Preferred Medical Treatment Research Articles

Religiosity and Preferences for Life-Prolonging Medical Treatments in African-American and White Elders: A Mediation Study

Research on end-of-life treatment preferences has documented robust racial differences, with African-Americans preferring more life-prolonging treatment than Whites. Although little research has attempted to explain these racial differences systematically, speculation has centered on religiosity. We examined a dimension of religiosity frequently invoked in end-of-life research-guidance by God's will-as a potential mediator of racial differences in such treatment preferences. Three hundred African-American and White men and women aged 60 or older participated in a 35-minute telephone interview that elicited preferences for four common life-prolonging treatments in each of nine health scenarios. The questionnaire included the five-item God's will (GW) scale, a health conditions checklist, a depression measure, and sociodemographic questions. GW mediated racial differences at least partially for most treatments and in most health scenarios. Implications are discussed for understanding end-of-life treatment preferences and why races tend to differ.

Minimal access surgery compared with medical management for chronic gastro-oesophageal reflux disease: UK collaborative randomised trial

Objective To determine the relative benefits and risks of laparoscopic fundoplication surgery as an alternative to long term drug treatment for chronic gastro-oesophageal reflux disease (GORD).Design Multicentre, pragmatic randomised trial...

The Default Effect in End-of-Life Medical Treatment Preferences

Living wills are intended to preserve patient autonomy, but recent studies suggest that they do not always have their desired effect. One possible explanation is that living wills do not capture the authentic preferences of the patients who write them but instead reflect transient contextual effects on preferences. Two experiments examined whether end-of-life treatment preferences expressed in a living will were influenced by the presence of default options. College students participated in 2 Web-based questionnaire experiments (Ns = 182 and 51). Participants were randomly assigned to 1 of 2 or 3 default conditions. In experiment 1, participants expressed significantly different treatment preferences in 3 normatively equivalent, check box-formatted living wills that were either positively worded ("indicate medical treatments you would want administered"), negatively worded ("indicate treatments you would want withheld"), or of forced-choice format (P = 0.01). Participants expressed a stronger preference to receive treatment in the negatively worded document than in the positively worded document as a consequence of preferring the default option in both cases. Participants in experiment 2 were also influenced by the presence of a default option, but this time, while writing narrative living wills after viewing 1 of 2 sample living wills. In this experiment, the sample living will represented the default preference. The participants' own living wills tended to express preferences similar to those in the sample (P = 0.0005). The default manipulations in both experiments had potent but transient effects and influenced what participants wrote in their living wills but not their responses to later medical scenarios. Expression of end-of-life treatment preferences appears to be temporarily constructed from the decision-making context. These results have implications for surrogate decision making and the use of the living will as a tool to preserve patient autonomy.

The Influence of Default Options on the Expression of End-of-Life Treatment Preferences in Advance Directives

Advance directives promise to preserve patient autonomy, but research indicates that end-of-life preferences can be influenced by the way in which questions are posed. To determine whether preferences expressed by geriatric patients on advance directives are influenced by the default response inherent in the question. Mailed survey containing 1 of 3 versions of an advance directive. General internal medicine outpatient medical practice. Outpatients aged 65 or older (n = 106, response rate = 27%). In the "withhold" version of the survey, participants indicated situations where they would want treatments withheld (i.e., the default preference was in favor of treatment). In the "provide" version, participants indicated situations where they would want treatment provided (i.e., the default preference was against treatment). In the forced-choice control version, participants made an explicit decision to withhold or provide treatment for each situation. Participants' treatment preferences. Preferences differed by condition, F(2, 103) = 3.61, MSE = 0.09, eta2 = .07, p = .03. Participants tended to express the default preference, and thus, were more likely to favor treatment in the "withhold" condition than in the "provide" condition. Preferences in the forced-choice control condition were intermediate. The default inherent in a question can impact preferences for medical treatment. This default effect limits the utility of advance directives.

How should treatment decisions be made for incapacitated patients, and why?

