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Obtaining informed consent is a frequent and important part of the practice of orthopaedic surgery. However, the process can be complicated, especially when there are impediments to communication and unusual decisions. An approach that considers each of the elements of informed consent permits the clinician to enhance the role of autonomy in patient decisions while maximizing the probability of achieving successful informed consent. Attending to (and testing when necessary) a patient's capacity to make decisions, ensuring comprehension of the clinical circumstances and proposed intervention and it's risks and benefits, and evaluating the decision-making mechanism are essential steps. A patient's capacity to participate in informed consent at times may be enhanced by selected interventions and may require serial reevaluation to identify the optimal time to discuss the issues. Implied consent has an important but delimited role in emergent circumstances. Prospective elicitation of patient preferences and delineation of surrogate decision makers can substantially enhance the ease and efficiency of informed consent while matching care with patient goals.

Objective: To identify the desired features of end-of-life medical decision making from the perspective of elderly individuals., Design: Qualitative study using in-depth interviews and analysis from a phenomenologic perspective., Setting: A senior center and a multilevel retirement community in Los Angeles., Participants: Twenty-one elderly informants (mean age 83 years) representing a spectrum of functional status and prior experiences with end-of-life decision making., Main Results: Informants were concerned primarily with the outcomes of serious illness rather than the medical interventions that might be used, and defined treatments as desirable to the extent they could return the patient to his or her valued life activities. Advanced age was a relevant consideration in decision making, guided by concerns about personal losses and the meaning of having lived a "full life." Decision-making authority was granted both to physicians (for their technical expertise) and family members (for their concern for the patient's interests), and shifted from physician to family as the patient's prognosis for functional recovery became grim. Expressions of care, both by patients and family members, were often important contributors to end-of-life treatment decisions., Conclusions: These findings suggest that advance directives and physician-patient discussions that focus on acceptable health states and valued life activities may be better suited to patients' end-of-life care goals than those that focus on specific medical interventions, such as cardiopulmonary resuscitation. We propose a model of collaborative surrogate decision making by families and physicians that encourages physicians to assume responsibility for recommending treatment plans, including the provision or withholding of specific life-sustaining treatments, when such recommendations are consistent with patients' and families' goals for care.

Background: Despite concern about the high costs and the uncertain benefit of prolonged treatment in the intensive care unit (ICU), there has been little research examining decision-making and outcomes for patients with prolonged ICU stays., Objectives: To evaluate decision-making and outcomes for seriously ill patients with an ICU stay of at least 14 days., Design: A prospective cohort study., Setting: Five teaching hospitals., Participants: Seriously ill patients enrolled in the Study To Understand Prognoses and Preferences for Risks and Outcomes of Treatments (SUPPORT)., Measurement: Patients, their surrogate decision-makers, and their physicians were interviewed about prognosis, communication, and goals of medical care. Based on age, diagnoses, comorbid illnesses, and acute physiology data, the SUPPORT Prognostic Model provided estimates of 6-month survival on study days 1, 3, 7, and 14. Hospital costs were estimated from hospital billing data., Results: Of the 9105 patients enrolled in SUPPORT, 1494 (16%) had ICU stays of 14 days or longer. The median length of stay in an ICU was 4 days for the entire SUPPORT cohort and 35 days for patients who were treated in an ICU for 14 days or longer. Median hospital costs were $76,501 for patients who had ICU stays 14 days or longer and $10,916 for patients who did not have long ICU stays. Fifty-five percent of patients with long ICU stays had died by 6 months, and an additional 19% had substantial functional impairment. Among patients with ICU stays of at least 14 days, only 20% had estimates of 6-month survival that fell below 10% at any time during their hospitalization. For patients with long ICU stays, the mean predicted probability of 6-month survival was 0.46 on study Day 3 and 0.47 on study Day 14. Fewer than 40% of patients (or their surrogates) reported that their physicians had talked with them about their prognoses or preferences for life-sustaining treatment. Among the patients who preferred a palliative approach to care, only 29% thought that their care was consistent with that aim. Those who discussed their preferences for care with a physician were 1.9 times more likely to believe that treatment was in accord with their preferences for palliation (95% CI, 1.4-2.5), Conclusions: Prolonged ICU stays were expensive and were often followed by death or disability. Patients reported low rates of discussions with their physicians about their prognoses and preferences for life-sustaining treatments. Many preferred that care focus on palliation and believed that care was inconsistent with their preferences. Patients were more likely to receive care consistent with their preferences if they had discussed their care preferences with their physicians.

