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T R Fried

Publications and source records attributed to T R Fried.

15 recordsLinked to original sources
PubMed1999

Older persons' preferences for site of terminal care.

BACKGROUND: Little is known about patients' preferences for site of terminal care. OBJECTIVE: To describe older persons' preferences for home or hospital as the site of terminal care and to explore potential reasons for their preferences. DESIGN: Cross-sectional quantitative and qualitative interviews. SETTING: Participants' homes. PATIENTS: Community-dwelling persons 65 years of age or older who were recently hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were not selected according to life expectancy; 246 patients participated in quantitative interviews and 29 participated in qualitative interviews. MEASUREMENTS: Preference for site of terminal care and the reasons for that preference. RESULTS: In quantitative interviews, 118 patients (48%) preferred terminal care in the hospital, 106 (43%) preferred home, and 22 (9%) did not know. One third changed their preference when asked about their preference in the event of a nonterminal illness. Reasons for preference identified during qualitative interviews included the desire to be with family members and concerns about burden to family members and their ability to provide necessary care. Concern about long-term care needs resulted in preference for a nursing home when choice was not constrained to home and hospital. CONCLUSIONS: Preference for home as the site of care for terminal illness exceeds existing practice. However, the current debate about home versus hospital as the ideal site for end-of-life care may ignore an important issue to older persons--namely, the care of disabilities that precede death.

Aged↗
PubMed1999

Older persons' perceptions of home and hospital as sites of treatment for acute illness.

PURPOSE: Home care is increasingly being used as a substitute for hospital care. This study examined older patients' perceptions of the home and of the hospital as treatment sites for acute illness and the patient characteristics that are associated with these perceptions. SUBJECTS AND METHODS: A series of questions derived from open-ended interviews supplemented by literature review were administered by telephone in a cross-sectional, descriptive study to community-dwelling persons age 65 years or older who had been hospitalized 2 months earlier with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia. RESULTS: Among 246 participants, nearly equal proportions agreed with statements that the home and the hospital would be comfortable sites of care (54% versus 55%), that the home and the hospital would provide rapid recovery (41% versus 37%), and that home treatment and hospital treatment would be burdensome on family and friends (40% versus 33%). Although 93% would feel safe in the hospital, only 42% would feel safe at home. Perceptions were not associated with sociodemographic characteristics, primary diagnosis, self-rated health, depression, or social support. Functionally dependent patients had more positive perceptions of treatment at home. CONCLUSIONS: Evaluation of perceptions of home and hospital can facilitate assessing the acceptability of shifting acute care from hospital to home. Our findings suggest that successful expansion of acute home care will require flexibility in the use of home and hospital as well as education to change perceptions about the safety and efficacy of treatment at home.

Acute Disease↗
PubMed1999

Who dies at home? Determinants of site of death for community-based long-term care patients.

OBJECTIVE: To determine characteristics associated with site of death in a cohort of long-term homecare patients. DESIGN: Cohort study. SETTING: Community-based long-term care program. SUBJECTS: All patients 65 years of age or older who died within 1 year of admission during 1989 and 1990. MAIN OUTCOME MEASURE: Site of death. RESULTS: Of 620 subjects, site of death was hospital for 302 (49%), home for 132 (21%), nursing home for 124 (20%), and inpatient hospice for 45 (7%). Among patients living at home before death, factors associated with dying at home rather than in a hospital or inpatient hospice included female gender (relative risk (RR) 1.40, 95% confidence interval (CI) 1.00, 1.90); severely dependent functional status (RR 2.38, CI 1.39, 4.17) and cognitive status (RR 1.51, CI 1.10, 2.06); and dying of cancer (RR 1.68, CI 1.11, 2.55), chronic lung disease (AOR 1.75, CI 1.04, 2.95), or coronary artery disease (RR 1.93, CI 1.21, 3.09). Living with a child (RR 1.45, CI .99, 2.11) showed a trend toward association with dying at home. CONCLUSIONS: Even among a subgroup of older persons receiving community-based long-term care, the frequency of home death is low. The finding of an association between functional, social, and disease status and site of death suggests that the relationship between these factors and patients' preferences and care needs must be examined in order to understand how to optimize the site of terminal care.

Activities of Daily Living↗
PubMed1998

"The slow code".

Explore the source record for details and available documents.

Aged↗
PubMed1998

Older persons' preferences for site of treatment in acute illness.

