Over the last 10-15 years, the incidence of treated end-stage renal disease (ESRD) among older adults has increased and dialysis is being initiated at progressively higher levels of estimated glomerular filtration rate (eGFR). Average life expectancy after dialysis initiation among older adults is quite limited, and many experience an escalation of care and loss of independence after starting dialysis. Available data suggest that treatment decisions about dialysis initiation in older adults in the United States are guided more by system- than by patient-level factors. Stronger efforts are thus needed to ensure that treatment decisions for older adults with advanced kidney disease are optimally aligned with their goals and preferences. There is growing interest in more conservative approaches to the management of advanced kidney disease in older patients who prefer not to initiate dialysis and those for whom the harms of dialysis are expected to outweigh the benefits. A number of small single center studies, mostly from the United Kingdom report similar survival among the subset of older adults with a high burden of comorbidity treated with dialysis vs. those managed conservatively. However, the incidence of treated ESRD in older US adults is several-fold higher than in the United Kingdom, despite a similar prevalence of chronic kidney disease, suggesting large differences in the social, cultural, and economic context in which dialysis treatment decisions unfold. Thus, efforts may be needed to adapt conservative care models developed outside the United States to optimally meet the needs of US patients. More flexible approaches toward dialysis prescription and better integration of treatment decisions about conservative care with those related to modality selection will likely be helpful in meeting the needs of individual patients. Regardless of the chosen treatment strategy, time can often be a critical ally in centering care on what matters most to the patient, and a flexible and iterative approach of re-evaluation and redirection may often be needed to ensure that treatment strategies are fully aligned with patient priorities.

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BackgroundGroup visits are a popular new type of patient-physician encounter. The goal of the group visit is to create an environment where patients with a shared chronic condition work together with a physician and other health care providers to manage their disease. This collaborative care model has been shown to decrease participants' utilization of the emergency room and increase the likelihood that patients receive recommended services for their chronic condition. To date, no studies of group visits have been done with low-income, community health center populations. Also, these studies have not examined the population of patients who are not interested in attending group visits. The Bothell Kenmore Community Health Center has proposed the use of group visits for their diabetic population.Study Design and MethodsA phone survey was created to determine whether there was a significant level of interest for this type of resource and what factors might determine an individual's decision to participate in group visits. The clinic hypothesized that a number of variables might influence patients' decisions to attend group visits. These variables include financial resources, older age, transportation resources, patients' perceived efficacy of their diabetes self-care, health status, and patients' perceived control over their health. The SF-12 and the locus of control were used to capture the last two variables. Fifty-two patients participated in the survey. Sixty-four percent of the patients were interested in participating, while 15% said they were unsure and 21% said they were not interested. For the above-mentioned variables, the only variable that had a significant impact on participation was financial. Fifty-five percent of those interested in group visits stated that finances would affect their decision and 0% of those not interested in group visits statied that it would affect their decision.ConclusionThe survey showed that the group visit model attracts individuals from a broad range of emotional and physical health statuses.

A 50-YEAR-OLD MAN WAS BROUGHT TO THE hospital by ambulance after being found unresponsive in his home. Information obtained from an acquaintance indicated the patient was in his usual state of health until 1 day prior to presentation when he threatened to consume a "stash" of benzodiazepines. The patient was found lying unresponsive in his apartment the following afternoon. After being intubated in the field for airway protection, the patient was transported to the emergency department for further evaluation. Past medical history obtained through a chart review was notable for human immunodeficiency virus infection, bipolar disorder, and a seizure disorder. Outpatient medications included lamotrigine, lithium, and trazodone. On presen-tation to the emergency department, the patient was unresponsive without corneal or gag reflexes. Vital signs were notable for moderate hypothermia (29.8°C) and a normal heart rate (70/min) and blood pressure (110/60 mm Hg). Findings from physical examination were notable for coarse breath sounds and a normal cardiac examination. The extremities were cool with palpable pulses. Initial laboratory investigations revealed a respiratory acidosis (pH 7.21) and an elevated lactate (3.8 mg/dL). A urine toxicologic test result was positive for benzodiazepines. An electrocardiogram (ECG) was obtained (Figure 1).Question: Should the patient be sent to the cardiac catheterization laboratory for management of an STelevation myocardial infarction? I aVR V 1 V4 II aVL V2 V5 III II aVF V3 V6Figure 1.