Objective: We evaluated prospectively the use of acute hemodialysis among hospitalized patients to identify demographic and clinical predictors of and chart documentation concerning dialysis withheld and withdrawn., Design: Prospective cohort study., Setting: Five teaching hospitals., Patients: Five hundred sixty-five seriously ill hospitalized patients who had not previously undergone dialysis who developed renal failure., Main Outcome Measures: Patient demographics, clinical characteristics, preferences, and prognostic estimates associated with having dialysis withheld rather than initiated and withdrawn rather than continued. Differences in chart documentation concerning decision-making for dialysis withheld, withdrawn, and continued., Results: Older patient age, cancer diagnosis, and male gender were associated with dialysis withheld rather than withdrawn. Age and gender differences persisted after adjustment for patients' aggressiveness of care preference. Worse 2-month prognosis was associated with both withholding and withdrawing dialysis. Chart documentation of decision-making was lacking more often for patients with dialysis withheld than for dialysis withdrawn., Conclusions: Measuring the equity of life-sustaining treatment use will require evaluation of care withheld, not just care withdrawn. Older patients and men, after accounting for prognosis and function, are more likely to have dialysis withheld than withdrawn after a trial. Further exploration is needed into this disparity and the inadequate chart documentation for patients with dialysis withheld.

Objective: To evaluate whether nursing home residents and their families reported discussions about life-sustaining treatment with their physicians, the relationship between such discussions and orders to limit therapy, and predictors of physician-patient communication about life-sustaining treatment., Design: Cross-sectional interviews and retrospective chart abstraction., Setting: Three regions: West Coast, New England, Western., Sample: A total of 413 nursing home residents, 363 family/surrogate interviews, and 192 resident interviews., Main Outcome Measures: Measured were (1) physician-resident communication about life-sustaining treatment and (2) presence of an advance directive or do not resuscitate (DNR) order in resident's chart., Results: Seventy-four percent of residents had DNR orders, and 32% had advance directives; only 29% of residents reported discussions about life-sustaining treatment. Of residents with DNR orders who could have participated in discussions about life-sustaining treatment, nearly half reported they had not discussed CPR with their caregivers. Older age, longer duration of time living in nursing home, location in a New England nursing home, physician-family member discussion, and the presence of an advance directive in the medical chart were positively associated with having DNR orders. Physician-resident discussion was not associated with having a DNR order. For the subsample of interviewed residents, age and a diagnosis of cognitive impairment were negatively associated with a physician-resident discussion about life-sustaining treatment, whereas the likelihood of having a discussion increased with increasing numbers of medical diagnoses., Conclusions: Chart orders to limit therapy are common, but physician-resident discussions about life-sustaining treatments are not. Far more family members than residents report such discussions with the resident's physicians.

Purpose: For patients hospitalized with serious illnesses, we identified factors associated with a stated preference to forgo cardiopulmonary resuscitation (CPR), examined physician-patient communication about these issues, and determined the relationship of patients' preferences to intensity of care and survival., Patients and Methods: The study was a cross-sectional evaluation of patient preferences. The setting was five geographically diverse academic acute-care medical centers participating in the SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments) project. Study participants were hospitalized patients > or = 18 years of age with 1 of 9 serious illnesses who were interviewed between days 3 and 6 after qualifying for the study. Using standardized interviews, patients provided information on demographics, preferences for CPR and other treatments, quality of life, functional status, perceptions of prognosis, and whether the patient had discussed CPR preferences with his or her physician. Data abstracted from the medical record included physiologic measures, therapeutic intensity, whether CPR was provided, and whether there was a do-not-resuscitate order., Results: Of 1,995 eligible patients, 84% were interviewed (mean age 62 years, 58% men, inhospital mortality 7%, 6-month mortality 33%). Of the respondents, 28% did not want CPR. Factors associated independently with not wanting CPR included: hospital site; diagnosis; being older; being more functionally impaired; and patient perception of a worse prognosis. Only 29% of patients had discussed their preferences with their physician; 48% of those who did not want CPR reported such discussions. After adjusting for illness severity and factors associated with CPR preferences, patients not wanting CPR had lower intensity of care; similar inhospital mortality; and higher mortality at 2 and 6 months following study entry., Conclusions: The diagnosis, patients' perception of the prognosis, and hospital site were significantly associated with patients' resuscitation preferences after adjusting for patient demographics, severity of illness, and functional status. The rate of discussing CPR was low even for patients who did not want CPR. Patient preferences not to receive CPR were associated with a small decrease in intensity of care but no difference in hospital survival.

Objective: To investigate the appropriateness of hospitalization as the time to elicit patients' medical care preferences, the authors evaluated the capability of seriously ill patients to participate in decision making early in hospitalization and their decision making capacity two weeks before hospital entry., Design: Cross-sectional study with retrospective evaluation of preadmission decision making capacity., Setting: Five acute care teaching hospitals., Patients: Four thousand three hundred one acutely ill hospitalized adults meeting predetermined severity of illness criteria in nine specific disease categories., Measurements: Surrogate decision makers' estimates of the prior mental capacities of patients unable to be interviewed early in hospitalization about care preferences due to intubation, coma, or cognitive impairment. Comparison of the demographics, degrees of sickness at admission, and outcomes of interviewable vs noninterviewable patients., Main Results: Forty percent of the patients were not interviewable concerning preferences. Of these, 83% could have participated in treatment decisions two weeks prior to hospitalization. The patients who were not interviewable were more acutely ill, had less chronic disease, and were more likely to die during hospitalization than the interviewable patients., Conclusions: Many acutely ill patients likely to die in the hospital lost their ability to make medical care decisions around the time of hospital admission. Preferences for care and advance directives should be discussed in the outpatient setting or very early in hospital admission.