Advance care planning should take into account patients' attitudes toward the burden of treatment, the possible outcomes, and their likelihood. The likelihood of adverse functional and cognitive outcomes of treatment requires explicit consideration.

The traditional objective of advance care planning has been to have patients make treatment decisions in advance in an attempt to provide care consistent with their goals. We argue that the objective for advance care planning ought to be the preparation of patients and surrogates to participate with clinicians in making the best possible in-the-moment medical decisions. We provide practical steps for clinicians to help patients and surrogate decision makers achieve this objective in the outpatient setting. Preparation for in-the-moment decision making shifts the focus from having patients make premature decisions based on incomplete information to preparing patients and their surrogates for the types of decisions and conflicts they may encounter when they do have to engage in in-the-moment decision making. This approach does not preclude the completion of advance directives, but acknowledges that they are but one piece of information to be used at the time of decision making.

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Background/Objectives Polypharmacy is receiving increased attention as a potential problem for older persons, who frequently have multiple chronic conditions. The purpose of this study was to summarize evidence regarding the health outcomes associated with polypharmacy, defined as number of prescribed medications,among older community-dwelling persons. Design Systematic review of MEDLINE (OvidSP 1946 to May Week 3 2014). Setting Community Participants Observational studies examining health outcomes according to the number of prescription medications taken. Measurements Association of number of medications with health outcomes. Because of the importance of comorbidity as a potential confounder of the relationship between polypharmacy and health outcomes, articles were assessed regarding the quality of their adjustment for confounding. Results Of the total of 50 studies identified, the majority studies that were rated as “good” in terms of their adjustment for comorbidity demonstrated relationships between polypharmacy and a range of outcomes, including falls/fall outcomes/fall risk factors; adverse drug events, hospitalization, mortality, and measures of function and cognition. However, a number of these studies failed to demonstrate associations, as did a substantial proportion of those studies rated as “fair” or “poor.” Conclusions Data are mixed regarding the relationship between polypharmacy, considered in terms of number of medications, and adverse outcomes among community-dwelling older persons. Because of the challenge of confounding, randomized controlled trials of medication discontinuation may provide more definitive evidence regarding this relationship.

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Objectives-To explore whether models of health behavior change can help to inform interventions for ACP. Design-Qualitative cross-sectional study. Setting-CommunityParticipants-Sixty-three community dwelling persons age ≥ 65 years and 30 caregivers with experience as surrogate decision-makers.Measurements-In focus groups conducted separately with older persons and with caregivers, participants were asked to discuss ways they had planned for future declines in health and why they had or had not engaged in such planning. Transcripts were analyzed using grounded theory.Results-Four themes illustrated the potential of applying models of health behavior change to improve ACP. 1) Participants demonstrated variable readiness to engage in ACP and could be in different stages of readiness for different components of ACP, including consideration of treatment goals, completion of advance directives, and communication with families and physicians. 2) Participants identified a wide range of benefits of and barriers to ACP. 3) Participants used a variety of processes of change to progress through stages of readiness, and ACP was only one of a broader set of behaviors that participants engaged in to prepare for declines in their health or for death. 4) Experience with healthcare decision-making for loved ones was a strong influence on perceptions of susceptibility and engagement in ACP. 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. Sponsor's Role:The sponsor had no role in the design, methods subject recruitment, data collection, analysis or preparation of the paper. Discussion-The variability in participants' readiness, barriers and benefits, perceptions of susceptibility, and use of processes to increase readiness_for participating in each component of ACP suggests the utility of tailored, stage-specific interventions based on individualized assessments to improve ACP. NIH Public Access

OBJECTIVES To examine caregiver burden over time among caregivers of patients with advanced chronic disease. DESIGN Observational cohort with interviews over 12 months. PARTICIPANTS Caregivers of 179 community-living persons age ≥ 60 years with advanced cancer, heart failure (HF), or chronic obstructive pulmonary disease (COPD). MEASUREMENTS Caregiver burden assessed using a short-form of the Zarit Burden Inventory (ZBI) to measure psychosocial distress. RESULTS At baseline, the median caregiver burden was 5 (interquartile range [IQR 1,11]), which indicates that the caregiver endorsed having at least 2 of 10 distressing concerns at least some of the time. Only 10% reported no burden. Although scores increased modestly over time, the association between time and burden was not significant in longitudinal multivariable analysis. High burden was associated with caregivers’ need for more help with daily tasks (odds ratio [OR] = 23.13, 95% confidence interval [CI] = 5.94, 90.06) and desire for greater communication with the patient (OR = 2.53, 95% CI = 1.16, 5.53). The longitudinal multivariable analysis did not yield evidence of associations of burden with patient sociodemographic or health characteristics. CONCLUSION Caregiver burden was common among caregivers of patients with cancer, HF, and COPD. High burden was associated with the caregiver’s report of need for greater help with daily tasks but not with objective measures of the patient’s need for assistance, such as symptoms or functional status, suggesting that burden may be a measure of the caregiver’s ability to adapt to the caregiving role.

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