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Original Investigation |

The Value of Disease Severity in Predicting Patient Readiness to Address End-of-Life Issues FREE

Mark P. Pfeifer; Charlene K. Mitchell; Lynell Chamberlain
[+] Author Affiliations

From the Divisions of General Internal Medicine (Drs Pfeifer and Mitchell) and Respiratory and Critical Care (Dr Chamberlain), Department of Medicine, University of Louisville, Louisville, Ky.


Arch Intern Med. 2003;163(5):609-612. doi:10.1001/archinte.163.5.609.
Text Size: A A A
Published online

Background  Although patient-physician discussion is the most important tool for end-of-life planning, less than 30% of seriously ill patients have held these discussions. While physicians use objective disease severity and recent clinical events to trigger end-of-life discussions, it is not known if such findings predict patient readiness. We evaluated the ability of disease severity measures and recent clinical events to predict patient readiness for end-of-life discussions in patients with chronic lung disease.

Methods  The desire for discussion about end-of-life care was evaluated in 100 outpatients with a diagnosis of chronic lung disease presenting for pulmonary function testing. Objective disease severity was indicated by the percentage of the predicted forced expiratory volume, use of oral corticosteroids, a functional status score, frequency of recent hospitalizations, and required use of mechanical ventilation.

Results  In multivariate analysis, patient desire for an end-of-life discussion with the physician was not associated with percentage of predicted forced expiratory volume in 1 second (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.96-1.03), oral corticosteroid use (OR, 1.34; 95% CI, 0.40-4.54), functional status score (OR, 1.37; 95% CI, 0.34-5.56), hospitalizations in the past year (OR, 0.33; 95% CI, 0.09-1.20), or previous mechanical ventilation (OR, 1.37; 95% CI, 0.34-5.56).

Conclusions  Patients appear no more or less interested in end-of-life discussions at later stages of chronic lung disease. Physicians cannot use disease severity measures or recent clinical events to accurately predict when patients desire end-of-life discussions. Focusing on physician skill in using specific communication strategies for patients at all stages of illness may be the most promising approach to increasing end-of-life discussions.

METHODS TO address and plan end-of-life care and the use of life-sustaining treatments fall generally into 3 categories: written advance directives; surrogate decisions by physicians, families, or friends; and direct discussions between patients and their physicians.

After initial optimism, advance directives such as living wills have proven disappointing. Only 10% to 20% of patients complete advance directives and, when completed, they are limited in their effect on future health care.18 Surrogate decisions by physicians and families are commonly used but poorly match patients' own desires and values,911 and often leave surrogates uncomfortable and favoring intense life support even in the face of medical futility and knowledge that such care may not be the patient's wish.1,2,913

Direct patient-physician discussion is thus the most important tool for end-of-life care planning. Although the vast majority of patients desire such discussions, generally less than 30% of even seriously ill patients have held them with their physicians.1,1317

Most patients and physicians agree that physicians should initiate discussions about end-of-life care.13,14,18,19 Studies have disclosed a number of physician-related barriers to initiating discussions, including deciding the timing of such discussions and concerns about patient receptiveness.20,21 These barriers are often derived from physician perception that the illness is not yet advanced enough for patients to want or accept these discussions.2124

If clinical clues, such as disease severity or major clinical events or findings, could signify patient receptiveness to end-of-life discussions, physicians could approach the subject with more certainty. While it is known that physicians use clinical events to trigger these discussions,2224 it is not known whether disease severity or major clinical events predict patients' desire or receptiveness.

In this study, we evaluated the ability of disease severity and major clinical events to assist physicians in predicting when patients might be ready to address end-of-life decisions. We chose chronic lung disease as a model because it presents a progressive chronic illness with established objective severity measures and a high probability of requiring future intensive care and life support.

This study was a cross-sectional analysis of 100 consecutive patients, 18 years and older, who were completing scheduled outpatient pulmonary function testing ordered by their physician. Study entry criteria consisted of a clinical diagnosis of chronic lung disease by either the patient's physician or American Thoracic Society standards, including the excessive production of mucus or phlegm for 3 months in each of 2 consecutive years.25 All consecutive patients were enrolled to obtain an unbiased cohort for intragroup comparison with various levels of objective chronic lung disease severity. Patients were modestly reimbursed for their time spent completing a 30-minute interview immediately after their pulmonary testing. Exclusion criteria included an active nondermatologic malignancy, impaired communication (visual, auditory, or speech), poor-quality pulmonary function tests, organic brain disease or psychiatric illness that impaired the ability to answer questions, and the use of pulmonary function testing solely for disability purposes. Only 1 eligible patient approached for enrollment refused participation. The institution's Human Studies Committee approved the study, and all patients completed informed consent. Enrollment continued until 100 patients completed the study.

