JAGS

JANUARY 2015–VOL. 63, NO. 1

used to calculate T-scores for the spine. The use of local reference data should not be used to calculate T-scores. Jose M. Moran, PhD Jesus M. Lavado-Garcıa, RN, PhD Raul Roncero-Martin, RN, PhD Maria Pedrera-Canal, MD Vincente Vera, PhD Pilar Fernandez, RN, PhD Juan D. Pedrera-Zamorano, MD, PhD Metabolic Bone Diseases Research Group, University of Extremadura, C aceres, Spain

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Moran, Pedrera-Zamorano: study concept, preparation of manuscript. Lavado-Garcia, RonceroMartin, Pedrera-Canal, Vera, Fernandez: study concept. Sponsor’s Role: None.

REFERENCES 1. Iucif N, Marchini JS, do Carmo Sitta M et al. Association between plasma testosterone level and bone mineral density in healthy elderly men. J Am Geriatr Soc 2014;62:981–982. 2. Moran JM, Roncero-Martin R, Pedrera-Canal M et al. Low testosterone levels are associated with poor peripheral bone mineral density and quantitative bone ultrasound at phalanges and calcaneous in healthy elderly men. Biol Res Nurs 2014. doi:10.1177/1099800414532710. 3. Isidori AM, Giannetta E, Greco EA et al. Effects of testosterone on body composition, bone metabolism and serum lipid profile in middle-aged men: A meta-analysis. Clin Endocrinol 2005;63:280–293. 4. Gennari L, Merlotti D, Martini G et al. Longitudinal association between sex hormone levels, bone loss, and bone turnover in elderly men. J Clin Endocrinol Metab 2003;88:5327–5333. 5. Emmelot-Vonk MH, Verhaar HJ, Nakhai Pour HR et al. Effect of testosterone supplementation on sexual functioning in aging men: A 6-month randomized controlled trial. JAMA 2008;299:39–52. 6. Schousboe JT, Shepherd JA, Bilezikian JP et al. Executive summary of the 2013 International Society for Clinical Densitometry Position Development Conference on bone densitometry. J Clin Densitom 2013;16:455– 466.

ESTABLISHING CODE STATUS: ARE PEOPLE’S DECISIONS TRULY INFORMED? To the Editor: More people are completing advance directives before they die,1 and a recent study in Oregon indicates that those who document their wishes not to be hospitalized at the end of life have those wishes honored.2 However, it is still common to find frail elderly adults or terminally ill individuals who have not documented or discussed their end-of-life wishes or request full resuscitation efforts, and the numbers of hospitalized individuals undergoing cardiopulmonary resuscitation (CPR) before dying is increasing.3 In contrast, essays and surveys by physicians and other healthcare professionals show a clear preference for not being resuscitated in the face of poor health.4,5 This discrepancy suggests that

LETTERS TO THE EDITOR

207

there is something that physicians understand about the process and prognosis of resuscitation that is not being effectively communicated. Code status discussions frequently focus on the low success rate ( 1).6 Another study examining survivors of cardiac arrest found that 66.3% had moderate to severe neurological disability 6 months after discharge.9 These data provide a different framework for discussion of code status than does focusing on the 20% chance of survival. Furthermore, when people are asked about code status, they are being asked to give permission to withhold potential treatment. Resuscitation is the only medical procedure for which consent not to proceed is needed. Although life-sustaining procedures are not withheld in emergency situations, all other medical procedures require prior consent unless the situation is life threatening. For example, when individuals who have experienced a trauma come into the emergency department needing blood, they receive it without delay, but before elective surgery, informed consent is obtained in case transfusion is needed. CPR should be no different. Code status discussions should communicate to the individual that, although the procedure can be life saving, there are inherent risks and potential for a bad outcome associated with it as well. Shifting the focus to asking for permission to perform CPR, rather than asking an individual to sign a do-notresuscitate order, can provide a more-balanced consent process. Ultimately, more needs to be known about prognosis before it will be possible to obtain adequate informed consent for a procedure. The Cardiac Arrest Survival Post Resuscitation In-hospital prediction tool10 examines 11 variables to predict the quality of neurological survival of individuals who undergo CPR. This tool can be a resource to help individuals and their families develop realistic expectations and make decisions about further code status and medical care after an arrest. This is a first step toward having a prearrest prediction tool to help guide decisionmaking during code status discussions. Further research is needed in this area.

