Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

https://www.who.int/respiratory/copd/GOLD_WR_06.pdf

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

https://caltcm.memberclicks.net/assets/documents/acc_aha_chf_2013_guidelines.pdf

2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Objective: The objective was to provide guidelines to clinicians for the evaluation, treatment, and prevention of vitamin D deficiency with an emphasis on the care of patients who are at risk for deficiency. Participants: The Task Force was composed of a Chair, six additional experts, and a methodologist. The Task Force received no corporate funding or remuneration. Consensus Process: Consensus was guided by systematic reviews of evidence and discussions during several conference calls and e-mail communications. The draft prepared by the Task Force was reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and cosponsoring associations, and it was posted on The Endocrine Society web site for member review. At each stage of review, the Task Force received written comments and incorporated needed changes. Conclusions: Considering that vitamin D deficiency is very common in all age groups and that few foods contain vitamin D, the Task Force recomme...

/pdf/evaluation-treatment-and-prevention-of-vitamin-d-deficiency-4wt9apc7iy.pdf

Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline

OBJECTIVE\nThe objective was to provide guidelines to clinicians for the evaluation, treatment, and prevention of vitamin D deficiency with an emphasis on the care of patients who are at risk for deficiency.\n\n\nPARTICIPANTS\nThe Task Force was composed of a Chair, six additional experts, and a methodologist. The Task Force received no corporate funding or remuneration.\n\n\nCONSENSUS PROCESS\nConsensus was guided by systematic reviews of evidence and discussions during several conference calls and e-mail communications. The draft prepared by the Task Force was reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee, Clinical Affairs Core Committee, and cosponsoring associations, and it was posted on The Endocrine Society web site for member review. At each stage of review, the Task Force received written comments and incorporated needed changes.\n\n\nCONCLUSIONS\nConsidering that vitamin D deficiency is very common in all age groups and that few foods contain vitamin D, the Task Force recommended supplementation at suggested daily intake and tolerable upper limit levels, depending on age and clinical circumstances. The Task Force also suggested the measurement of serum 25-hydroxyvitamin D level by a reliable assay as the initial diagnostic test in patients at risk for deficiency. Treatment with either vitamin D(2) or vitamin D(3) was recommended for deficient patients. At the present time, there is not sufficient evidence to recommend screening individuals who are not at risk for deficiency or to prescribe vitamin D to attain the noncalcemic benefit for cardiovascular protection.

Evaluation, treatment, and prevention of vitamin D deficiency: An endocrine society clinical practice guideline (Journal of Clinical Endocrinology and Metabolism (2011) 96, (1911-1930))

CA : A Cancer Journal for Clinicians

Case Vignette Anne is a 59-year-old woman who is weighing her future and wondering whether she’ll see her granddaughter grow up. She has breast cancer, and so far her treatments haven’t beaten the disease or prevented its spread. She completed an advance directive when she was 50 years old, after her parents’ unexpected deaths from lung cancer and a stroke and years before her diagnosis of breast cancer. Her mother spent a short time in hospice and her father’s stroke was fatal within 24 hours. When she completed her advance directive 9 years ago, she indicated that her sister Betty would have her power of attorney for health care and that if she were terminally ill she would not want to be intubated. She returns to see you as her primary care physician. You’ve taken care of her for 3 years but have seen her only three times, since the oncology team has coordinated most of her care. She initially received a diagnosis of localized estrogen-receptor–negative, progesterone-receptor–negative, and human epidermal growth factor receptor type 2–negative (so-called triple negative) breast cancer 4 years ago. She underwent lumpectomy, breast radiation therapy, and 6 months of adjuvant chemotherapy for nodepositive disease. Twelve months after she completed treatment, a mass developed in her other breast, and staging evaluation revealed metastatic lesions in her spine and lung. The other breast was removed, and she received chest radiation therapy along with radiation therapy to the spine. She was given paclitaxel, carboplatin, capecitabine, cyclophosphamide, eribulin, docetaxel, and liposome-encapsulated doxorubicin in succession, each for a few months. Over a 22-month period, her disease has slowly progressed, and she now has several metastatic lesions in her liver and an increase in the size and number of cancer nodules in her lungs. Before the visit, you talk to the oncology social worker, who reviews the records and tells you that Anne is in moderate pain and has some limitation of function but is still managing her activities of daily living. Anne wants to discuss treatment options to gain more time with her family. When you ask about daily activities, she says that her groceries are now being delivered and that she naps twice a day. She asks whether her back pain might be due to fractures caused by the spread of the breast cancer but then says that she wants to pursue therapy that will help her make it to next spring “and beyond.” Anne also tells you that her sister Betty is worried about what kind of decisions she might have to make. You think that she needs to understand her prognosis more clearly and have a “goals of care” conversation that explores her long-standing values.

