What do older patients and their families think about the limitation of therapeutic effort?

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"tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "449" "paginaFinal" => "451" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Pérez Figueras, A. Blanco Portillo, G. Navarro Jiménez, M. Velasco Arribas" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Pérez Figueras" "email" => array:1 [ 0 => "mperezfigueras@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Blanco Portillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "G." "apellidos" => "Navarro Jiménez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Velasco Arribas" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Investigación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Qué opinan los pacientes mayores y sus familiares sobre la limitación del esfuerzo terapéutico?" ] ] "textoCompleto" => "In recent decades, a physician–patient relationship model has been advocated in which patient autonomy is paramount, a model that presents greater capacity for making and controlling their medical decisions,<a class="elsevierStyleCrossRefs" href="#bib0075">1,2</a> as mentioned in the law on patient autonomy.<a class="elsevierStyleCrossRef" href="#bib0085">3</a>Given the scarce number of advance directives<a class="elsevierStyleCrossRef" href="#bib0090">4</a> and the growing modernization of health care, we often find situations where a patient cannot make decisions and where another individual, typically a family member, assumes the decision-making process to safeguard the patient's autonomy. The aim of this study was to determine the opinion of elderly patients without dementia on the limitation of diagnostic and therapeutic efforts and its correlation with their relatives’ opinions.The study was conducted with patients hospitalized in internal medicine between June and September 2016. We included all patients older than 75 years without dementia and their relatives who responded to a self-administered survey, which was submitted at admission. The study assessed the degree of acceptance (never, exceptionally, most of the time and always) for performing 15 diagnostic and therapeutic maneuvers: cardiopulmonary resuscitation (CPR), noninvasive or invasive diagnostic procedures, transfusion, intravenous and repeated antibiotherapy, nasogastric tube (NGT), oxygen therapy, serotherapy, analgesia, dialysis, aggressive surgery and hospital readmission. The patient and their relatives were asked how they would act in situations where the patient was incapable of making decisions.The patient's comorbidities and degree of dependence was assessed with the Charlson and Barthel scales, respectively. We also collected the patients’ age, sex and location of regular residence. The study was approved by the medical research ethics committee. We performed a descriptive statistical analysis and multiple regression using SPSS® v.19. The degree of concordance was expressed using the Kappa index and prevalence and bias adjusted kappa (PABAK).<a class="elsevierStyleCrossRef" href="#bib0095">5</a>We collected 32 pairs of completed surveys, which represented 28% of the admissions. The patients’ mean age was 84±5.9 years (66% were older than80 years), and 59.4% were men. The mean Barthel and Charlson scores were 75.5±29.4 and 2.4±1.7, respectively. None of the patients were institutionalized. Some 43.8% lived at the home of a family member, and 50% of the family members were the main caregiver. More than 80% chose the options “most of the time” and “always” for all questions, except dialysis, where only 64.5% agreed with “most of the time” or “always”. Among the interventions that the patients stated should always be performed, serotherapy was the most accepted (93.5%; n=29), followed by repeated antibiotherapy (81.3%; n=26), transfusion (81.3%; n=26), noninvasive diagnostic procedures (81.3%; n=26), oxygen therapy (78.1%; n=25), intravenous antibiotherapy (75%; n=24) and analgesia (74.2%; n=23).The least accepted interventions were the implementation of dialysis (25.8%; n=8), hospital readmission (9.7%; n=3), NGT placement (3%; n=1) and implementation of CPR (3%; n=1).After analyzing the effect of patient sex, comorbidities and degree of dependence on the patients’ opinion, we observed that those older than 80 years expressed the desire to not be readmitted more often than the younger patients (80% vs. 33.3%; p<.05). There were no significant differences in the other variables.The correlation between the patients and their family members in favor of performing interventionist procedures was >80% for all procedures, except the use of NGT (69%) and hospital readmission (67.9%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Regarding the patients’ opinion when making decisions in the event they are unable to do so, 59.4% chose to delegate the decision to their relatives. None of the patients had formalized the advance directives document.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Knowing the patients’ opinion regarding implementing medical procedures is a seldom analyzed topic in the medical literature, and there is barely any information on its correlation with the family members’ opinion in the departments other than the intensive care unit (ICU),<a class="elsevierStyleCrossRefs" href="#bib0100">6,7</a> where the physician's opinion is powerful. Another setting in which the delegation of responsibility has been assessed is that of patients in palliative situations. The SUPPORT study is notable in this respect in that it described the decision-making process of more than 4000 patients with limited life prognoses, with or without the support of a healthcare practitioner, showing a significant variety of preferences.