Patients have gained unprecedented levels of control over their medical care, including prospective control over what treatments they will receive if they lose the ability to make decisions. The landmark Cruzan and Quinlan cases helped to secure patients' right to prospectively refuse life-sustaining treatments [1,2], while the Patient Self-Determination Act of 1990 mandated that patients be informed of the option to document their treatment preferences in an advance directive [3]. Despite these efforts, many individuals fail to complete an advance directive and seldom discuss their medical treatment preferences, often leaving clinicians with little indication for how they want to be treated [4–7]. Several groups have attempted to increase the number of people who complete an advance directive, and several approaches offer promise in this regard [8]. Yet, no method, no matter how exhaustive, will result in all individuals completing an advance directive, and no advance directive, no matter how detailed, will provide clear instructions for all clinical scenarios. For the foreseeable future, then, clinicians will continue to face the dilemma of how to treat some incapacitated patients in the absence of clear evidence regarding their treatment wishes. Most states in the US direct clinicians to turn to surrogate decision makers, identified through standardized relationship hierarchies, to make treatment decisions for incapacitated patients who did not designate a surrogate while capacitated. Surrogates, whether designated by the patient or the state's standardized hierarchy, are instructed to make the treatment decision the patient would have made if capacitated. Under this “substituted judgment” standard, a surrogate asked to decide whether to initiate dialysis for a comatose patient, for example, should try to determine what decision the patient would have made in the circumstances. Individuals often fail to complete an advance directive. The medical profession's reliance on surrogates to make treatment decisions for incapacitated patients gains support from the fact that the relevant considerations for choosing a substitute decision maker all seem to point to the family and loved ones. Allowing the patient's family and loved ones to make treatment decisions seems to respect their status as vital individuals in the patient's life [9–11] and may provide comfort at a difficult time. Reliance on those who know the patient best also seems to promote patient autonomy by maximizing the chances that the incapacitated patient's preferences will guide what treatments they receive. Finally, current practice seems consistent with patients' preferences for how treatment decisions should be made [12–14]. To test whether, in fact, these considerations all support the same approach, we assessed whether a population-based decision aid might predict patients' treatment preferences more accurately than surrogates.

Accuracy and Bias in Perceptions of Spouses' Life‐Sustaining Medical Treatment Preferences1

This research investigated accuracy, projection bias, and base‐rate utilization in spouses' perceptions of end‐stage renal disease patients' preferences for life‐sustaining medical treatment in hypothetical conditions of declining health. Multilevel models revealed that spouses' perceptions were largely biased, determined by their own preferences for the patients' treatment (projection bias) and by typical treatment preferences (base‐rate utilization). Both biases, however, served as indirect routes to a modest degree of accuracy. Moreover, spouses who overestimated patients' preferences for life‐sustaining treatment and who perceived patients' preferences as consistent with their own reported higher levels of marital adjustment than did those who were less biased. Results suggest that spouses' biases in judgments of patients' treatment preferences may promote accuracy and marital adjustment functionally.

Racial/ethnic differences in preferences for total knee replacement surgery

Objectives To determine whether there are ethnic differences in preferences for surgery vs. medical treatment of knee osteoarthritis (OA). Study Design and Setting Cross-sectional in-person interviews using conjoint analysis methodology, a technique often used in marketing, involved individuals making choices between alternative hypothetical scenarios for medical or surgical treatment of knee OA. One hundred ninety-three individuals over the age of 20 were recruited through random digit dialing in Harris County, TX, and 198 individuals with knee OA were recruited from a large outpatient health care provider in Houston, TX. Results African Americans were significantly less likely to chose surgery than whites (odds ratio 0.63 [0.42, 0.93]). Women and older individuals were also less likely to choose surgery (0.69 [0.51, 0.94], 0.98 [0.97, 0.99]). Larger reductions in negative symptoms with surgery significantly increased the likelihood of choosing surgery. There was no difference between the public and patients, and no effect of income level. Conclusions Disparities in knee replacement rates among ethnic groups may be partly due to differences in preferences for surgery. Conjoint analysis was shown to be a feasible methodology for collecting preferences in health research. This methodology has great promise in contributing to our knowledge of drivers of health care decision making in individuals.

