This study shows that vignettes are a valid tool for measuring the quality of clinical practice. They are particularly useful for evaluating quality when practice-based assessment is difficult beca...

Measuring the quality of physician practice by using clinical vignettes: A prospective validation study

ContextAlthough advance directives are commonly used in the community, little
is known about the effects of their systematic implementation.ObjectivesTo examine the effect of systematically implementing an advance directive
in nursing homes on patient and family satisfaction with involvement in decision
making and on health care costs.DesignRandomized controlled trial conducted June 1, 1994, to August 31, 1998.Setting and ParticipantsA total of 1292 residents in 6 Ontario nursing homes with more than
100 residents each.InterventionThe Let Me Decide advance directive program included educating staff
in local hospitals and nursing homes, residents, and families about advance
directives and offering competent residents or next-of-kin of mentally incompetent
residents an advance directive that provided a range of health care choices
for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing
homes were pair-matched on key characteristics, and 1 home per pair was randomized
to take part in the program. Control nursing homes continued with prior policies
concerning advance directives.Main Outcome MeasuresResidents' and families' satisfaction with health care and health care
services utilization over 18 months, compared between intervention and control
nursing homes.ResultsOf 527 participating residents in intervention nursing homes, 49% of
competent residents and 78% of families of incompetent residents completed
advance directives. Satisfaction was not significantly different in intervention
and control nursing homes. The mean difference (scale, 1-7) between intervention
and control homes was −0.16 (95% confidence interval [CI], −0.41
to 0.10) for competent residents and 0.07 (95% CI, −0.08 to 0.23) for
families of incompetent residents. Intervention nursing homes reported fewer
hospitalizations per resident (mean, 0.27 vs 0.48; P
= .001) and less resource use (average total cost per patient, Can $3490 vs
Can $5239; P = .01) than control nursing homes. Proportion
of deaths in intervention (24%) and control (28%) nursing homes were similar
(P = .20).ConclusionOur data suggest that systematic implementation of a program to increase
use of advance directives reduces health care services utilization without
affecting satisfaction or mortality.

https://jamanetwork.com/journals/jama/articlepdf/192502/JOC90890.pdf

Systematic Implementation of an Advance Directive Program in Nursing Homes: A Randomized Controlled Trial

Systematic Implementation of an Advance Directive Program in Nursing Homes

Objective. —To examine the attitudes of health care workers regarding the withdrawal of life support. Design. —Cross-sectional survey. Participants. —Attending staff, house staff, and intensive care unit (ICU) nurses in 37 Canadian university-affiliated hospitals. Main Outcome Measures. —Health care workers' ratings of the importance of 17 factors considered in the decision to withdraw life support, and their ratings of five levels of care ranging from comfort measures to intensive care in two of 12 different clinical scenarios. Results. —We surveyed 1361 respondents (149 of 167 potentially eligible ICU attending staff, 142 of 173 ICU house staff, and 1070 of 1455 ICU nurses, with response rates of 89%, 82% and 74%, respectively). The most important factors were likelihood of surviving the current episode, likelihood of long-term survival, premorbid cognitive function, and age of the patient. In choosing the level of care for the patient scenarios, the same option was chosen by more than 50% of respondents in only one of 12 scenarios; opposite extremes of care were chosen by more than 10% of the respondents in eight of 12 scenarios. Respondent characteristics affecting choices included the number of years since graduation, the city and province in which they worked, the number of beds in their ICU, and their assessment of the likelihood that they would withdraw life support in comparison with their colleagues (P Conclusions. —While ICU health care workers consistently identify a number of patient factors as important in decisions to withdraw care, there is extreme variability, which may be explained in part by the values of individual health care providers. (JAMA. 1995;273:703-708)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=jama&articleId=387265&pdfFileName=jama_273_9_033.pdf

Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill

Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine

OBJECTIVES: To determine what treatment decisions physicians will make when faced with an incompetent elderly patient with life-threatening gastrointestinal bleeding and to identify the factors that affect their decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. OUTCOME MEASURE: A self-administered questionnaire containing three case vignettes. Each provided the same details on an incompetent elderly patient; however, one gave no information about the wishes of the patient and his family (no directive), the second provided a do-not-resuscitate (DNR) request, and the third included a detailed therapeutic and resuscitative effort chart (DTREC) requesting maximum therapeutic care without admission to the intensive care unit (ICU). The four treatment options were supportive care only, limited therapeutic care, maximum therapeutic care without admission to the ICU and maximum care with admission to the ICU. MAIN RESULTS: Treatment decisions varied and were systematically related to age, level of training and country (p less than 0.001). The older physicians and those in family medicine were less likely than the others to choose aggressive treatment options. Brazilian and US physicians were the most aggressive; Australian physicians were the most conservative. The DNR request resulted in a significant decrease in the number of physicians choosing aggressive options (p less than 0.001). The DTREC resulted in a move toward more aggressive treatment, as outlined in the directive (p less than 0.001). Overall, however, about 40% of the physicians chose a level of care different from what had been requested. Furthermore, over 10% would have tried cardiopulmonary resuscitation despite the DNR request. CONCLUSION: Treatment of incompetent elderly patients with life-threatening illness varies widely within and between countries. Uniform standards should be developed on the basis of societal values and be communicated to physicians.

Variability in physicians' decisions on caring for chronically ill elderly patients: an international study

OBJECTIVES: To determine what treatment decisions physicians will make when faced with a hypothetical incompetent elderly patient with life-threatening gastrointestinal bleeding and to examine the relative importance of physician characteristics and factors (legal and ethical concerns, hospital costs, level of dementia, patient9s age, physician9s religion, patient9s wishes and family9s wishes) in making those decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. MAIN OUTCOME MEASURES: A self-administered questionnaire describing the elderly patient. Respondents were asked to choose one of four levels of care and to identify the level of importance factors had in making that decision. Older physicians, those less concerned about litigation, those for whom the level of dementia was important and those for whom the patient9s age was important were expected to give less aggressive care than the other physicians. MAIN RESULTS: Supportive care was chosen by 8.1% of the respondents, limited therapeutic care by 41.5%, maximum therapeutic care without admission to the intensive care unit (ICU) by 32.2% and maximum care with admission to the ICU by 18.2%. The patient9s wishes were reported by 91.0% as being extremely or very important in choosing the treatment. Stepwise logistic regression analysis revealed that the following variables independently predicted the level of treatment: level of dementia, country of residence, duration of practice, legal concerns, patient9s age and ethical concerns. These factors were significantly correlated with the physicians9 treatment choices (p less than 0.05). CONCLUSIONS: The importance that the physicians placed on the level of dementia was the strongest predictor of the level of care that would be provided. A societal consensus on the influence of cognitive function on the appropriate level of care as well as training of physicians in ethical issues are required.

Alice Zelmanowicz

Papers

Variability in physicians' decisions on caring for chronically ill elderly patients: an international study

Factors affecting physicians' decisions on caring for an incompetent elderly patient: an international study