Agarwal, Nimit

Objective Designation of a Medical Power of Attorney (MPOA) is a key component of advance care planning (ACP) that ensures patient preferences are honored when decision-making capacity is not present. This study aimed to quantify MPOA documentation rates and identify demographic and clinical factors associated with documentation presence. Methods We conducted a retrospective observational study using electronic health record data from 979 610 adult hospitalization encounters representing 459 365 unique patients within a large U.S. healthcare system from January 1, 2020, through December 31, 2021. All hospitalized patients aged ≥18 years were included. The primary outcome was MPOA documentation. Demographic and clinical variables were analyzed using multivariable logistic regression. Statistical significance was defined as P < .05. Results Among 979 610 encounters, 260 752 encounters (26.6%) had documented MPOA. Male sex, White race, older age (67.0 vs 54.3 years), and unmarried status were associated with a higher MPOA documentation rate (all, P < .001). In multivariable analyses, male sex (adjusted odds ratio [AOR], 1.07; 95% CI, 1.06-1.08) and unmarried status (AOR range, 1.41-1.75) were associated with higher odds of MPOA documentation. Dementia (AOR, 1.90; 95% CI, 1.86-1.93) and malignancy (AOR, 2.22; 95% CI, 2.19-2.25) were associated with higher odds, while discharge against medical advice was associated with lower odds (AOR, 0.91; 95% CI, 0.88-0.94) of MPOA documentation. Conclusions MPOA documentation rates were low, highlighting missed opportunities to identify alternate decision makers when a patient lacks capacity. Targeted interventions to promote surrogate decision-maker designation and documentation are needed, especially in inpatient care settings.

ABSTRACT Advanced chronic diseases, or multicomplexity in older adults presents unique challenges. Transthyretin cardiac amyloidosis (ATTR‐CA) is one such scenario where heart failure is a common presentation, and management remains challenging. We describe the challenges involved in the diagnosis of ATTR‐CA in older adults, which has implications on treatment options. We discuss the application of comprehensive geriatric assessment (CGA) and shared decision making (SDM) in the context of these challenges. Based on geriatric medicine principles, an innovative framework for applying SDM in ATTR‐CA patients is proposed, including consideration of the patient priorities care approach. The proposed framework emphasizes assessing functionality, frailty, and life expectancy to help categorize risk. This framework can be applied in various advanced chronic diseases or multicomplexity. Based on risk categorization, treatment burden, and alignment with values and preferences, management pathways are suggested for each risk category. Incorporating CGA and SDM, the proposed framework supports patient‐centered care, ensuring that clinical recommendations are tailored to each older adult's unique needs and goals. In ATTR‐CA, a collaboration between cardiology and geriatric medicine provides significant value in managing older adults. The need to prevent age‐related bias in clinical decision‐making exists across all health conditions, and the proposed framework allows for a thorough evaluation of multimorbidity, frailty, disability, and patient preferences. While ATTR‐CA is used as a prototype, this integrated approach can be applied across all health conditions and is essential for delivering holistic care, improving communication, and aligning treatment plans with patient values.

Abstract This is an exciting time in Geriatrics, with numerous opportunities in health care for Geriatrics specialists to innovate and lead. Geriatrics specialists should know how to implement innovative care models to lead healthcare changes in their organizations and effectively facilitate change management. We highlight a 10‐step framework that Geriatrics specialists can leverage to quickly move their ideas from development to implementation at a system level. This framework adapts concepts from business management to provide a step‐by‐step guide to move from idea generation to implementation. We provide different practical examples that a Geriatrician can correlate to in their practice, including value proposition and business canvas model. Though small components of the business canvas model may vary based on organization and program/idea‐specific needs, the outlined skills will establish Geriatrics specialists as leaders of change, a resource for education, and valued consultants to a health system that is in dire need of direction to improve the quality of care, and health outcomes, for older adults.