcare providers who care for older adults are at times put in situations outside of their elder care settings. Elder law is one area that sometimes overlaps with elder care. Elder law is the practice of law that addresses the legal needs of older adults. Some of the common legal documents executed as part of an elder law practice are wills, trusts, transfers of property, living wills, and healthcare proxies. It is not as important for healthcare providers to understand the intricacies of the above-mentioned documents as it is to understand that all of the above are important legal documents that can have significant consequences and are a means for older adults to put their wishes into writing. Often, and many times because of convenience, healthcare providers are asked to witness the execution of these documents. This letter aims to touch on some general ethical points before one agrees to serve as a witness in the execution of a legal document. Before agreeing to take part in the execution any of the above-mentioned documents, it is important to understand the four “Cs” of elder law practice:1 understanding who the client is, understanding the importance of confidentiality, the potential of conflicts of interest, and questions regarding the capacity of the client.1 The client is often your older adult patient in the hospital setting or a resident in the senior living center. Litigation with respect to elder law often involves determining whether the client had legal capacity to execute the document in question and whether there were any conflicts of interest. Legal capacity exists on a continuum and is context specific.1 That is, the standard of legal capacity is different with respect to the document being executed. Affidavits are sometimes executed along with the primary legal document to reassure the courts that legal capacity was met. Before signing as a witness to any of these documents, be sure to carefully read the affidavit itself because it often outlines some of the capacity standards. If there is an attorney present, ask the attorney for clarification before signing as a witness. Does the client truly understand the consequences of executing a given document, and is the client mentally able to make such decision? If there is any question with respect to capacity, one should not take part in the execution of the legal document. Like geriatric practices, elder law practices also often involve family members. Similar to conducting family conferences in a geriatrics practice, when taking part in the execution of a legal document, it is always important to remember who the client is. A conflict of interest may arise when an adult child seeks arrangements for a loved one, but the child clearly will gain from the execution of a particular legal document.1 It is important not to get distracted with the needs and instructions of family members but to speak directly with the client (your patient). If there is any question with respect to conflict of interest, one should not take part in the execution of the legal document. It is helpful and often convenient for healthcare providers in older adult settings to serve as witnesses to the execution of important legal documents, but before agreeing to serve as a witness, one should be aware of the four Cs and make sure that the client's (patient's) rights and needs are not being compromised. Conflict of Interest: None. The University of Rochester CTSA award KL2 RR024136 funded this work. Author Contributions: Both authors contributed significantly to the research and writing of this paper. Sponsor's Role: None.

Advance directives in the context of end-of-life palliative care

To review the definition of advanced directive, understand the implications for the patient, family and healthcare team, and address the obstacles involved in the implementation. Advanced directives propose a model of healthcare based on patient preferences. Although there is sufficient evidence related to their usefulness, various factors are known to affect the use of advanced directives. Therefore, rules need to be established in order to optimize the implementation process. An advanced directive is a legal document based on the principle of autonomy that expresses the desire of the patient in relation to different medical treatments when the patient is unable to make those decisions. The advanced directives are represented in three formats: Living Will, Appointment of a Healthcare Proxy and Legal Status of Preferences. The uses of advanced directives have an impact not only on the patients and their families, but also on the healthcare team. Despite their utility being well known, there are several general barriers that affect implementation, as well as factors related to characteristics of each study population.