Clinical decisions. End-of-life advance directive.

Palliative care in inpatient units.

n 1990, the population prevalence of dementia in the I United States was estimated at 10.2% of the 65 and older age group and 40% of people aged 85 years and older.’ The number of persons more than 85 years of age, the group most likely to suffer from dementing illness, is projected to quadruple over the next 40 years. As a result, in the year 2040, the prevalence estimate for dementia lies somewhere between 7 and 12 million persons, almost half of whom will have advanced disease and will require complete custodial care, often for years, before death.2 Medical decisions for dementia patients are usually made by family members acting in consultation with clinicians. Ideally these decisions are based on knowledge of the patient’s previously expressed wishes, such as are found in advance directives, or on knowledge of the patient’s wishes gained from specific conversations on the topic occurring before the onset of significant cognitive impairment. This kind of evidence of patient preference does not exist for the vast majority of dementia patients, either because the onset of dementia predated the widespread availability of advance directives or because physicians, patients, and family members failed to engage in the necessary discussion about preferences before the patient lost the capacity to participate. In the absence of such information, surrogate decision-makers are generally advised to decide as they think the patient would have under these circumstances or to decide based on what they think would constitute the patient’s best interests. In most states, surrogate decision-making laws support such a family centered model of decision-making for patients who lack decisional capacity.” Though there may be some risks to family centered surrogate decision-making for patients without decisional capacity, studies suggest that this is the approach preferred by patients and is that most likely to preserve both their autonomy and their best interests. But what about dementia patients who have no one to speak for them when decisions must be made on their behalf? Very little is known about the numbers of dementia patients in the United States who either have no one to serve as a surrogate decision-maker or whose potential surrogates are incapable, unavailable, or otherwise not functional when decisions must be made. A MEDLINE search and extensive personal communication with colleagues in the field revealed almost no data on the prevalence of this problem, a statement in itself of the lack of attention to this extremely vulnerable, but voiceless, population. In a study by Fader et al., 45% of next of kin listed for nursing home residents could not be reached for participation in major decisions about their relative’s resuscitation status, suggesting that a significant number of long-term care residents are functionally without a ~ur roga te .~ A 1994 survey on treatment decision-making policies and procedures for decisionally impaired residents of nursing homes in New York State found that 27 to 37% of respondents believed that major medical decisions “sometimes or often” had to be made for patients without families.’ In an ongoing randomized controlled trial of palliative approaches to the care of hospitalized patients with advanced dementia conducted at Mount Sinai Hospital in New York City: 45 % of otherwise eligible, severely demented, subjects could not be randomized because they either had no surrogate or their surrogate was unable to engage in any deliberative process on their behalf. Medical decisions for these acutely ill patients with advanced dementia were made by their attending physician, presumably based on the attending physician’s conception of the patient’s best interest. Similar reversion to physician-based decisions are presumed to occur in long-term care settings when no surrogates are available.’

Voiceless and Vulnerable: Dementia Patients Without Surrogates in an Era of Capitation

Background: The escalating demand for palliative care physicians has led to the proliferation of postgraduate fellowship programs to train physicians in the United States and Canada. There is currently little data regarding the extent to which clinical, research, educational or administrative skills and competencies have been incorporated into fellowship training. Objective: The survey aims were to describe: (1) fellows' interests and relative priorities for receiving training in the clinical, educational, research, and administrative aspects of palliative medicine; (2) quantity of training received in each area; (3) fellows' satisfaction with the teaching received in each area; (4) postfellowship employment experiences. Design: A survey was conducted via mail and in person, with e-mail utilized for reminders. Setting/subjects: All palliative medicine fellows from the United States and Canada between 1997 and 2002 were surveyed. Measurements: The survey instrument was based on a Health Resources Services ...

Training of palliative medicine fellows: a report from the field.

Meeting the Needs of Patients with Heart Failure Palliative and hospice care remain underused for patients with heart failure. In the next phase of serious-illness care, care delivery innovations c...

Diane E. Meier

Papers

Clinical decisions. End-of-life advance directive.

Palliative care in inpatient units.

Voiceless and Vulnerable: Dementia Patients Without Surrogates in an Era of Capitation

Training of palliative medicine fellows: a report from the field.

Serious-Illness Care 2.0 — Meeting the Needs of Patients with Heart Failure