DATA COLLECTION AND STUDY INSTRUMENT

Pulmonary function tests were interpreted by means of American Thoracic Society criteria.26 The percentage of the predicted forced expiratory volume in 1 second (FEV1) is a common estimate of lung impairment, often categorized as normal (>80%), mild (>65%-80%), moderate (50%-65%), and severe to very severe (<50%). We used these categories to classify our patients' respiratory impairment. To compare results with our earlier end-of-life work in patients without chronic lung disease in the same setting,18 the Karnofsky Performance Scale was used to measure functional status.

The survey instrument was designed on the basis of previous studies in qualitative and quantitative end-of-life research.18,19 The structured, standardized survey was administered by a trained research associate, blinded to the patient's other data, in a confidential, private setting. The 53 items in the survey included questions about patients' end-of-life beliefs, desires, opinions, and attitudes, as well as information on the intensity of their previous health care. Life-sustaining treatments were defined for the patients in this study as possibly including "mouth-to-mouth breathing, pumping on your chest (CPR), feeding tubes, and ventilators (breathing machines)."

STATISTICAL ANALYSIS

Power calculations, based on patient responses in an earlier study, determined an a priori minimum sample size of 81 patients to detect a 10% effect in patient end-of-life preferences with 95% confidence. The SPSS-PC software (SPSS Inc, Chicago, Ill) was used for all analyses. Univariate analysis included χ2 testing for categorical variables and t test for continuous variables. For Likert scale questions (5 possible responses) there were no significant differences in continuous and categorical analysis; therefore, dichotomous results are reported for simplicity and clarity.

A logistic regression model was developed to assess the effect of patient variables on the dependent variable: the patients' desires to have end-of-life discussions. Variables in the disease severity domain included percentage of predicted FEV1, oral corticosteroid use for lung disease, and functional status by the Karnofsky Performance Scale. Measures of intensity of recent care included previous mechanical ventilation for respiratory failure and the number of hospitalizations in the past year. Variables remained in the model if the P values were equal to or less than .05. Results are reported as odds ratios with confidence intervals.

Demographic characteristics of the patients are shown in Table 1.

Table Graphic Jump LocationTable 1. Characteristics of 100 Patients*

Objective measures of disease showed the expected broad range of severity. Patients were distributed among severity categories of percentage of predicted FEV1 as follows: normal, 17; mild, 34; moderate, 21; and severe, 28. Of the 83 patients with abnormal results of pulmonary function tests, 47 had obstructive disease, 20 restrictive, and 16 mixed obstructive and restrictive disease. Their mean and median percentage of predicted FEV1 were 64% and 66%, respectively. Eleven patients were receiving home oxygen therapy and 57 required oral corticosteroids for their chronic lung disease either currently or at some time in the past. The patients' mean and median Karnofsky Performance Scale scores were 73.5 and 70.0, respectively, representing functional status at the minimal level of self-care, unable to carry on normal activity or work.

Intensity of care characteristics of the patients showed that 59% had been hospitalized in the past year, with 15% having had 3 or more hospitalizations. Twenty-two of the 100 patients had received mechanical ventilation for their chronic lung disease previously.

Multivariate analysis results are shown in Table 2. Objective measures of chronic lung disease severity and intensity of recent health care did not predict the patients' wish to discuss end-of-life care with their physicians. The mean percentage of predicted FEV1 was similar in patients wanting and not wanting discussions (64% vs 65%, respectively; P = .87). Of 57 patients requiring oral corticosteroids, 48 (84%) desired discussions, compared with 37 (86%) of 43 who had not required corticosteroids (P = .80). In univariate analysis, functional performance was lower in patients wanting discussions, with a mean Karnofsky Performance Scale score of 72 vs 80 in those not wanting discussions (P = .03). However, functional status did not predict readiness for discussions when adjusted for other variables in the multivariate model. Recent hospitalizations also did not correlate with the desire for discussions. Of 59 patients hospitalized in the past year, 48 (81%) desired discussions vs 37 (90%) of 41 not hospitalized (P = .22).

