Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.

OBJECTIVE:To compare results of a specific capacity assessment administered by the treating clinician, and a Standardized Mini-Mental Status Examination (SMMSE), with the results of expert assessments of patient capacity to consent to treatment. DESIGN:Cross-sectional study with independent comparison to expert capacity assessments. SETTING:Inpatient medical wards at an academic secondary and tertiary referral hospital. PARTICIPANTS:One hundred consecutive inpatients facing a decision about a major medical treatment or an invasive medical procedure. Participants either were refusing treatment, or were accepting treatment but were not clearly capable according to the treating clinician. MEASUREMENTS AND MAIN RESULTS:The treating clinician (medical resident or student) conducted a specific capacity assessment on each participant, using a decisional aid called the Aid to Capacity Evaluation. A specific capacity assessment is a semistructured evaluation of the participant's ability to understand relevant information and appreciate reasonably foreseeable consequences with regard to the specific treatment decision. Participants also received a SMMSE administered by a research nurse. Participants then had two independent expert assessments of capacity. If the two expert assessments disagreed, then an independent adjudication panel resolved the disagreement after reviewing videotapes of both expert assessments. Using the two expert assessments and the adjudication panel as the reference standard, we calculated areas under the receiver-operating characteristic curves and likelihood ratios. The areas under the receiveroperating characteristic curves were 0.90 for specific capacity assessment by treating clinician and 0.93 for SMMSE score (2 p ‫؍‬ .48). For the treating clinician's specific capacity assessment, likelihood ratios for detecting incapacity were as follows: definitely incapable, 20 (95% confidence interval [CI] 3.6, 120); probably incapable, 6.1 (95% CI 2.

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12011 Background: Older people experience significant adverse effects of cancer and anti-cancer therapy due to age-related vulnerabilities, including medical, functional, cognitive, nutritional and psychosocial issues. Comprehensive geriatric assessment and management (CGAM) provides a powerful framework to assess an older person’s health status and offers a coordinated, person-centered approach to care. Despite its effectiveness, the uptake of CGAM in oncology has been limited due to a lack of randomized evidence in this setting. This study evaluated the effectiveness of CGAM in older people with cancer. Methods: INTEGERATE is a prospective, randomized, parallel group, open-label study in patients aged >70 years with cancer planned for chemotherapy, targeted therapy or immunotherapy. Patients were randomly assigned (1:1) to receive either geriatrician-led CGAM integrated with usual care (integrated oncogeriatric care) or usual care alone, using minimization to balance treatment intent, cancer type, age, sex and performance status. Health-related quality of life (HRQOL) was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and QLQ-ELD14 at 0, 12, 18 and 24 weeks. The primary outcome was HRQOL measured by the validated Elderly Functional Index (ELFI) score. Major secondary outcomes included function, mood, nutrition, health utility, treatment delivery, healthcare utilization and survival. Results: Of the 154 patients who underwent randomization, 13 died by week 12 and 130 (92.2% of the remaining patients) completed at least two primary outcome assessments. For the primary outcome, patients in the intervention group had significantly better ELFI score than the usual care group across all followup timepoints, with a maximal difference at week 18 (estimated marginal mean ELFI score 72.0 vs 58.7, p= 0.001). In addition, significant differences favoring the intervention group over the usual care group were seen in HRQOL (domains: physical, role and social functioning; mobility, burden of illness and future worries), unplanned hospital admissions (-1.2 admissions per person-years, p< 0.001) and early treatment discontinuation (32.9% vs 53.2%, p = 0.01). Conclusions: Integrated oncogeriatric care led to improvements in HRQOL, unplanned hospital admissions and treatment discontinuation in older people receiving systemic anti-cancer therapy. Older people (>70 years) planned for anti-cancer therapy should receive CGAM to optimize their clinical care and health outcomes. Clinical trial information: ACTRN12614000399695 .

Statistical associations are not sufficient to infer adequate predictive value, especially when crucial decisions such as whether one can continue driving are at stake. The predictors we examined have limited predictive value if used as stand-alone screening tests.

ObjectivesTo understand from a patient and carer perspective: (1) what features of the discharge process could be improved to avoid early unplanned hospital readmission (within 72 hours of acute care discharge) and (2) what elements of discharge planning could have enhanced the discharge experience.DesignA qualitative descriptive design was used. Study data were collected using semi-structured interviews that were transcribed verbatim and analysed using inductive thematic analysis. Data related to participant characteristic were collected by medical record audit and summarised using descriptive statistics.SettingThree acute care hospitals from one health service in Australia.ParticipantsPatients who had an early unplanned hospital readmission and/or their carers, if present during the interviews and willing to participate, with patient permission.FindingsThirty interviews were conducted (23 patients only; 6 patient and carer dyads; 1 carer only). Five themes were constructed: ‘experiences of care’, ‘hearing and being heard’, ‘what’s wrong with me’, ‘not just about me’ and ‘all about going home’. There was considerable variability in patients’ and carers’ experiences of hospital care, discharge processes and early unplanned hospital readmission. Features of the discharge process that could be improved to potentially avoid early unplanned hospital readmission were better communication, optimal clinical care including ensuring readiness for discharge and shared decision-making regarding discharge timing and goals on returning home. The discharge experience could have been enhanced by improved communication between patients (and carers) and the healthcare team, not rushing the discharge process and a more coordinated approach to patient transport home from hospital.ConclusionsThe study findings highlight the complexities of the discharge process and the importance of effective communication, shared decision-making and carer engagement in optimising hospital discharge and reducing early unplanned hospital readmissions.

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Using rigorous methods, health workers can make reproducible and valid assessments of capacity to complete an advance directive. The SMMSE accurately differentiates people who can learn about and ultimately complete advance directives from those who cannot.