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Zhang et al conducted a prospective study of 396 patients with advanced cancer and their informal caregivers from enrollment to patient death a median of 4.1 months later to determine factors that affected quality of life at end of life. Patients who avoid hospitalizations and the intensive care unit, who are less worried, who pray or meditate, who are visited by a pastor in the hospital/clinic, and who feel a therapeutic alliance with their physicians have the highest quality of life at the end of life.
Red blood cells are a limited resource and are associated with heightened risk of morbidity complications following cardiac surgery. Jehovah's Witness patients hold beliefs that disallow use of red blood cell transfusion and therefore offered a natural experiment in extreme perioperative blood conservation. Jehovah's Witness patients who underwent cardiac surgery were not at an increased risk for surgical complications or reduced long-term survival. Hence, current extreme blood management strategies do not appear to increase postoperative morbidity or mortality.
In a study of patients in the National Cardiovascular Data Registry undergoing percutaneous coronary intervention, Amin et al examined recent practice patterns of drug-eluting stent (DES) use and their clinical and economic implications. The authors found that DESs were used at a high rate even in patients not expected to derive substantial benefit from them, with 73.9% of patients at low risk for target-vessel revascularization receiving DESs, compared with 78.0% and 83.2% in the moderate- and high-risk groups, respectively. A reduction in DES use by 50% in the low-risk group was projected to lower US health care costs by more than $200 million per year, while increasing the rate of target-vessel revascularization by 0.5%. Formally incorporating the predicted benefit of new technologies into clinical decisions may be useful in enhancing shared decision making, preserving physician autonomy, and improving health care sustainability.
Odden et al proposed that walking speed, as a measure of physiologic age and frailty, could identify which elderly patients were most at risk for the adverse effects of hypertension. Using data based on 2340 participants 65 years or older in the National Health and Nutrition Examination Survey (1999-2000 and 2001-2002), the authors found a significant interaction between walking speed and blood pressure (BP) for predicting mortality. Among faster walkers, those with elevated systolic BP (≥140 mm Hg) had a greater adjusted risk of mortality compared with those without, whereas there was no association in slower walkers. In participants who did not complete the walk test—and who may be most at risk for frailty—there was a strong and inverted association of higher BP and lower mortality.
Effective patient-physician communication is essential for shared decision making. In an online panel of 1340 adult participants responding to a hypothetical scenario about the treatment of heart disease, nearly all could envision asking questions (93%) and discussing preferences (94%) about treatment options, but few would voice disagreement with their physician if their preferences conflicted with his or her recommendation (14%; P < .001). While most felt they had the ability to disagree (79%), few thought disagreement was socially acceptable or would lead to good outcomes (14% and 15% respectively; P < .001). The reluctance to disagree appears to be a significant barrier to shared decision making that was found to be pervasive and equally prevalent across all sociodemographic strata in our sample.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2012;172(15):1121. doi:10.1001/archinternmed.2011.972