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Objective The study objective was to describe self-reported advance care planning, health care preferences, use of advance directives, and health perceptions in a very elderly community-dwelling sample. Methods We interviewed surviving participants of the original cohort of the Framingham Heart Study who were cognitively intact and attended a routine research examination between February 2004 and October 2005. Participants were queried about discussions about end-of-life care, preferences for care, documentation of advance directives, and health perceptions. Results Among 220 community-dwelling respondents, 67% were women with a mean age of 88 years (range 84-100 years). Overall, 69% discussed their wishes for medical care at the end of life with someone, but only 17% discussed their wishes with a physician or health care provider. Two thirds had a health care proxy, 55% had a living will, and 41% had both. Most (80%) respondents preferred comfort care over life-extending care, and 71% preferred to die at home; however, substantially fewer respondents said they would rather die than receive specific life-prolonging interventions (chronic ventilator [63%] or feeding tube [64%]). Many were willing to endure distressing health states, with fewer than half indicating that they would rather die than live out their life in a great deal of pain (46%) or be confused and/or forgetful (45%) all of the time. Conclusions Although the vast majority of very elderly community-dwellers in this sample appear to prefer comfort measures at the end of life, many said they were willing to endure specific life-prolonging interventions and distressing health states to avoid death. Our results highlight the need for physicians to better understand patients' preferences and goals of care to help them make informed decisions at the end of life.

Breast-conserving surgery (BCS) has been the recommended treatment for early-stage breast cancer since 1990 yet many women still do not receive this procedure.To examine the relationship between birthplace and use of BCS in Asian-American and Pacific-Islander (AAPI) women, and to determine whether disparities between white and AAPI women persist over time.Retrospective cohort study.Women with newly diagnosed stage I or II breast cancer from 1992 to 2000 in the Surveillance, Epidemiology, and End Results program.Receipt of breast -conserving surgery for initial treatment of stage I or II breast cancer.Overall, AAPI women had lower rates of BCS than white women (47% vs 59%; P.01). Foreign-born AAPI women had lower rates of BCS than U.S.-born AAPI and white women (43% vs 56% vs 59%; P.01). After adjustment for age, marital status, tumor registry, year of diagnosis, stage at diagnosis, tumor size, histology, grade, and hormone receptor status, foreign-born AAPI women (adjusted OR [aOR], 0.49; 95% CI, 0.32 to 0.76) and U.S.-born AAPI women (aOR, 0.77; 95% CI, 0.62 to 0.95) had lower odds of receiving BCS than white women. Use of BCS increased over time for each racial/ethnic group; however, foreign-born AAPI women had persistently lower rates of BCS than non-Hispanic white women.AAPI women, especially those who are foreign born, are less likely to receive BCS than non-Hispanic white women. Of particular concern, differences in BCS use among foreign-born and U.S.-born AAPI women and non-Hispanic white women have persisted over time. These differences may reflect inequities in the treatment of early-stage breast cancer for AAPI women, particularly those born abroad.

Studies have evaluated the prevalence of domestic violence in populations of patients in emergency and primary care settings, but there are little data on patients admitted to hospitals. We undertook a study to evaluate the prevalence of domestic violence among female inpatients. Of 131 consecutive female patients between the ages of 18 and 60 admitted to a nontrauma urban teaching hospital asked to complete a self-administered survey about domestic violence, 101 completed the questionnaire. Twenty-six percent of the respondents reported being in an abusive relationship at one time. Two patients felt that domestic violence contributed to their current reason for admission. No respondents were asked about domestic violence by health care providers. Domestic violence is an uncommon but important precipitant to nontrauma hospital admissions. Physicians should query all female inpatients about domestic assault.