OBJECTIVE: To explore how older persons form preferences for site of medical care by examining their perceptions of home care and hospital care. DESIGN: Qualitative analysis of in-depth interviews using the constant comparative method. SETTING: Respondents' homes. PARTICIPANTS: Twenty-nine persons age 65 to 89 years who had been hospitalized with congestive heart failure, chronic obstructive pulmonary disease, or pneumonia and were receiving home care services. MAIN RESULTS: Respondents, who thought of home care only as a means to provide low-intensity and low-frequency services, were initially skeptical about expanded home care services to treat acute illness. Regardless of their opinions about home and hospital, all respondents preferred the site associated with the greatest chance of survival. If the sites offered equal survival, 52% of the respondents preferred treatment at home because of freedom from the constraints of the hospital and the comfort of familiar surroundings. For respondents who preferred the hospital, the home represented a frightening and lonely place to be sick. Respondents' views of the home and hospital were shaped by their social supports, self-reliance, religious beliefs, and past illness experiences. CONCLUSIONS: Because survival appears to be the most important determinant of preference, home treatment of acute illness is a viable alternative only if it provides outcomes equivalent to those of hospitalization. Strongly held perceptions that home care can only be a low-intensity service may limit preferences for home treatment. When expected outcomes at the two sites are similar, the challenge to the health care system will be incorporating patient preference about the process of care into decisions about the appropriate site of care.

Acute Disease↗
PubMed1998

Factors associated with six-month mortality in recipients of community-based long-term care.

OBJECTIVES: To determine factors associated with short-term mortality in recipients of community-based long-term care (CBLTC). DESIGN: A cohort study. SETTING: A Medicaid home- and community-based waiver and state-funded homecare program. PARTICIPANTS: All persons age 65 and older newly admitted to the program from January 1, 1988, to March 31, 1991. MEASUREMENTS: Demographics, functional, cognitive, and health status, depression, and social support were obtained in an admission assessment. Six-month mortality data were obtained by linking assessment data to a state mortality registry. RESULTS: There were 718 deaths among 6784 CBLTC clients. Male sex (AOR 1.8, 95% CI 1.5-2.1), the presence of cancer (AOR 3.2, CI 2.6-3.9), heart disease (AOR 1.3, CI 1.1-1.5), chronic obstructive pulmonary disease (AOR 1.8, CI 1.4-2.2), or nutritional problems (AOR 1.7, CI 1.4-2.0), functional impairment (AOR for lowest compared to highest quartile 2.9, CI 2.0-4.1), severe cognitive impairment (AOR 1.6, CI 1.3-2.1), self-assessment of health as poor (AOR 1.5, CI 1.1-2.0), feeling depressed (AOR 1.2, CI 1.1-1.3), and hospitalization (AOR 2.7, CI 2.2-3.2) were independently associated with 6-month mortality in bivariate and multivariate analyses. CONCLUSIONS: Clinical data obtained during routine assessment of CBLTC clients can be used to assess short-term mortality. Six-month mortality is associated with poor functional and cognitive status, the presence of cancer, heart disease, COPD, and nutritional problems, depression, perception of poor health, and hospitalization.

Activities of Daily Living↗
PubMed1998

When the patient cannot come to the doctor: a medical housecalls program.

OBJECTIVES: To describe a medical housecalls program and to assess its ability to meet the medical needs of homebound patients. PROGRAM STRUCTURE: The housecalls program is part of a larger ambulatory practice situated in a senior center staffed by geriatricians and nurse practitioners. The practice serves as the major teaching site of outpatient geriatrics for a medical residency program. Scheduled visits are made every 3 to 4 months, and unscheduled visits are made weekday days for acute problems. PARTICIPANTS: Patients are eligible for the housecalls program if they live within a 15- minute drive of the center and are unable to leave their home. PROGRAM EVALUATION: The majority of the 71 patients in the housecalls program between 1993 and 1995 were female (81%), aged 85 years or older (52%), and dependent in one or more activities of daily living: 65% were dependent in bathing and 42% in dressing. A substantial minority (16%) had severe cognitive impairment. Patients received a mean of 5.0 visits per patient-year. The majority of patients (59%) were treated at home for an acute illness or symptom ranging from upper respiratory tract infections to pneumonia and congestive heart failure. Approximately one-quarter of the patients or their proxies elected to avoid hospitalization; several of these patients had complex illnesses managed in their homes. CONCLUSIONS: A wide range of medical problems can be addressed in patients' homes. Because our patients could not leave their homes easily, or at all, it is probable they would not have received routine medical care and would have used the emergency room for evaluation of acute problems if the housecalls program were not available. Despite their potential value in the care of frail older patients, housecalls will likely not become a widespread practice until barriers to their performance cited by physicians are addressed.

