Alexia Torke

Permanent URI for this collection

https://hdl.handle.net/1805/6821

Assessing Surrogate Decision Making For Older Adults

Hospitalized older adults are often unable to make their own medical decisions due to dementia, delirium or other conditions that impair cognitive function. In such cases, physicians must work with surrogates, usually close family members, to make choices for the patient. Although there is evidence of unwanted medical treatment for seriously ill patients and strain on surrogate decision makers, there has been little study of the frequency, characteristics or outcomes of surrogate decision making for older, hospitalized adults. An observational study conducted by Dr. Torke will characterize the frequency and outcomes of decisions made by surrogates with emphasis on the surrogate's own perspective on decision making. Results from the study will serve as the basis for an intervention to improve the quality and outcomes of surrogate decision making for older, hospitalized adults and their families.

Browse

Now showing 1 - 10 of 43

Making Decisions for Hospitalized Older Adults: Ethical Factors Considered by Family Surrogates
(2013-08) Fritch, Jenna; Petronio, Sandra; Helft, Paul R.; Torke, Alexia M.
Background Hospitalized older adults frequently have impaired cognition and must rely on surrogates to make major medical decisions. Ethical standards for surrogate decision making are well delineated, but little is known about what factors surrogates actually consider when making decisions. Objectives To determine factors surrogate decision makers consider when making major medical decisions for hospitalized older adults, and whether or not they adhere to established ethical standards. Design Semi-structured interview study of the experience and process of decision making. Setting A public safety-net hospital and a tertiary referral hospital in a large city in the Midwest. Participants Thirty-five surrogates with a recent decision making experience for an inpatient age 65 and older. Measurements Key factors surrogates considered when making decisions. Interview transcripts were coded and analyzed using the grounded theory method of qualitative analysis. Results Surrogates considered patient-centered factors and surrogate-centered factors. Patient-centered factors included: 1) respecting the patient’s input, (2) using past knowledge of patient to infer the patient’s wishes, and (3) considering what is in the patient’s best interests. Some surrogates expressed a desire for more information about the patient’s prior wishes. Surrogate-centered factors included 1) Surrogate’s wishes as a guide, (2) The surrogate’s religious beliefs and/or spirituality, (3) The surrogate’s interests, (4) Family consensus and (5) Obligation and guilt. Conclusion These data show that surrogate decision making is more complex than the standard ethical models, which are limited to patient autonomy and beneficence. Because surrogates also imagine what they would want under the circumstances and consider their own needs and preferences, models of surrogate decision making must account for these additional considerations. Surrogates’ desire for more information about patient preferences suggests a need for greater advance care planning.
Timing of Do‐Not‐Resuscitate Orders for Hospitalized Older Adults Who Require a Surrogate Decision‐Maker
(2011-07) Torke, Alexia M.; Sachs, Greg A.; Helft, Paul R.; Petronio, Sandra; Purnell, Christianna E.; Hui, Siu; Callahan, Christopher M.
OBJECTIVES: To examine the frequency of surrogate decisions for in-hospital do-not-resuscitate (DNR) orders and the timing of DNR order entry for surrogate decisions. DESIGN: Retrospective cohort study. SETTING: Large, urban, public hospital. PARTICIPANTS: Hospitalized adults aged 65 and older over a 3-year period (1/1/2004–12/31/2006) with a DNR order during their hospital stay. MEASUREMENTS: Electronic chart review provided data on frequency of surrogate decisions, patient demographic and clinical characteristics, and timing of DNR orders.
A Conceptual Model of the Role of Communication in Surrogate Decision Making for Hospitalized Adults
(2012-04) Torke, Alexia M.; Petronio, Sandra; Sachs, Greg A.; Helft, Paul R.; Purnell, Christianna E.
OBJECTIVE: To build a conceptual model of the role of communication in decision making, based on literature from medicine, communication studies and medical ethics. METHODS: We proposed a model and described each construct in detail. We review what is known about interpersonal and patient-physician communication, described literature about surrogate-clinician communication, and discussed implications for our developing model. RESULTS: The communication literature proposes two major elements of interpersonal communication: information processing and relationship building. These elements are composed of constructs such as information disclosure and emotional support that are likely to be relevant to decision making. We propose these elements of communication impact decision making, which in turn affects outcomes for both patients and surrogates. Decision making quality may also mediate the relationship between communication and outcomes. CONCLUSION: Although many elements of the model have been studied in relation to patient-clinician communication, there is limited data about surrogate decision making. There is evidence of high surrogate distress associated with decision making that may be alleviated by communication-focused interventions. More research is needed to test the relationships proposed in the model. PRACTICE IMPLICATIONS: Good communication with surrogates may improve both the quality of medical decisions and outcomes for the patient and surrogate.
Communicating with Clinicians: The Experiences of Surrogate Decision‐Makers for Hospitalized Older Adults
(2012-08) Torke, Alexia M.; Petronio, Sandra; Purnell, Christianna E.; Sachs, Greg A.; Helft, Paul R.; Callahan, Christopher M.
