Trajectories of Disability in the Last Year of Life

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Jul 15, 2010 - and especially durable power of attorney for health care. From a European viewpoint, we are very impressed by the percentage of decedents ...
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Trajectories of Disability in the Last Year of Life To the Editor: In their study identifying five potentially useful trajectories of disability in activities of daily living during the last year of life, Gill et al. (April 1 issue)1 conclude that the illness leading to death does not predict a patient’s trajectory. Although their team adapted methods from our work,2 they addressed a different question. We had sought an evidence base for differentiating needs for health care services that were based on three population groups: short-term decline, long-term disability, and frequent decline– recovery cycles. Gill et al. might have identified the frequently fluctuating trajectory by using different analytic approaches.3 Like us, the authors were challenged to find indicators (other than dementia) to characterize patients who have sustained disabilities before death. Previous research had found a weak relationship between the frailty phenotype and disability.4 We continue to contend that clinical evaluations performed long ahead of death could help to anticipate and categorize needs and that prudent system design would align services for these three population groups, each of which has a set of similar needs at the end of life.5 June R. Lunney, Ph.D., R.N. Hospice and Palliative Nurses Association Pittsburgh, PA [email protected]

Joanne Lynn, M.D.

disability in the last year of life. N Engl J Med 2010;362:1173-80. 2. Lunney JR, Lynn J, Foley DJ, Lipson S, Guralnik JM. Patterns of functional decline at the end of life. JAMA 2003;289:2387-92. 3. Cappola AR, O’Meara ES, Guo W, Bartz TM, Fried LP, Newman AB. Trajectories of dehydroepiandrosterone sulfate predict mortality in older adults: the Cardiovascular Health Study. J Gerontol A Biol Sci Med Sci 2009;64:1268-74. 4. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56:M146-M156. 5. Lynn J, Straube BM, Bell K, Jencks SF, Kambic RT. Using population segmentation to provide better health care for all: the “Bridges to Health” model. Milbank Q 2007;85:185-208.

To the Editor: In their study involving a New England cohort of older persons, Gill and colleagues elegantly describe five trajectories of disability in the last year of life. On the basis of their previous work,1 studies by other investigators,2 and experience in clinical practice, we are surprised that a sixth trajectory of fluctuating disability and recovery in the last year of life did not emerge from the analyses. We speculate that this pattern might have been seen if the cohort had been larger or perhaps if more activities of daily living had been considered. Susan Kurrle, M.B., B.S., Ph.D. Ian D. Cameron, M.B., B.S., Ph.D.

Andrea B. Maier, M.D., Ph.D.

this week’s letters

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1. Gill TM, Gahbauer EA, Han L, Allore HG. Trajectories of

University of Sydney Sydney, NSW, Australia [email protected]

Colorado Foundation for Medical Care Englewood, CO

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Trajectories of Disability in the Last Year of Life

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Advance Directives and Surrogate Decision Making before Death

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No potential conflict of interest relevant to this letter was reported.

Are All Readmissions Bad Readmissions?

Leiden University Medical Center Leiden, the Netherlands No potential conflict of interest relevant to this letter was reported. 1. Hardy SE, Gill TM. Recovery from disability among commu-

nity-dwelling older persons. JAMA 2004;291:1596-602. 2. Verbrugge LM, Reoma JM, Gruber-Baldini AL. Short-term dynamics of disability and well-being. J Health Soc Behav 1994; 35:97-117.