Table Graphic Jump LocationTable 2. Multivariate Analysis of Disease Severity and Intensity Association With Patients' Desire to Discuss End-of-Life Care With Their Physician

Eighty-five patients were interested in end-of-life discussions with their physician and 18 (21%) reported having held such discussions.

Most patients and physicians expect physicians to initiate end-of-life discussions.13,14,18,19 Timing these discussions remains difficult for physicians, who must balance candor, hope, and individual patient characteristics.19,22

It is consistent with other areas of medical practice that physicians use available clinical clues to initiate action on their part. Just as 30 lb of involuntary weight loss prompts appropriate diagnostic tests, so might a prolonged and uncomfortable period of mechanical ventilation in a patient with chronic lung disease lead a physician to judge future mechanical ventilation as potentially undesirable to the patient, and consider initiating an end-of-life discussion.

There is evidence that physicians do, in fact, use disease severity and intensity of recent care to begin end-of-life discussions in chronic lung disease. Sullivan et al22 found that physicians use objective measures such as FEV1 and deteriorating nutritional status as prompts for end-of-life discussions. McNeely et al23 found that physicians use FEV1 and recent hospitalization to initiate end-of-life care discussions. For a variety of chronic diseases, including chronic lung disease, McGrew24 suggested "trigger points," defined as objective clinical findings or events that indicate appropriate times for physicians to initiate end-of-life discussions.

Our study shows that, for chronic lung disease, objective disease severity and intensity of recent care are not associated with patient desire or readiness for end-of-life discussions. Distinctive values and characteristics of individual patients appear to eliminate any benefit that objective clinical clues might offer physicians in this regard. Although physicians might still wish to use worsening objective data or significant clinical events as helpful reminders to initiate end-of-life discussions, previous studies caution that awaiting such disease progression will delay discussions past the period most patients desire them.13,14,19 Further concern about this practice is provided by McNeely et al,23 who found that 68% of pulmonary physicians discussed end-of-life care with less than half of their patients with chronic lung disease before mechanical ventilation was required, and Heffner et al,14 who found that only 14% of patients in a pulmonary rehabilitation program believed their physicians understood their end-of-life wishes.

Our study suggests that patients are no more or less interested in discussing end-of-life care at advanced disease severity than at earlier disease stages. Yet, in the face of this uncertainty about individual patient responsiveness, physicians must still proceed with discussions. Several strategies have emerged from a growing body of work in health communication to assist physicians in addressing end-of-life care in all patients.19,2731 A common goal of the strategies is to approach the subject without stimulating common, and often incorrect, patient assumptions about their physician's view of disease status, hopefulness, future physician effort, or even imminent death. To accomplish this, it has been suggested that end-of-life plans be discussed routinely as part of patient intake histories, during preoperative visits, or during first posthospitalization follow-up visits.1719 In addition, specific measures have been suggested to help in difficult discussions. These include the use of open-ended questions, neutral topic introductions, specific phrasing and prompts, focused listening, soliciting patient goals and values, clarifying strategies, and minimizing the discussion of treatment details.19,2731 An example initiation using these methods might be: "Some of my patients with your illness have thought about how they want their medical care at the end of life. How would you like us to deal with this?"

This study is the first, to our knowledge, to show the dissociation of chronic lung disease severity and patient receptiveness for end-of-life discussions. Little other work has been reported in this area. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) study17 evaluated seriously ill hospitalized patients and found no association between disease severity or functional capacity and having held an end-of-life discussion. The study was limited in its use of specific objective disease severity measures because of a patient population with a variety of diagnoses.

The current study has strengths and weaknesses. It enrolled actual patients with chronic lung disease rather than using hypothetical health scenarios. In addition, the patient population showed a heterogeneous mix of disease severity, typical in medical practice, and the study addressed these issues in the ambulatory setting as suggested by the SUPPORT study.20 The findings of this study may have limited applicability to other populations with higher socioeconomic or educational status, and the study is limited by a one-time, cross-sectional patient analysis.

With more than 100 000 patients in the United States dying of chronic lung disease each year,32 physicians will frequently encounter end-of-life issues in these patients. Aware of the failures of advance directives and the inaccuracies and difficulties of surrogate decision making, physicians cannot use objective disease progression to predict which patients are most receptive to end-of-life discussions. Focusing on physician skill in using specific communication strategies in all patients appears to be the most promising approach to make direct discussion of end-of-life issues a more customary and comfortable part of chronic lung disease management.

