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Personalized decision aid did not help surrogates and clinicians agree on treatment goals for critically ill patients

January 28, 2019

1. Personalized decision aid did not help surrogates and clinicians agree on treatment goals for critically ill patients
Almost all surrogates remained overly optimistic about their loved one's survival, despite evidence to the contrary


Abstract: http://annals.org/aim/article/doi/10.7326/M18-2335Editorial:http://annals.org/aim/article/doi/10.7326/M18-3691
URLs go live when the embargo lifts A personalized web-based decision aid did not help surrogate decision makers and clinicians agree on treatment goals for patients on life support for longer than average. Nearly all surrogates chose a more aggressive treatment goal than was suggested by the decision aid, despite the aid being based on the surrogate's report of patient values. Results from a multi-center randomized clinical trial are published in Annals of Internal Medicine.

Patients who receive prolonged mechanical ventilation typically lack the ability to make their own medical decisions and rely on family members or close loved ones to act as surrogate decision makers. These decisions are complex and difficult for surrogates and clinicians alike, as they involve choosing goals of care between life-prolonging therapy, comfort-focused care possibly including withdrawal of life support, or some intermediary goal. Decision aids used in outpatient settings can improve the quality of decision making by providing surrogates with relevant information, helping set realistic expectations, and aligning choice with personal values. However, no clinical trials have tested decision aids in an acute care setting or among surrogates in intensive care units.

Researchers from Duke University, the University of North Carolina, the University of Pittsburgh, and the University of Washington compared a theory-based decision aid that was individualized to the clinical condition of each critically ill patient to usual care. The decision aid guided each family member in thinking about what their loved one valued most and then considering which ICU goal of care was best aligned with these values. The researchers found that although the decision aid reduced surrogates' decisional conflict and improved their understanding of physicians' prognostic beliefs, it did not change clinician-surrogate concordance about 1-year survival estimates, surrogates' distress symptoms, patients' clinical outcomes, or the actual decisions made in comparison to control. Almost half of decision aid group surrogates disagreed with the decision aid-suggested goals of care choice it calculated from surrogates' own reports about patient values, with nearly all surrogates choosing a more aggressive treatment goal.

According to the authors, this trial is timely because it challenges the notion that decision aids can easily change resource utilization in the location of the greatest healthcare expenditure: the acute care hospital. The authors suggest that this trial should prompt the field to reconsider how decision aids can be better applied and operationalized in acute care settings.
Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Christopher E. Cox, MD, please contact Samiha Khanna at samiha.khanna@duke.edu

2. MEESSI-AHF tool shows promise for more widespread risk stratification of patients with acute heart failure in the ED
Abstract: http://annals.org/aim/article/doi/10.7326/M18-1967
URLs go live when the embargo lifts

The MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF) risk score that was shown to accurately predict 30-day mortality in patients with acute heart failure in Spain has been externally validated in Switzerland. These findings suggest that the tool may be useful for other populations, as well. Findings from a cohort study are published in Annals of Internal Medicine.

Acute heart failure (AHF) is the most common cause of hospitalization in patients aged 50 years or older, with more than 2 million hospitalizations annually in both Europe and the U.S. The MEESSI-AHF risk score considers 12 independent cardiovascular risk factors to predict 30-day mortality in patients presenting with acute heart failure. While the score has been proven accurate in Spain, its performance in other countries is unknown.

Researchers from the Department of Cardiology at University Hospital Basel in Switzerland studied 1,572 patients presenting to the emergency departments of two university hospitals and two nonacademic tertiary care centers in Switzerland to externally validate the MEESSI-AHF risk score. They found that the score predicted 30-day mortality with excellent discrimination in a population that differed from that in which the score was developed, suggesting that it is a promising tool for more widespread risk stratification of patients with acute heart failure in the emergency department. However, the authors note that recalibration may be needed when the score is introduced to new populations.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Christian Mueller, MD, please contact him directly at Christian.mueller@usb.ch.

3. Patients taking tenofovir alafenamide for HIV and HBV infection may be at risk for Fanconi syndrome
Abstract: http://annals.org/aim/article/doi/10.7326/L18-0592
URLs go live when the embargo lifts

Clinicians should monitor renal function in patients taking tenofovir alafenamide (TAF), as treatment may cause Fanconi syndrome. A case report is published in Annals of Internal Medicine.

Tenofovir disoproxil fumarate (TDF) therapy has been almost completely replaced by TAF for treatment of HIV infection and chronic hepatitis B virus infection in the United States. This is because TAF is associated with less kidney damage than TDF. However, clinicians caution that Fanconi syndrome could be a complication of TAF treatment. They cite the case of a 54-year-old man who had been taking TDF for 10 years and then transitioned to TAF. Following the medication change, the patient showed highly elevated creatinine levels and was admitted to the hospital. All of his lab results were consistent with Fanconi syndrome, so the clinicians discontinued all antiretroviral medications. The patient improved and was started on an antiretroviral regimen that did not contain tenofovir.

According to the authors, this case is important because it demonstrates that renal injury is a risk in patients taking TAF. They suggest that clinicians consider monitoring renal function in these patients.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Nathan C. Bahr, MD, please contact nbahr@kumc.edu
-end-
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Ideas & Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2673

American College of Physicians

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