OBJECTIVES: To describe communication experiences of surrogates who had recently made a major medical decision for a hospitalized older adult. DESIGN: Semistructured interviews about a recent hospitalization. SETTING: Two hospitals affiliated with one large medical school: an urban public hospital and a university-affiliated tertiary referral hospital. PARTICIPANTS: Surrogates were eligible if they had recently made a major medical decision for a hospitalized individual aged 65 and older and were available for an interview within 1 month (2-5 months if the patient died). MEASUREMENTS: Interviews were audio-recorded, transcribed, and analyzed using methods of grounded theory. RESULTS: Thirty-five surrogates were interviewed (80% female, 44% white, 56% African American). Three primary themes emerged. First, it was found that the nature of surrogate-clinician relationships was best characterized as a relationship with a "team" of clinicians rather than individual clinicians because of frequent staff changes and multiple clinicians. Second, surrogates reported their communication needs, including frequent communication, information, and emotional support. Surrogates valued communication from any member of the clinical team, including nurses, social workers, and physicians. Third, surrogates described trust and mistrust, which were formed largely through surrogates' communication experiences. CONCLUSION: In the hospital, surrogates form relationships with a "team" of clinicians rather than with individuals, yet effective communication and expressions of emotional support frequently occur, which surrogates value highly. Future interventions should focus on meeting surrogates' needs for frequent communication and high levels of information and emotional support.
Disclosing Medical Mistakes: A Communication Management Plan for Physicians
(2013-04) Petronio, Sandra; Torke, Alexia M.; Bosslet, Gabriel T.; Isenberg, Steven; Wocial, Lucia D.; Helft, Paul R.
Introduction: There is a growing consensus that disclosure of medical mistakes is ethically and legally appropriate, but such disclosures are made difficult by medical traditions of concern about medical malpractice suits and by physicians’ own emotional reactions. Because the physician may have compelling reasons both to keep the information private and to disclose it to the patient or family, these situations can be conceptualized as privacy dilemmas. These dilemmas may create barriers to effectively addressing the mistake and its consequences. Although a number of interventions exist to address privacy dilemmas that physicians face, current evidence suggests that physicians tend to be slow to adopt the practice of disclosing medical mistakes. Methods: This discussion proposes a theoretically based, streamlined, two-step plan that physicians can use as an initial guide for conversations with patients about medical mistakes. The mistake disclosure management plan uses the communication privacy management theory. Results: The steps are 1) physician preparation, such as talking about the physician’s emotions and seeking information about the mistake, and 2) use of mistake disclosure strategies that protect the physician-patient relationship. These include the optimal timing, context of disclosure delivery, content of mistake messages, sequencing, and apology. A case study highlighted the disclosure process. Conclusion: This Mistake Disclosure Management Plan may help physicians in the early stages after mistake discovery to prepare for the initial disclosure of a medical mistakes. The next step is testing implementation of the procedures suggested.
Older Adults and Forgoing Cancer Screening
(2013-04) Torke, Alexia M.; Schwartz, Peter H.; Holtz, Laura R.; Montz, Kianna
Importance Although there is a growing recognition that older adults and those with extensive comorbid conditions undergo cancer screening too frequently, there is little information about patients' perceptions regarding cessation of cancer screening. Information on older adults' views of screening cessation would be helpful both for clinicians and for those designing interventions to reduce overscreening. Objective To obtain a deeper understanding of older adults' perspectives on screening cessation and their experiences communicating with clinicians about this topic. Design Semistructured interview study. Setting Senior health center affiliated with an urban hospital. Participants We interviewed 33 older adults presenting to a senior health center. Their median age was 76 years (range, 63-91 years). Of the 33 participants, 27 were women; 15 were African American, 16 were white, 1 was Asian, and 1 was American Indian. Main Outcome Measures We transcribed audio recordings of interviews and analyzed them using methods of grounded theory to identify themes and illustrative quotes. Results Undergoing screening tests was perceived by participants as morally obligatory. Although many saw continued screening as a habit or custom not involving any decision, cessation of screening would require a major decision. Many asserted that they had never discussed screening cessation with their physicians or considered stopping on their own; some reported being upset when their physician recommended stopping. Although some would accept a physician's strong recommendation to stop, others thought that such a physician's recommendation would threaten trust or lead them to get another opinion. Participants were skeptical about the role of statistics and the recommendations of government panels in screening decisions but were more favorable toward stopping because of the balance of risks and benefits, complications, or test burdens. Conclusions and Relevance For many older adults, stopping screening is a major decision, but continuing screening is not. A physician's recommendation to stop may threaten patient trust. Effective strategies to reduce nonbeneficial screening may include discussion of the balance of risks and benefits, complications, or burdens.
CEASE: A guide for clinicians on how to stop resuscitation efforts