Corresponding author and reprints: Mark P. Pfeifer, MD, School of Medicine, University of Louisville, 323 E Chestnut St, Louisville, KY 40202 (e-mail: markp@louisville.edu).

Accepted for publication June 19, 2002.

This study was sponsored in part by the Bayer Institute for Health Care Communication, West Haven, Conn.

We thank Carlton Hornung, PhD, MPH, for his assistance with multivariate analysis and the logistic regression models.

Covinsky  KEFuller  JDYaffe  K  et al.  Communication and decision-making in seriously ill patients: findings of the SUPPORT project. J Am Geriatr Soc. 2000;48 ((suppl)) S187- S193
Ditto  PHDanks  JHSmucker  WD  et al.  Advance directives as acts of communication: a randomized controlled trial. Arch Intern Med. 2001;161421- 430
Link to Article
Fischer  GSTulsky  JARose  MRSiminoff  LAArnold  RM Patient knowledge and physician predictions of treatment preferences after discussion of advance directives. J Gen Intern Med. 1998;13447- 454
Link to Article
Teno  JMStevens  MSpernak  SLynn  J Role of written advance directives in decision-making: insights from qualitative and quantitative data. J Gen Intern Med. 1998;13439- 446
Link to Article
Danis  MSoutherland  LIGarrett  JM  et al.  A prospective study of advance directives for life-sustaining care. N Engl J Med. 1991;324882- 888
Link to Article
Schneiderman  LJKronick  RKaplan  RMAnderson  JPLanger  RD Effects of offering advance directives on medical treatments and costs. Ann Intern Med. 1992;117599- 606
Link to Article
Teno  JLynn  JConnors  AF  et al.  The illusion of end-of-life resource savings with advance directives. J Am Geriatr Soc. 1997;45513- 518
Teno  JLynn  JWenger  N  et al.  Advance directives for seriously ill hospitalized patients: effectiveness with the Patients Self-Determination Act and the SUPPORT intervention. J Am Geriatr Soc. 1997;45500- 507
Emanuel  EJEmanuel  LL Proxy decision making for incompetent patients: an ethical and empirical analysis. JAMA. 1992;2672067- 2071
Link to Article
Suhl  JSimons  PReedy  TGarrick  T Myth of substituted judgment: surrogate decision making regarding life support is unreliable. Arch Intern Med. 1994;15490- 96
Link to Article
Hare  JPratt  CNelson  C Agreement between patients and their self-selected surrogates on difficult medical decisions. Arch Intern Med. 1992;1521049- 1054
Link to Article
Coppola  KMDitto  PHDanks  JHSmucker  WD Accuracy of primary care and hospital-based physicians' predictions of elderly outpatients' treatment preferences with and without advance directives. Arch Intern Med. 2001;161431- 440
Link to Article
Layson  RTAdelman  HMWallach  PMPfeifer  MPJohnston  SJMcNutt  RAfor the End-of-Life Study Group, Discussions about the use of life-sustaining treatments: a literature review of physicians' and patients' attitudes and practices. J Clin Ethics. 1994;5195- 203
Heffner  JEFahy  BHilling  LBarbieri  C Attitudes regarding advance directives among patients in pulmonary rehabilitation. Am J Respir Crit Care Med. 1996;1541735- 1740
Link to Article
Travaline  JMSilverman  HJ Discussions with outpatients with chronic obstructive pulmonary disease regarding mechanical ventilation as life-sustaining therapy. South Med J. 1995;881034- 1038