Aged↗
PubMed1997

Frailty and hospitalization of long-term stay nursing home residents.

OBJECTIVE: To determine the relationship between characteristics of older, long-term stay nursing home patients and hospitalization. DESIGN: A cohort study. SETTING: One hundred three proprietary nursing homes. PARTICIPANTS: All residents of these nursing homes aged 65 or older admitted between January 1, 1991, and December 30, 1993, who had no transitions out of the nursing home during the first 6 months of their stay. MEASUREMENTS AND MAIN RESULTS: Among the cohort of 3782 residents, 931 (25%) were hospitalized at least once during the second 6 months of their nursing home stay. In a logistic regression model, severe functional impairment (adjusted odds ratio (AOR) 1.20, 95% confidence interval (CI) 1.01, 1.43), worsening ADL self-performance (AOR 1.22, 95% CI 1.04, 1.43), presence of a decubitus ulcer (AOR 1.62, 95% CI 1.17, 2.24), presence of a feeding tube (AOR 2.03, 95% CI 1.54, 2.67), primary diagnosis of congestive heart failure (AOR 1.61, 95% CI 1.11, 2.34), and primary diagnosis of respiratory disease (AOR 1.77, 95% CI 1.24, 2.54) were associated with hospitalization. No form of advance directive was associated with a lower rate of hospitalization. CONCLUSIONS: Physically frail patients, who may be the least likely to benefit from hospitalization, are the most likely to be hospitalized. The lack of an association between "Do not-hospitalize" orders and lower rates of hospitalization suggests that there are substantial barriers to providing acute care in the nursing home. The association between recent functional decline, primary diagnoses of congestive heart failure and respiratory disease, and hospitalization indicates, however, that certain patient groups may be targeted successfully to reduce hospitalization rates.

Activities of Daily Living↗
PubMed1997

Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer.

OBJECTIVE: To determine 2-month mortality and functional status outcomes after resolution of pneumonia in older long-term care facility (LTCF) patients treated with and without hospital transfer. DESIGN: Retrospective cohort study. SETTING: Hebrew Rehabilitation Center for Aged, a 725-bed LTCF affiliated with an academic medical center, whose residents are cared for by staff physicians and geriatric fellows. PATIENTS: LTCF residents with an acute episode of pneumonia, defined as a new respiratory sign or symptom and a new infiltrate on chest radiograph. MEASUREMENTS: Functional decline or death in the 2 months after the resolution of pneumonia. RESULTS: Of 312 cases of pneumonia, 246 (79%) were treated in the LTCF and 66 (21%) were treated in the hospital. Equal proportions of patients died of their pneumonia (13% vs 12%), but a larger proportion of those hospitalized had either worsening in their functional status or had died at 2 months (P = .005, Mantel-Haenszel trend test). In a logistic regression model controlling for differences between patients treated at the two sites, hospital treatment remained associated with poorer 2-month outcome (AOR 3.02, 95% CI 1.32, 7.22), with a significant interaction between respiratory rate and treatment site. LTCF treatment was associated with better 2-month outcomes only among patients with a lower respiratory rate. For these patients, the difference in outcome between LTCF treatment and hospital treatment was greatest for patients who were independent or mildly dependent at baseline. CONCLUSIONS: In this academic LTCF, treatment for pneumonia without hospital transfer resulted in better 2-month outcomes compared with hospital treatment. Although the difference in outcome may be explained in part by differences between patients treated with and without hospital transfer, it persisted after correcting for these differences. The benefits of LTCF treatment appear to be greatest for those with less severe pneumonia and more independent functional status.

Activities of Daily Living↗
PubMed1996

The association between age of hospitalized patients and the delivery of advanced cardiac life support.