208

LETTERS TO THE EDITOR

Physicians witness not just the brutality of resuscitation, but also the suffering of surviving it. Discussion of code status should not just focus on a good or bad death experience, but also on good or bad survival. As with any procedure, informed consent should be obtained after reviewing the risks and benefits of the procedure, including the potentially bad outcomes, and offering the alternative, which is to allow natural death. Switching from an optout model to an opt-in model would be an important first step in communicating the reality of this procedure to people. Rebecca J. Stetzer, MD Department of Family and Community Medicine, Albany Medical College, Albany, New York

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the author and has determined that the author has no financial or any other kind of personal conflicts with this paper. Author Contributions: Rebecca J. Stetzer is responsible for the entire content of this paper. Sponsor’s Role: None.

REFERENCES 1. Silveira MJ, Wiitala W, Piette J. Advance directive completion by elderly Americans: A decade of change. J Am Geriatr Soc 2014;62:706–710. 2. Fromme EK, Zive D, Schmidt TA et al. Association between physician orders for life-sustaining treatment for scope of treatment and in-hospital death in Oregon. J Am Geriatr Soc 2014;62: 1246–1251. 3. Ehlenbach WH, Barnato AE, Curtis JR et al. Epidemiologic study of inhospital cardiopulmonary resuscitation in the elderly. N Engl J Med 2009;361:22–31. 4. Murray K. How doctors die: It’s not like the rest of us, but it should be. Zocalo Public Square. November 30, 2011 [on-line]. Available at http:// www.zocalopublicsquare.org/2011/11/30/how-doctors-die/ideas/nexus/ Accessed July 14, 2014. 5. Span P. Do not resuscitate: What young doctors would choose. The new old age blog, The New York Times. May 20, 2014 [on-line]. Available at http://newoldage.blogs.nytimes.com/2014/05/20/do-not-resuscitate-what-youngdoctors-would-choose/ Accessed July 14, 2014. 6. Chan PS, Nallamothu BK, Krumholz HM et al. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. N Engl J Med 2013; 368:1019–1026.

JANUARY 2015–VOL. 63, NO. 1

JAGS

7. Chan PS, Spertus JA, Nallamothu BK. Correspondence: Reply to letters to the editor. N Engl J Med 2013;368:2437–2439. 8. Peberdy MA, Kaye W, Ornato JP et al. Cardiopulmonary resuscitation of adults in the hospital: A report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 2003;58:297– 308. 9. Seder DB, Patel N, McPherson J et al. Geriatric experience following cardiac arrest at six interventional cardiology centers in the United States 2006–2011: Interplay of age, do-not-resuscitate order and outcomes. Crit Care Med 2014;42:289–295. 10. Chan PS, Spertus JA, Krumholz HM et al. A validated prediction tool for initial survivors of in-hospital cardiac arrest. Arch Intern Med 2012;172:947–953.

MORLEY-JAGS LINK TO PERSPECTIVES OF GERIATRICS PAPER To the Editor: The invitation to me from Drs. Yoshikawa and Ouslander to write “The Birth of Geriatrics in America”1 for the new series “Pioneers in Aging” was a muchappreciated opportunity. I inadvertently omitted from the table two colleagues: John Morley, MD, whose creativity and energy have done so much for our field and for the growth of the Journal of Gerontology—Medicine, the Journal of the American Medical Directors Association, and the Journal of the American Geriatrics Society, and John Burton, MD, who provided me with a stimulating “Visiting Professorship” to his renowned program at Johns Hopkins. Leslie S. Libow, MD Departments of Geriatrics and Medicine, Mount Sinai School of Medicine, New York, New York

ACKNOWLEDGMENTS Conflict of Interest: None. Author Contributions: Author is the sole contributor to this paper. Sponsor’s Role: None.

REFERENCE 1. Libow LS. The Birth of Geriatrics in America. J Am Geriatr Soc 2014;62:1369–1376.

Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Establishing code status: are people's decisions truly informed?

Establishing code status: are people's decisions truly informed? - PDF Download Free
48KB Sizes 0 Downloads 10 Views