Link to Article
Bradley  EHPeiris  VWetle  T Discussions about end-of-life care in nursing homes. J Am Geriatr Soc. 1998;461235- 1241
Golin  CEWenger  NSLiu  H  et al.  A prospective study of patient-physician communication about resuscitation. J Am Geriatr Soc. 2000;48 ((suppl)) S52- S60
Johnston  SCPfeifer  MPMcNutt  R The discussion about advance directives: patient and physician opinions about when and how it should be conducted. Arch Intern Med. 1995;1551025- 1030
Link to Article
Pfeifer  MPSidorov  JESmith  ACBoero  JFEvans  ATSettle  MBfor the End-of-Life Study Group, The discussion of end-of-life medical care by primary care patients and physicians: a multicenter study using structured qualitative interviews. J Gen Intern Med. 1994;982- 88
Link to Article
SUPPORT Principal Investigators, A controlled trial to improve care for seriously ill hospitalized patients. JAMA. 1995;2741591- 1598
Link to Article
Curtis  JRPatrick  DLCaldwell  ESCollier  AC Why don't patients and physicians talk about end-of-life care? barriers to communication for patients with acquired immunodeficiency syndrome and their primary care clinicians. Arch Intern Med. 2000;1601690- 1696
Link to Article
Sullivan  KEHebert  PCLogan  JO'Connor  AMMcNeely  PD What do physicians tell patients with end-stage COPD about intubation and mechanical ventilation? Chest. 1996;109258- 264
Link to Article
McNeely  PDHebert  PCDales  RE  et al.  Deciding about mechanical ventilation in end-stage chronic obstructive pulmonary disease: how respirologists perceive their role. CMAJ. 1997;156177- 183
McGrew  DM Chronic illnesses and the end of life. Prim Care. 2001;28339- 347
Link to Article
American Thoracic Society, Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1995;152 ((5, pt 2)) S77- S120
American Thoracic Society, Lung function testing: selection of reference values and interpretative strategies. Am Rev Respir Dis. 1991;1441202- 1218
Link to Article
Balaban  RB A physician's guide to talking about end-of-life care. J Gen Intern Med. 2000;15195- 200
Link to Article
Carrese  J Out of darkness: shedding light on end-of-life care. J Gen Intern Med. 2001;1668- 69
Link to Article
Roter  DLLarson  SFischer  GSArnold  RMTulsky  JA Experts practice what they preach: a descriptive study of best and normative practices in end-of-life discussions. Arch Intern Med. 2000;1603477- 3485
Link to Article
Baile  WFGlober  GALenzi  RBeale  EAKudelka  AP Discussing disease progression and end-of-life decisions. Oncology (Huntingt). 1999;131021- 1031discussion1031- 10361038
Quill  TE Perspectives on care at the close of life: initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room." JAMA. 2000;2842502- 2507
Link to Article
Petty  TLWeinmann  GG Building a national strategy for the prevention and management of and research in chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute Workshop Summary. Bethesda, Maryland, August 29-31, 1995. JAMA. 1997;277246- 253
Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Characteristics of 100 Patients*
Table Graphic Jump LocationTable 2. Multivariate Analysis of Disease Severity and Intensity Association With Patients' Desire to Discuss End-of-Life Care With Their Physician

