Association of prognostic estimates with burdensome interventions in nursing home residents with advanced dementia

JAMA Internal Medicine Jun 13, 2018

Loizeau AJ, et al. - Researchers analyzed two studies together to assess the accuracy of proxies’ prognostic estimates for nursing home residents with advanced dementia, identifying factors related with those estimates, and looking at the link between their estimates and use of burdensome interventions. In the end, they found proxies had moderate accuracy in estimating the prognosis of nursing home residents with advanced dementia. They reported that having been asked about their opinion about the goal of care was correlated with the proxies’ perception that the resident had less than 6 months to live and that perception was linked with a lower probability of the resident experiencing burdensome interventions.

Methods

  • For this analysis, information was combined from 2 studies that prospectively followed 764 residents with advanced dementia and their proxies in Boston-area nursing homes for 12 months:
    • The Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia, conducted from September 2009 to November 2012 (362 resident/proxy dyads; 35 facilities);
    • The Educational Video to Improve nursing home Care in End-Stage Dementia, conducted from March 2013 to July 2017 (402 resident/proxy dyads; 62 facilities).
  • Proxies were the residents’ formally or informally designated medical decision makers.
  • Proxies stated whether they believed the resident would live less than 1 month, 1 to 6 months, 7 to 12 months, or more than 12 months during quarterly phone interviews.
  • They compared prognostic estimates with resident survival, and they determined resident and proxy characteristics associated with proxy prognostic estimates.
  • The relationship between prognostic estimates and whether residents experienced hospital transfers, parenteral therapy, tube feeding, venipunctures, or bladder catheterizations was assessed.

Results

  • According to the findings, the residents’ mean (SD) age was 86.6 (7.3) years, and 631 (82.6%) were women and 133 (17.4%) were men.
  • Researchers reported that out of 764 residents, 310 (40.6%) died later than 12 months.
  • They found that proxies estimated survival with moderate accuracy (C statistic, 0.67).
  • Results revealed that when proxies perceived the resident would die within 6 months, they were more likely to report being asked (183 [7.2%] of 2526) vs not being asked (126 [5.0%] of 2526) about goals of care by nursing home clinicians (adjusted odds ratio [AOR], 1.94; 95% CI, 1.50-2.52).
  • The outcomes suggested that residents were less likely to experience burdensome interventions when the proxy prognostic estimate was less than 6 months (89 [4.4%] of 2031) vs greater than 6 months (1008 [49.6%] of 2031) (AOR, 0.46; 95% CI, 0.34-0.62).
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