<a class="elsevierStyleCrossRef" href="#bib0110">8</a>Cherniack observed that physicians often ignored the patients’ opinion regarding the implementation of invasive procedures such as CPR, especially for the elderly, despite the fact that the patients wanted to express their opinion.<a class="elsevierStyleCrossRef" href="#bib0115">9</a>Our study observed a high degree of concordance between the patients’ and families’ opinions. This finding is relevant because it reinforces the family's role as a substitute for the patient in the decision-making process in our setting. Similar articles are scarce but show similar results to those of our study, showing that family members have a highly interventional approach a priori.<a class="elsevierStyleCrossRefs" href="#bib0120">10,11</a> This attitude could be attributed to a lack of significant impairment among the patients, to disproportionate expectations regarding healing or to a lack of understanding regarding the procedures. It is worth noting that the interventions that the patients more easily understood as invasive were less accepted, such as dialysis, invasive diagnostic tests, NGT and CPR.We should emphasize that the patients did not want to be readmitted to the hospital. We can extract from this finding the need to improve medium-stay and home hospitalization units, which have decreased readmission rates and reduced the impact of hospitalization on patients with limited life prognoses.<a class="elsevierStyleCrossRefs" href="#bib0130">12,13</a>A relevant aspect of this study is that none of the patients had signed an advance directives document. This attitude had already been reflected in another article in which very few patients who required ICU admission had signed the document.<a class="elsevierStyleCrossRef" href="#bib0120">10</a> Since the implementation of advance directives, few patients have known about or implemented them.<a class="elsevierStyleCrossRef" href="#bib0140">14</a>Lastly, patients trust their medical decisions to their family members. Although the physician-patient relationship is changing, the paternalistic model will probably remain dominant in this age group. This relationship could change in future generations due to the current changes in access to information.Our study has limitations. The study patients had a moderate grade of dependence and comorbidity, which could make them susceptible to accepting more aggressive procedures a priori and, therefore, align more easily with that of their family members. The sample was also small for the inclusion characteristics of the patients and relatives.In conclusion, the wishes of elderly patients align with those that their family members believe the patients hold and favors the implementation of diagnostic and therapeutic maneuvers, even the more invasive ones. Although information is constantly growing and resources such as advance directives have been created, their use has not become widespread. In critical conditions in which the patient cannot decide, the family (in conjunction with the physician) are the ones to make this decision in most cases." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Pérez Figueras M, Blanco Portillo A, Navarro Jiménez G, Velasco Arribas M. ¿Qué opinan los pacientes mayores y sus familiares sobre la limitación del esfuerzo terapéutico?. Rev Clin Esp. 2018;218:449–451." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: KI, Kappa index; PABAK, prevalence and bias-adjusted kappa; CPR, cardiopulmonary resuscitation; NGT, nasogastric tube." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage of total agreement, % \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">KI \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">PABAK \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CPR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Invasive test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Invasive tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transfusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IV antibiotic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Repeated antibiotic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NGT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxygen therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serotherapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">NE \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Analgesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital readmission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1883062.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Concordance table." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "1982" "editorial" => "US Government Printing Office" "editorialLocalizacion" => "Washington" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0080" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "La relación médico-paciente en una sociedad en transformación" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. 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