No difference in stroke knowledge between Korean adherents to traditional and western medicine – the AGE study: an epidemiological study

BackgroundEffective stroke intervention and risk reduction depend on the general public's awareness and knowledge of stroke. In Korea, where both traditional Oriental medicine and Western medicine are practiced, estimates of the general public's awareness and knowledge of stroke are poor. The present study sought to describe the inception cohort of the Ansan Geriatric Study (AGE study) and to determine baseline stroke awareness and preferred medical treatment for stroke in this Korean sample.MethodsA total of 2,767 subjects selected randomly from the Ansan Geriatric Study in South Korea were questioned about stroke. Their answers were compared with their sociodemographic data and other variables.ResultsOnly 44.8% of participants correctly identified stroke as a vascular disease in the human brain. Sudden numbness or weakness was the most frequently identified stroke warning sign (60.2%). Hypertension (66.7%) and mental stress (62.2%) were most frequently identified as stroke risk factors. The contributions of diabetes mellitus and cardiovascular disease to stroke were underestimated; they were identified as risk factors by 28.3% and 18.6% of participants, respectively. The predictors for poor knowledge of stroke warning signs and risk factors were similar irrespective of preference for Western or Oriental medical treatment, and included those with lower levels of education and inaccurate definition of stroke. Television and radio (40.3%) were the most frequent sources of stroke information for both groups.ConclusionThis study shows that knowledge of stroke is similar among Koreans with preferences for either Western or Oriental medical treatment and that misunderstandings about stroke are common among the Korean elderly. In order to prevent and manage stroke effectively, public health education regarding basic concepts of stroke is necessary. This should target those with a lower level of education and a misunderstanding of the definition of stroke.

A Case of Acromegaly Caused by Double Pituitary Adenomas

Acromegaly is a clinical syndrome, which is caused by an excess of growth hormone (GH), most commonly secreted from a pituitary solitary adenoma. However, our patient had bilateral GH-secreting pituitary tumors, the incidence of which has been reported in only 1.3 to 1.69% of all acromegalic patients. A 59-year-old female, with no family history of pituitary adenomas, demonstrated an increased level of serum insulin-like growth factor-1 (IGF-1), and GH not suppressed after 75 g oral glucose loading. On a preoperative MRI, only one pituitary tumor, measuring 1.1 × 0.7 cm, could be observed using sellar MRI. After surgical resection of the tumor, her headache and myalgia were sustained, and the IGF-1 level was still in a high titer. Therefore, a follow-up sellar MRI was taken, and a 0.6 × 0.7 cm sized newly growing pituitary tumor was found on the other side. With a retrospective review of radiological exa minations, the patient was found to have bilateral tumors. The 0.3 cm sized tumor on the left was too small to be detected on the preoperative MRI. As the patient preferred medical treatment after surgery, she was treated with sandostatin analogues. Acromegaly with bilateral GH-secreting pituitary tumors, is a very rare disease, with no previous case having been reported in Korea. Herein, we report the case with a review of the literature (J Kor Soc Endocrinol 21:53~57, 2006).

The development of advance care directives in New South Wales

Advance Care Directives (ACDs) are becoming an increasingly popular way for people to state their wishes about the treatment they do or do not want at the end of their lives. This paper records some of the background to their introduction in NSW and reflects on the motivations and backgrounds of those who have been involved in developments to date. These developments came in response to changes in social attitudes and shifted the focus in advance planning for later life from financial and property decisions to encompass personal and medical treatment preferences. The relevant legislation in NSW is the Guardianship Act 1987, which governs substitute medical consent for adults who are unable to consent to their own treatment and enables competent adults to appoint an enduring guardian to be their substitute decision maker for personal and medical decisions. Although proclaimed in 1989, its provisions are still not well understood by the medical profession, much less by the general public. Action is underway on many fronts to increase awareness of all the ways in which people can plan ahead to have their wishes respected if they lose their mental competence.

Medical Advance Care Planning for Persons With Serious Mental Illness

This study examined preferences regarding medical advance care planning among persons with serious mental illness, specifically, experience, beliefs, values, and concerns about health care proxies and end-of-life issues. A structured interview, the Health Care Preferences Questionnaire, was administered to a convenience sample of 150 adults with serious mental illness who were receiving community-based services from the Massachusetts Department of Mental Health. Clinical information and demographic data were also collected. A total of 142 participants completed the questionnaire. Although more than one-quarter had thought about their medical treatment preferences in the event that they became seriously medically ill, very few had discussed these preferences. A majority of respondents (72 percent) believed that someone should be designated to make medical health care decisions for a person who is too sick to make or communicate these decisions him- or herself. Common end-of-life concerns included financial and emotional burdens on family, pain and suffering, interpersonal issues such as saying "goodbye," spiritual issues, and funeral arrangements. Participants were most uneasy about the prolonging or stopping of life support by proxy decision makers. A total of 104 respondents (69 percent) expressed interest in formally selecting a health care proxy. Although persons with serious and persistent mental illness have little experience with medical advance care planning, they show substantial interest in it. Furthermore, they are able to consider and communicate their preferences. This study supports the feasibility, acceptability, and utility of a standardized approach to medical advance care planning with this population.