OBJECTIVE: To determine the extent of variability in the administration of advanced cardiac life support (ACLS) and to determine if age is associated with variability. DESIGN: Retrospective cohort. SETTING: Urban teaching hospital. PATIENTS: One hundred twenty-two adult inpatients without a "do-not resuscitate" order who suffered cardiopulmonary arrest during 1993. MEASUREMENTS AND MAIN RESULTS: Of the total, 35 (29%) survived the arrest and 87 (71%) died. Among the nonsurvivors, two patients received no ACLS and six were not intubated, despite the inclusion of intubation in all ACLS protocols. Of the 87 nonsurvivors, 31 had a single electrocardiographic rhythm during their arrest and should have had similar ACLS trials. However, the 9 nonsurvivors with ventricular fibrillation received a range of 0 to 17 interventions, the 11 with electromechanical dissociation received 1 to 22, and the 11 with asystole received 0 to 14. Based on a protocol-derived definition of a minimal trial of ACLS (a "short ACLS trial") for all 87 nonsurvivors, age greater than 75 was associated with receiving a short trial. Dependent functional status and being on a medical service were also associated with a short ACLS trial. In a logistic regression model including these variables as covariates, age remained significantly associated with a short ACLS trial; odds ratio, 9.71 (95% confidence interval 1.68, 56.1). CONCLUSIONS: Wide variability exists in the administration of ACLS at the studied site. The finding that some patients receive no ACLS suggests that physicians at this site may be making bedside determinations of the likelihood of its benefit based on individual patient characteristics. The association between older age and short ACLS trials among all nonsurvivors suggests that age is most important of these characteristics.

Adult↗
PubMed1995

Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients with pneumonia.

OBJECTIVE: To determine factors associated with the decision to treat elderly long-term care patients with pneumonia in the hospital vs in the long-term care facility (LTCF) and factors associated with patient outcomes. DESIGN: Retrospective cohort study. SETTING: Hebrew Rehabilitation Center for Aged. PATIENTS: Nursing home residents who had an episode of pneumonia, defined as a new respiratory sign or symptom and a new infiltrate. MEASUREMENTS AND MAIN RESULTS: The majority of the 316 pneumonia episodes (78%) were managed in the LTCF, most (77%) with oral antibiotics. Both patient-related factors, such as elevated respiratory rate, and non-patient-related factors, such as evening evaluation, were associated with hospitalization. No patient who had a do-not-hospitalize (DNH) order was hospitalized. Equal proportions of patients given LTCF therapy (87%) and hospital therapy (88%) survived. Elevated respiratory rate was associated with dying from pneumonia in the LTCF but not in the hospital. Dependent functional status was associated with dying from pneumonia in both sites. CONCLUSIONS: Many episodes of pneumonia can be managed in the LTCF with oral antibiotics. Because, in the absence of DNH orders, both patient-related and non-patient-related factors are associated with hospital transfer, discussion regarding preferences for hospitalization should occur prior to the development of an acute illness. A high respiratory rate may be a good marker for those LTCF patients requiring hospitalization. Dependent functional status may be a good marker for those LTCF patients unlikely to benefit from hospital transfer.

Aged↗
PubMed1995

Older community-dwelling adults' attitudes toward and practices of health promotion and advance planning activities.

OBJECTIVE: To describe the attitudes toward and practice of health prevention and advance planning measures by a group of community-dwelling older adults and to examine the effect of age on these practices. DESIGN: A descriptive study performed by mail survey. PARTICIPANTS: Members of a research registry who were 65 years of age or older. MEASUREMENTS: By means of a written questionnaire, we asked about knowledge of various health prevention and advance planning topics, including exercise, cholesterol screening, rectal examination, influenza vaccination, sigmoidoscopy, mammography, prostate cancer screening, organ donation, autopsy, health care proxy, and advance directives. Of those who knew about the topic, we asked if the respondent had discussed it with a physician, who initiated the conversation, and if the respondent participated in the activity. We also asked how important the topic was to the respondent. RESULTS: We received 598 completed surveys, a response rate of 83%. Respondents had a mean age of 74 years, were predominately white (96%), and were well educated, with 44% having completed college. The respondents were all knowledgeable about the topics, and, with the exception of sigmoidoscopy, organ donation, and autopsy, more than 70% thought these topics were important. In the case of health screening and prevention activities, a large percentage of respondents reported having discussed the topic with a physician, and a slightly smaller percentage reported regular participation. In the case of health care proxies and advance directives, however, only about one-half of those who had made these arrangements said they had discussed them with a physician. When discussion did occur, it was much more likely to have been initiated by the respondent. Controlling for level of education, age was inversely associated with the likelihood of a woman reporting she had undergone mammography (P < .05). Age, however, was not associated with decreased frequency of undergoing other screening tests. CONCLUSIONS: Among a group of well educated older adults, reported interest in and compliance with health screening, health promotion, and advance planning activities were high. However, sigmoidoscopy, a relatively more invasive procedure that is generally recommended as a screening tool, is reported less likely to be practiced than prostate cancer screening, a less invasive procedure without such recommendation. Older adults state they are pursuing health care proxies and advance directives, often without the involvement of their physicians. Of the screening tests about which we asked, age was associated only with less frequent practice of mammography.

