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This research examined the quality of resuscitation decisions documented in the clinical notes of 99 older patients within 48 h of admission. Only 34 had current documentation that was frequently inconsistent and ambiguous, leaving patients at risk of receiving inappropriate and unwanted resuscitation. Clear guidelines with community input to guide the implementation and documentation of end-of-life decisions are essential.

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BackgroundThe external validity, or generalizability, of trials and guidelines has been considered poor in the context of multiple morbidity. How multiple morbidity might affect the magnitude of benefit of a given treatment, and thereby external validity, has had little study.ObjectiveTo provide a method of decision analysis to quantify the effects of age and comorbidity on the probability of deriving a given magnitude of treatment benefit.DesignWe developed a method to calculate probabilistically the effect of all of a patient’s comorbidities on their underlying utility, or well-being, at a future time point. From this, we derived a distribution of possible magnitudes of treatment benefit at that future time point. We then expressed this distribution as the probability of deriving at least a given magnitude of treatment benefit. To demonstrate the applicability of this method of decision analysis, we applied it to the treatment of hypercholesterolaemia in a geriatric population of 50 individuals. We highlighted the results of four of these individuals.ResultsThis method of analysis provided individualized quantifications of the effect of age and comorbidity on the probability of treatment benefit. The average probability of deriving a benefit, of at least 50% of the magnitude of benefit available to an individual without comorbidity, was only 0.8%.ConclusionThe effects of age and comorbidity on the probability of deriving significant treatment benefits can be quantified for any individual. Even without consideration of other factors affecting external validity, these effects may be sufficient to guide decision-making.

Introduction: Heterogeneity of stroke outcome measures has increased the complexity of there usefulness across institutions. We sought to identify factors that determine post stroke functional outcome and discharge destination following rehabilitation. Method:Retrospective study of 482 stroke patients admitted to a rehabilitation centre between July 07 to July 12 were studied. Selection criteria included ischemic or hemorrhagic stroke with completed admission notes. Sixty-eight variables were analysed. Partition modeling was used to identify significant variables. Results:Total of 426 patients met inclusion criteria (mean age 70.67 SD = 13.31, SEM 0.645; male 58%, n=245). Mean length of rehabilitation was 48.36 d. Majority of patients were from home prior to stroke and 80% returned home, the mean length of rehabilitation was 45.22 d. A significant difference was noted in the total Functional Independence Measure (FIM) for patients who were discharged home compared to those discharged to high level residential care (HLOC)(p<0.001) or low level residential care (LLOC) (p=0.0497), and those who were discharged to LLOC compared to HLOC (p=0.0044). Total FIM ≥77, carer support, and age ≤77 y were associated with returning home. For patients with total FIMS 36-77, age <82 y and carer support were associated with returning home. HLOC was predictable if age ≥82 y, length of stay in acute hospital ≥14 d, and FIM for upper body dressing of <5. Conclusion:Total FIMS together with other predictors prior to enrolling in inpatient stroke rehabilitation would improve efficiency and patient outcomes.