Beliefs, Death Anxiety, Denial, and Treatment Preferences in End-of-Life Care

This study examined cultural and religious beliefs, death anxiety, denial, and medical treatment preferences in end-of-life care in a sample of social work students, community residents, and medical students in a mid-western city of 49,000. Results indicated that most social work students, community residents, and medical students preferred palliative as opposed to life-prolonging care during terminal illness. The three groups differed in cultural and religious beliefs and all three reported a moderate amount of death anxiety. Students reported less denial of terminality than community residents. Implications for personal and professional preparation to provide end-of-life care are discussed.

Perceptions of tuberculosis: attributions of cause, suggested means of risk reduction, and preferred treatment in the Limpopo province, South Africa.

Despite the availability of effective treatment regimens, exceptionally high rates of tuberculosis persist in South Africa. A better understanding of public perceptions of tuberculosis is important for the improvement of the existing tuberculosis-control programmes. This study was aimed at investigating public perceptions about causes, suggested means of risk reduction, and preferred treatment of tuberculosis. The cross-sectional study included a sample of 80 community members from four different age groups chosen by quota sampling in a semi-urban community. Results indicated that 13.75% of the community members reported biomedical causes of tuberculosis, 35% suggested biomedical methods as a means for risk reduction, and 91.25% preferred medical treatment. Significant gender but not age difference was found. Women reported more often than men a biomedical cause of tuberculosis. A number of misconceptions about the cause and risk reduction of tuberculosis were also mentioned. The results suggest that people in a semi-urban area of the Limpopo province have limited knowledge and understanding of tuberculosis. It is suggested that healthcare workers provide services for increasing basic knowledge about causes and risk reduction of tuberculosis of the population in every age group.

Micromanaging Death: Process Preferences, Values, and Goals in End-of-Life Medical Decision Making

This study examined patients' and surrogates' attitudes about using advance directives to manage end-of-life medical care. It also explored process preferences, or how patients want decisions to be made. Data come from the third wave of the Advance Directives, Values Assessment, and Communication Enhancement project, a longitudinal study designed to investigate psychological assumptions underlying the use of advance directives. Three-hundred thirty-seven outpatients aged 65 and older and their designated surrogate decision makers completed interviews and questionnaires. Very few individuals wished to document specific medical treatment preferences and mandate that they be followed, without exception, near death. Most desired to express more general preferences, such as values and goals for care, in addition to (or, instead of) specific treatment preferences and to allow surrogate decision makers leeway in decision making. Patient-to-patient variability with regard to process preferences was substantial, as was surrogates' misunderstanding of the patients' process preferences. Very few individuals may desire the standard approach to advance care planning whereby preferences for specific life-sustaining treatments are documented and these requests are strictly followed near death. Instead, patient autonomy may be better served by emphasizing discussion of process preferences and leeway in decision making.

The Effect of a Social Work Intervention to Enhance Advance Care Planning Documentation in the Nursing Home

To assess the effect of a multicomponent advance care planning intervention directed at nursing home social workers on identification and documentation of preferences for medical treatments and on patient outcomes. Controlled clinical trial. New York City nursing home. One hundred thirty-nine newly admitted long-term care residents. Nursing home social workers were randomized to the intervention or control groups. The intervention consisted of baseline education in advance care planning that incorporated small-group workshops and role play/practice sessions for intervention social workers; structured advance care planning discussions with residents and their proxies at admission, after any change in clinical status, and at yearly intervals; formal structured review of residents' goals of care at preexisting regular team meetings; "flagging" of advance directives on nursing home charts; and feedback to individual healthcare providers of the congruence of care they provided and the preferences specified in the advance care planning process. Control social workers received an educational training session on New York State law regarding advance directives but no additional training or interventions. Subjects were enrolled from January 9, 2001 through May 25, 2003 and followed for 6 months after enrollment. Nursing home chart documentation of advance directives (healthcare proxies, living wills) and do-not-resuscitate orders; preferences for artificial nutrition and hydration, intravenous antibiotics, and hospitalization; and concordance of treatments received with documented preferences were compared for residents assigned to intervention and control social workers. Intervention residents were significantly more likely than residents in the control group to have their preferences regarding cardiopulmonary resuscitation (40% vs 20%, P=.005), artificial nutrition and hydration (47% vs 9%, P<.01), intravenous antibiotics (44% vs 9%, P<.01), and hospitalization (49% vs 16%, P<.01) documented in the nursing home chart. Control residents were significantly more likely than intervention residents to receive treatments discordant with their prior stated wishes. Two of 49 (5%) intervention residents received a treatment in conflict with their prior stated wishes (one hospitalization, one episode of intravenous antibiotics), compared with 17 of 96 (18%) control patients (P=.04). This generalizable intervention directed at nursing home social workers significantly improved the documentation and identification of patients' wishes regarding common life-sustaining treatments and resulted in a higher concordance between patients' prior stated wishes and treatments received.

