What really matters in end-of-life discussions? Perspectives of patients in hospital with serious illness and their families

Background:

The guideline-recommended elements to include in discussions about goals of care with patients with serious illness are mostly based on expert opinion. We sought to identify which elements are most important to patients and their families.

Methods:

We used a cross-sectional study design involving patients from 9 Canadian hospitals. We asked older adult patients with serious illness and their family members about the occurrence and importance of 11 guideline-recommended elements of goals-of-care discussions. In addition, we assessed concordance between prescribed goals of care and patient preferences, and we measured patient satisfaction with goals-of-care discussions using the Canadian Health Care Evaluation Project (CANHELP) questionnaire.

Results:

Our study participants included 233 patients (mean age 81.2 yr) and 205 family members (mean age 60.2 yr). Participants reported that clinical teams had addressed individual elements of goals-of-care discussions infrequently (range 1.4%–31.7%). Patients and family members identified the same 5 elements as being the most important to address: preferences for care in the event of life-threatening illness, values, prognosis, fears or concerns, and questions about goals of care. Addressing more elements was associated with both greater concordance between patients’ preferences and prescribed goals of care, and greater patient satisfaction.

Interpretation:

We identified elements of goals-of-care discussions that are most important to older adult patients in hospital with serious illness and their family members. We found that guideline-recommended elements of goals-of-care discussions are not often addressed by health care providers. Our results can inform interventions to improve the determination of goals of care in the hospital setting.In Canada, dying is often an in-hospital, technology-laden experience.^1–4 Rates of cardiopulmonary resuscitation (CPR) before death continue to increase among older adult patients in hospital,⁵ and one-fifth of deaths in hospital occur in an intensive care unit.^1,2,6,7 These observations contrast sharply with patient-reported preferences. A recent Canadian study found that 80% of older adult patients in hospital with a serious illness prefer a less aggressive and more comfort-oriented end-of-life care plan that does not include CPR.⁸Such patients and their families have identified communication with health care providers and decision-making about goals of care as high priorites for improving end-of-life care in Canada.^9,10 We define “decision-making about goals of care” as an end-of-life communication and decision-making process that occurs between a clinician and a patient (or a substitute decision-maker if the patient is incapable) in an institutional setting to establish a plan of care. Often, this process includes deciding whether to use life-sustaining treatments.¹¹ Current guidelines recommend that health care providers address 11 key elements when discussing goals of care with patients and families (Box 1).^12–14 However, these elements are mostly based on expert opinion and lack input from patients and their families.

Box 1:

Key elements of goals-of-care discussions with patients in hospital with serious illness^12–14

• Ask about previous discussions or written documentation about the use of life-sustaining treatments
• Offer a time to meet to discuss goals of care
• Provide information about advance care planning to review before conversations with the physician
• Disclose prognosis
• Ask about patients’ values (i.e., what is important to them when considering health care decisions)
• Provide information about outcomes, benefits and risks of life-sustaining treatments
• Provide information about outcomes, benefits and risks of comfort measures
• Prompt for additional questions about goals of care
• Provide an opportunity to express fears or concerns
• Ask about preferences for care in the event of a life-threatening illness
• Facilitate access to legal documents to record patients’ wishes

Our primary objective was to determine which of these elements are most important to patients and their families. In addition, we examined whether these discussions were associated with concordance between patients’ (or family members’) preferences and prescribed goals of care, and with satisfaction with end-of-life communication and decision-making.     

Solution structure of conserved AGNN tetraloops: insights into Rnt1p RNA processing.

Rnt1p, the yeast orthologue of RNase III, cleaves rRNAs, snRNAs and snoRNAs at a stem capped with conserved AGNN tetraloop. Here we show that 9 bp long stems ending with AGAA or AGUC tetraloops bind to Rnt1p and direct specific but sequence-independent RNA cleavage when provided with stems longer than 13 bp. The solution structures of these two tetraloops reveal a common fold for the terminal loop stabilized by non-canonical A-A or A-C pairs and extensive base stacking. The conserved nucleotides are stacked at the 5' side of the loop, exposing their Watson-Crick and Hoogsteen faces for recognition by Rnt1p. These results indicate that yeast RNase III recognizes the fold of a conserved single-stranded tetraloop to direct specific dsRNA cleavage.     

Glucagon-Like Peptide-1 Induced Signaling and Insulin Secretion Do Not Drive Fuel and Energy Metabolism in Primary Rodent Pancreatic β-Cells

Background

Glucagon like peptide-1 (GLP-1) and its analogue exendin-4 (Ex-4) enhance glucose stimulated insulin secretion (GSIS) and activate various signaling pathways in pancreatic β-cells, in particular cAMP, Ca²⁺ and protein kinase-B (PKB/Akt). In many cells these signals activate intermediary metabolism. However, it is not clear whether the acute amplification of GSIS by GLP-1 involves in part metabolic alterations and the production of metabolic coupling factors.

Methodology/Prinicipal Findings

GLP-1 or Ex-4 at high glucose caused release (∼20%) of the total rat islet insulin content over 1 h. While both GLP-1 and Ex-4 markedly potentiated GSIS in isolated rat and mouse islets, neither had an effect on β-cell fuel and energy metabolism over a 5 min to 3 h time period. GLP-1 activated PKB without changing glucose usage and oxidation, fatty acid oxidation, lipolysis or esterification into various lipids in rat islets. Ex-4 caused a rise in [Ca²⁺]_i and cAMP but did not enhance energy utilization, as neither oxygen consumption nor mitochondrial ATP levels were altered.

Conclusions/Significance

The results indicate that GLP-1 barely affects β-cell intermediary metabolism and that metabolic signaling does not significantly contribute to GLP-1 potentiation of GSIS. The data also indicate that insulin secretion is a minor energy consuming process in the β-cell, and that the β-cell is different from most cell types in that its metabolic activation appears to be primarily governed by a “push” (fuel substrate driven) process, rather than a “pull” mechanism secondary to enhanced insulin release as well as to Ca²⁺, cAMP and PKB signaling.     

Persistent maternal effects on juvenile survival in North American red squirrels

Maternal effects can have lasting fitness consequences for offspring, but these effects are often difficult to disentangle from associated responses in offspring traits. We studied persistent maternal effects on offspring survival in North American red squirrels (Tamiasciurus hudsonicus) by manipulating maternal nutrition without altering the post-emergent nutritional environment experienced by offspring. This was accomplished by providing supplemental food to reproductive females over winter and during reproduction, but removing the supplemental food from the system prior to juvenile emergence. We then monitored juvenile dispersal, settlement and survival from birth to 1 year of age. Juveniles from supplemented mothers experienced persistent and magnifying survival advantages over juveniles from control mothers long after supplemental food was removed. These maternal effects on survival persisted, despite no observable effect on traits normally associated with high offspring quality, such as body size, dispersal distance or territory quality. However, supplemented mothers did provide their juveniles an early start by breeding an average of 18 days earlier than control mothers, which may explain the persistent survival advantages their juveniles experienced.