References

Covinsky  KEFuller  JDYaffe  K  et al.  Communication and decision-making in seriously ill patients: findings of the SUPPORT project. J Am Geriatr Soc. 2000;48 ((suppl)) S187- S193
Ditto  PHDanks  JHSmucker  WD  et al.  Advance directives as acts of communication: a randomized controlled trial. Arch Intern Med. 2001;161421- 430
Link to Article
Fischer  GSTulsky  JARose  MRSiminoff  LAArnold  RM Patient knowledge and physician predictions of treatment preferences after discussion of advance directives. J Gen Intern Med. 1998;13447- 454
Link to Article
Teno  JMStevens  MSpernak  SLynn  J Role of written advance directives in decision-making: insights from qualitative and quantitative data. J Gen Intern Med. 1998;13439- 446
Link to Article
Danis  MSoutherland  LIGarrett  JM  et al.  A prospective study of advance directives for life-sustaining care. N Engl J Med. 1991;324882- 888
Link to Article
Schneiderman  LJKronick  RKaplan  RMAnderson  JPLanger  RD Effects of offering advance directives on medical treatments and costs. Ann Intern Med. 1992;117599- 606
Link to Article
Teno  JLynn  JConnors  AF  et al.  The illusion of end-of-life resource savings with advance directives. J Am Geriatr Soc. 1997;45513- 518
Teno  JLynn  JWenger  N  et al.  Advance directives for seriously ill hospitalized patients: effectiveness with the Patients Self-Determination Act and the SUPPORT intervention. J Am Geriatr Soc. 1997;45500- 507
Emanuel  EJEmanuel  LL Proxy decision making for incompetent patients: an ethical and empirical analysis. JAMA. 1992;2672067- 2071
Link to Article
Suhl  JSimons  PReedy  TGarrick  T Myth of substituted judgment: surrogate decision making regarding life support is unreliable. Arch Intern Med. 1994;15490- 96
Link to Article
Hare  JPratt  CNelson  C Agreement between patients and their self-selected surrogates on difficult medical decisions. Arch Intern Med. 1992;1521049- 1054
Link to Article
Coppola  KMDitto  PHDanks  JHSmucker  WD Accuracy of primary care and hospital-based physicians' predictions of elderly outpatients' treatment preferences with and without advance directives. Arch Intern Med. 2001;161431- 440
Link to Article
Layson  RTAdelman  HMWallach  PMPfeifer  MPJohnston  SJMcNutt  RAfor the End-of-Life Study Group, Discussions about the use of life-sustaining treatments: a literature review of physicians' and patients' attitudes and practices. J Clin Ethics. 1994;5195- 203
Heffner  JEFahy  BHilling  LBarbieri  C Attitudes regarding advance directives among patients in pulmonary rehabilitation. Am J Respir Crit Care Med. 1996;1541735- 1740
Link to Article
Travaline  JMSilverman  HJ Discussions with outpatients with chronic obstructive pulmonary disease regarding mechanical ventilation as life-sustaining therapy. South Med J. 1995;881034- 1038
Link to Article
Bradley  EHPeiris  VWetle  T Discussions about end-of-life care in nursing homes. J Am Geriatr Soc. 1998;461235- 1241
Golin  CEWenger  NSLiu  H  et al.  A prospective study of patient-physician communication about resuscitation. J Am Geriatr Soc. 2000;48 ((suppl)) S52- S60
Johnston  SCPfeifer  MPMcNutt  R The discussion about advance directives: patient and physician opinions about when and how it should be conducted. Arch Intern Med. 1995;1551025- 1030
Link to Article
Pfeifer  MPSidorov  JESmith  ACBoero  JFEvans  ATSettle  MBfor the End-of-Life Study Group, The discussion of end-of-life medical care by primary care patients and physicians: a multicenter study using structured qualitative interviews. J Gen Intern Med. 1994;982- 88
Link to Article
SUPPORT Principal Investigators, A controlled trial to improve care for seriously ill hospitalized patients. JAMA. 1995;2741591- 1598
Link to Article
Curtis  JRPatrick  DLCaldwell  ESCollier  AC Why don't patients and physicians talk about end-of-life care? barriers to communication for patients with acquired immunodeficiency syndrome and their primary care clinicians. Arch Intern Med. 2000;1601690- 1696
Link to Article
Sullivan  KEHebert  PCLogan  JO'Connor  AMMcNeely  PD What do physicians tell patients with end-stage COPD about intubation and mechanical ventilation? Chest. 1996;109258- 264
Link to Article
McNeely  PDHebert  PCDales  RE  et al.  Deciding about mechanical ventilation in end-stage chronic obstructive pulmonary disease: how respirologists perceive their role. CMAJ. 1997;156177- 183
McGrew  DM Chronic illnesses and the end of life. Prim Care. 2001;28339- 347
Link to Article
American Thoracic Society, Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1995;152 ((5, pt 2)) S77- S120
American Thoracic Society, Lung function testing: selection of reference values and interpretative strategies. Am Rev Respir Dis. 1991;1441202- 1218
Link to Article
Balaban  RB A physician's guide to talking about end-of-life care. J Gen Intern Med. 2000;15195- 200
Link to Article
Carrese  J Out of darkness: shedding light on end-of-life care. J Gen Intern Med. 2001;1668- 69
Link to Article
Roter  DLLarson  SFischer  GSArnold  RMTulsky  JA Experts practice what they preach: a descriptive study of best and normative practices in end-of-life discussions. Arch Intern Med. 2000;1603477- 3485
Link to Article
Baile  WFGlober  GALenzi  RBeale  EAKudelka  AP Discussing disease progression and end-of-life decisions. Oncology (Huntingt). 1999;131021- 1031discussion1031- 10361038
Quill  TE Perspectives on care at the close of life: initiating end-of-life discussions with seriously ill patients: addressing the "elephant in the room." JAMA. 2000;2842502- 2507
Link to Article
Petty  TLWeinmann  GG Building a national strategy for the prevention and management of and research in chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute Workshop Summary. Bethesda, Maryland, August 29-31, 1995. JAMA. 1997;277246- 253
Link to Article

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