Making better decisions: From measuring to constructing preferences.

The authors examine how a constructive preferences perspective might change the prevailing view of medical decision making by suggesting that the methods used to measure preferences for medical treatments can change the preferences that are reported. The authors focus on 2 possible techniques that they believe would result in better outcomes. The 1st is the wise selection of default options. Defaults may be best applied when strong clinical evidence suggests a treatment option to be correct for most people but preserving patient choice is appropriate. The 2nd is the use of environments that explicitly facilitate the optimal construction of preferences. This seems most appropriate when choice depends on a patient's ability to understand and represent probabilities and outcomes. For each technique, the authors describe the background and literature, provide a case study, and discuss applications.

ENURESIS NOCTURNA PREVALENCE AND RISK FACTORS AMONG SCHOOL AGE CHILDREN IN NORTHWEST TURKEY

To find out prevalence of enuresis nocturna (EN) among school age children, and to determine associated factors and regional differences, an epidemiological study was performed among children between 7 to 12 years living in Zonguldak, Turkey. Data were collected at schools by a questionnaire. EN prevalence was found as 8.9 %, most (75.7 %) were primary, and the rest were secondary. Prevalence decreased as the age increased in both genders. There was a positive relationship of EN with positive family history, presence of EN in a brother or a sister, encopresis, sleep disturbances, a maternal education of primary school or less, working mother, low monthly income, low school success and introversion or extroversion. Only 19.8 % of the cases preferred medical treatment modalities, other preferences were waiting for spontaneous improvement, awaking the child for voiding, water restriction and diapering, in decreasing order. As EN is a disease that can result in low self-esteem, some other psychological problems and low school success, it must be treated. Informing these parents wherever they are met, especially at primary health care settings, is necessary both not to miss patients and to convince the parents for treatment.

229 Eliciting preferences for benign prostatic hyperplasia medical treatment

229 Eliciting preferences for benign prostatic hyperplasia medical treatment

Enhancing communication for end-of-life care: an electronic advance directive process.

An advance directive, a description of one's future preferences for medical treatment, must be easily available to care providers to ensure that one's treatment preferences are honored. The transition of our health care system to an electronic medical record complicated the availability of a patient's written advance directive. This paper describes the development of an electronic advance directive to facilitate access to a patient's treatment wishes at any site in our health care system. The successes and challenges encountered in the development process are discussed.

Australian women's prediagnostic decision-making styles, relating to treatment choices for early breast cancer treatment.

Women diagnosed with early breast cancer are now asked by their doctors to choose from a range of options for their preferred medical treatment plan. Little information is known about women's treatment decision-making and therefore nurses do not have evidence to guide this decision support. The aim of this descriptive survey was to investigate the prediagnostic decision-making behavior of a sample (N = 377) of Australian women, regarding their treatment choices for early breast cancer. The data were collected using the Pre-Decision Portfolio Questionnaire (PDPQ) by Pierce (1996), which includes the Michigan Assessment of Decision Styles (MADS). Of 366 participating women, 19.9% strongly agreed to all three items of the MADS factor Deferring Responsibility; 0.3% strongly agreed to all four factors of Avoidance; 32.7% strongly agreed on all four items of Information Seeking; and 63.4% strongly agreed to all five items of Deliberation. Women showed a variety of preferred decision styles, depending on age, education, occupation and employment status. Only 36% of women indicated it was critically important to "get the treatment over as soon as possible;" 55% to "participate in selecting treatment;" and 53% to "read a lot of information:" The understanding of factors that are important to women when they are making decisions for medical treatment is a mandatory step in designing customized evidence-based decision support, which can be delivered by nurses to help women during this distressing experience.