(ATS, 2015-03) Torke, Alexia M.; Bledsoe, Patricia; Wocial, Lucia D.; Bosslet, Gabriel T.; Helft, Paul R.; Department of Medicine, IU School of Medicine
Resuscitation programs such as Advanced Cardiac Life Support, Cardiac Life Support, Pediatric Advanced Life Support, and the Neonatal Resuscitation Program offer inadequate guidance to physicians who must ultimately decide when to stop resuscitation efforts. These decisions involve clinical and ethical judgments and are complicated by communication challenges, group dynamics, and family considerations. This article presents a framework, summarized in a mnemonic (CEASE: Clinical Features, Effectiveness, Ask, Stop, Explain), for how to stop resuscitation efforts and communicate that decision to clinicians and ultimately the patient’s family. Rather than a decision rule, this mnemonic represents a framework based on best evidence for when physicians are considering stopping resuscitation efforts and provides guidance on how to communicate that decision.
Surrogate Decision Makers and Proxy Ownership: Challenges of Privacy Management in Health Care Decision Making
(Taylor and Francis, 2015-08) Bute, Jennifer J.; Petronio, Sandra; Torke, Alexia M.; Department of Communication Studies, School of Liberal Arts
This study explored the communicative experiences of surrogates who served as decision makers for patients who were unable to convey health information and choices about treatment options. Drawing on assumptions from communication privacy management theory (Petronio, 2002), 35 surrogates were interviewed to explore how they navigated the role of guardian of patients’ private health information while the patient was hospitalized. This research determined that not only are surrogates guardians and thereby co-owners of the patients’ private health information, they actually served in a “proxy ownership” role. Surrogates described obstacles to both obtaining and sharing private health information about the patient, suggesting that their rights as legitimate co-owners of the patients’ information were not fully acknowledged by the medical teams. Surrogates also described challenges in performing the proxy ownership role when they were not fully aware of the patient’s wishes. Theoretical and practical implications of these challenges are discussed.
Doctor, What Would You Do?: An ANSWER for patients requesting advice about value-laden decisions
(AAP, 2015-10) Edmonds, Brownsyne Tucker; Torke, Alexia M.; Helft, Paul; Wocial, Lucia D.; Department of Obstetrics and Gynecology, IU School of Medicine
This article presents a previously published framework, summarized in the mnemonic ANSWER (A, Active listening; N, Needs assessment; S, Self-awareness/reflection; W, Whose perspective?; E, Elicit values; R, Respond) for how to respond to the question, “Doctor, what would you do?” when considering medical decisions that are preference-sensitive, meaning there is limited or debatable evidence to guide clinical recommendations, or are value-laden, such that the “right” decision may differ based on the context or values of a given individual. Using the mnemonic and practical examples, we attempt to make the framework for an ethically appropriate approach to these conversations more accessible for clinicians. Rather than a decision rule, this mnemonic represents a set of points to consider when physicians are considering an ethically acceptable response that fosters trust and rapport. We apply this approach to a case of periviable counseling, among the more emotionally challenging and value-laden antenatal decisions faced by providers and patients.
Symptom Burden in Geriatric Hospitalized ESRD Patients: Quantifying symptoms to increase Nephrologist Awareness and use of Palliative Care Consultation
(Office of the Vice Chancellor for Research, 2016-04-08) Moe, Jawed A.; Moorthi, R.N.; Moe, S.M.; Torke, Alexia M.; Eadon, M.T.
Background: End Stage Renal Disease (ESRD) patients have significant symptom burden. Reduced provider awareness of symptoms contributes to underutilization of symptom management resources. Hypothesis: We hypothesize that improved nephrologist awareness of symptoms will lead to symptom improvement. Methods: In this prospective, multicenter intervention study, 27 geriatric ESRD inpatients underwent symptom assessment using the modified Edmonton Symptom Assessment System (ESAS) at admission and 1 week post-discharge. Enrollees were sequentially randomized into 2 groups. In group 1, the nephrologist of each individual was provided baseline symptom assessment and not in group 2. Severity ratings were compared between in-hospital and post discharge scores as well as between the 2 groups. Results: 26 patients completed the study; 1 died. There were no significant differences in baseline characteristics and scores, except increased diabetes in Group 2(P = 0.03). For 70% of the total cohort physicians reported not being surprised if the patient died within a year. Among the total cohort, total ESAS scores improved between initial and follow-up assessments except for depression, anxiety, lack of appetite and nausea. The absolute change in total ESAS scores was 10.9 in group1 and 6.8 in group2 (NS). Among individual symptoms significant improvement was found in pain and itching in group 1 only. Drowsiness and dyspnea improved in both groups. There was one palliative care consult. Conclusions: Our findings reinforce the high symptom burden in geriatric ESRD patients. Residual symptoms post hospitalization and low utilization of palliative care resources is suggestive of a missed opportunity by nephrologists to address the high symptom burden at the inpatient encounter which is selective for sicker patients and/or inadequacy of dialysis to control these symptoms. The trend in improvement in pain and itching in group 1 may indicate better achievable symptom control if physician awareness is increased and simple pharmacological interventions are available.

Browse

Browsing Alexia Torke by browse.metadata.dateaccessioned

Results Per Page

Sort Options