Advance Directives↗
PubMed1994

Medical decision-making in the last six months of life: choices about limitation of care.

OBJECTIVE: To characterize the limitation of care in routine geriatric practice in advance of and at the time of a patient's final episode of illness. DESIGN: A descriptive study performed by retrospective chart review. SETTING: An outpatient geriatric practice affiliated with a community teaching hospital. PATIENTS: Fifty-nine recipients of primary care who were community-dwelling and older than 65, died in the years 1988-1991, and were enrolled in the practice for at least 6 months prior to death. MEASUREMENTS: We recorded the type(s) of care patients (or, in the case of incompetence, their families) and their physicians chose to limit during the last episode of illness preceding death and during previous episodes of illness by examining those instances when therapy other than that considered "standard" was given. We also examined whether the presence of dementia, functional impairment, chronic disease, terminal illness, site of routine care (home vs hospital), and location of death were associated with the limitation of care. RESULTS: A choice to limit diagnostic tests or treatment was made by the patient or surrogate in 40% of the 59 patients during the 6 months before the patient's final episode of illness. Most frequently limited were diagnostic tests, surgery, and hospitalization for purposes other than surgery. Terminal illness and location of death were associated with the limitation of care, but dementia, functional impairment, chronic illness, and location of care were not. By comparison, 89% of the patients had limitation of care during the final episode of illness, and more aggressive therapies such as cardiopulmonary resuscitation and intubation constituted the majority of therapies withheld. CONCLUSIONS: In one geriatric practice, care is frequently limited before a patient's final illness in the course of routine practice. In contrast to recent discussion focusing on limitation of end-of-life interventions or interventions in the severely impaired, these results suggest that there are multiple points in the course of a community-dwelling elderly patient's illness at which choices about level of care can be made. Given this opportunity, a significant number of elderly patients of their surrogates will choose less intensive therapy.

Activities of Daily Living↗
PubMed1993

Limits of patient autonomy. Physician attitudes and practices regarding life-sustaining treatments and euthanasia.

BACKGROUND: In making decisions about life-sustaining medical interventions, respect for patient autonomy has been widely advocated, yet little is known about what variables may compete with a physician's ability to honor patient requests in clinical situations. We investigated physician attitudes and behaviors about end-of-life decisions by means of a questionnaire that posed five hypothetical scenarios in which an elderly, competent, terminally ill patient made a request that, if agreed to by the physician, could result in the patient's death. METHODS: We surveyed 392 physicians in Rhode Island and asked them to decide (1) whether or not they would comply with a specific patient request, (2) the justifications they used in making their decision, and (3) whether they had been approached with such a request in their clinical practices. RESULTS: Two hundred fifty-six physicians (65%) responded. Of the respondents, 98% agreed not to intubate the patient in the face of worsening respiratory failure. Eighty-six percent agreed to give the patient a dose of narcotics that could cause respiratory compromise and death to treat his pain adequately. Fifty-nine percent agreed, once the patient was intubated without hope of coming off the respirator, to turn the respirator off. Nine percent agreed to give the patient a prescription for an amount of sleeping pills that would be lethal if taken all at once. Only 1% agreed to give the patient a lethal injection. When they complied with patient requests, physicians cited patient autonomy as the principle most important to their decision making. Physicians who would not comply with patient requests also, paradoxically, often cited this principle but agreed with it less strongly; others cited concerns about the ethical nature of the request, legal questions, and the perception that they were "killing the patient." Sixty-five percent of respondents had been asked by patients to turn off a respirator, and 12% had been asked to administer lethal injections. Twenty-eight percent of respondents indicated that they would comply with requests for lethal injection more frequently if such an action were legal. CONCLUSIONS: Difficult clinical decisions regarding potentially life-prolonging measures are commonly heard in clinical practice. Physicians value the concept of patient autonomy but place it in the context of other ethical and legal concerns and do not always accept specific actions derived from this principle.

Adult↗