n engl j med 363;3  nejm.org  july 15, 2010

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correspondence

The authors reply: The two groups of correspondents question whether there might be a fluctuating trajectory of disability in the last year of life that was not uncovered with our analytic methods. In Figure 1 of our article, the observed trajectories, representing the mean number of activities of daily living in which the participants had disability over time, are plotted as solid lines, and the predicted trajectories are plotted as dashed lines. The observed trajectories do not increase monotonically but are characterized by slight decreases and increases in the severity of disability. As noted in the figure legend, nearly two thirds of the observed trajectories that had a poor fit with the predicted trajectories were characterized by episodes of recovery from a more severe form of disability. However, such trajectories were observed in only 6% of the 383 decedents, making it difficult to identify a distinct trajectory of fluctuating disability. Furthermore, because group tra-

jectories were estimated, rather than individual trajectories, the periodicity of fluctuations in disability would need to be in sync in order for another group trajectory to emerge. In light of the high rates of recovery reported in previous studies,1,2 our results suggest that fluctuations in disability may be less common during the last year of life than during earlier periods in life. Heather G. Allore, Ph.D. Ling Han, M.D., Ph.D. Thomas M. Gill, M.D. Yale University School of Medicine New Haven, CT [email protected] Since publication of their article, the authors report no further potential conflict of interest. 1. Hardy SE, Gill TM. Recovery from disability among commu-

nity-dwelling older persons. JAMA 2004;291:1596-602. 2. Hardy SE, Dubin JA, Holford TR, Gill TM. Transitions between states of disability and independence among older persons. Am J Epidemiol 2005;161:575-84.

Advance Directives and Surrogate Decision Making before Death To the Editor: In their Special Article on ad- Gerald Kierzek, M.D., Ph.D. vance directives, Silveira et al. (April 1 issue)1 rec- Hôtel-Dieu Cochin Hospital ommend the continued use of advance directives Paris, France [email protected] and especially durable power of attorney for health Valeria Rac, M.D., Ph.D. care. From a European viewpoint, we are very St. Michael’s Hospital impressed by the percentage of decedents who Toronto, ON, Canada reportedly had an advance directive (67.6%) among Jean-Louis Pourriat, M.D. subjects who lacked decision-making capacity. We Hôtel-Dieu Cochin Hospital are also surprised by the power of a surrogate to Paris, France No potential conflict of interest relevant to this letter was reoverrule all decisions, even when surrogate decisions are inconsistent with the patient’s written ported. preferences. 1. Silveira MJ, Kim SY, Langa KM. Advance directives and outWe acknowledge that the U.S. model of the comes of surrogate decision making before death. N Engl J Med 2010;362:1211-8. patient–physician relationship is historically estab- 2. Lautrette A, Peigne V, Watts J, Souweine B, Azoulay E. Surlished on the patient’s autonomy, but after years rogate decision makers for incompetent ICU patients: a European of debate favoring paternalism over autonomy,2 perspective. Curr Opin Crit Care 2008;14:714-9. 3. Council of the European Union. Council conclusions on comthe ethical principle of autonomy is now fully mon values and principles in European Union Health Systems. endorsed by French and other European authori- Official Journal of the European Union, June 22, 2006. (Accessed ties.3,4 However, French legislation moved toward June 24, 2010, at http://eur-lex.europa.eu/LexUriServ/LexUriServ .do?uri=OJ:C:2006:146:0001:0003:EN:PDF.) a model in which decision making in end-of-life 4. French Parliament. Law No. 2002-303 of 4 March 2002 on situations is shared among physicians, patients, patients’ rights and the quality of the health system. (Accessed and family members. Advance directives and di- June 24, 2010, at http://www.legifrance.gouv.fr/affichCode Article.do;jsessionid=AB85CDED5DA6C2F01D482487F7BC0C7E rectives by the patient’s family or a surrogate deci- .tpdjo07v_2?cidTexte=LEGITEXT000006072665&idArticle=LE sion maker have only a consultative role, and care GIARTI000006685759&dateTexte=20100225&categorieLien=id.) decisions are made after a collegial procedure5 in 5. Idem. Law No. 2005-370 of 22 April 2005 on patients’ rights and end of life. (Accessed June 24, 2010, at http://www.legifrance case of irreversible cause to ensure a balanced deci- .gouv.fr/html/actualite/actualite_legislative/decrets_application/ sion in the patient’s best interests. 2005-370.htm.) n engl j med 363;3  nejm.org  july 15, 2010

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