Publications

OBJECTIVES

To estimate the proportion of seniors in a large health maintenance organization (HMO) who had been asked about their end-of-life care preferences (EOLCPs) by a clinician and who had completed an advance directive (AD). To examine the association of having had an EOLCP discussion and AD completion.

SUBJECTS AND METHODS

A random sample of HMO members aged 65 years or older were asked to complete a mailed survey about health and health-related issues in 1996. Data provided by 5117 seniors (80% response rate) were used to estimate the prevalence of EOLCP and AD among seniors overall and in specific risk groups. Bivariate and multiple logistic regression models were used to identify predictors of AD completion, especially having been asked about EOLCP.

RESULTS

One third of seniors reported having an AD on file with the HMO, but only 15% had talked with a clinician about EOLCP. Both having been asked about EOLCP and having an AD were positively associated with age, but not significantly associated with sex, race/ethnicity, marital status, or self-rated health status. Having been asked by a clinician about EOLCP was significantly associated with completion of an AD.

CONCLUSION

Clinicians can play an important role in increasing AD completion rates among seniors by bringing up the subject of EOLCPs.

Experimental leishmaniasis offers a well characterized model of T helper type 1 cell (Th1)-mediated control of infection by an intracellular organism. Susceptible BALB/c mice aberrantly develop Th2 cells in response to infection and are unable to control parasite dissemination. The early CD4(+) T cell response in these mice is oligoclonal and reflects the expansion of Vbeta4/ Valpha8-bearing T cells in response to a single epitope from the parasite Leishmania homologue of mammalian RACK1 (LACK) antigen. Interleukin 4 (IL-4) generated by these cells is believed to direct the subsequent Th2 response. We used T cells from T cell receptor-transgenic mice expressing such a Vbeta4/Valpha8 receptor to characterize altered peptide ligands with similar affinity for I-Ad. Such altered ligands failed to activate IL-4 production from transgenic LACK-specific T cells or following injection into BALB/c mice. Pretreatment of susceptible mice with altered peptide ligands substantially altered the course of subsequent infection. The ability to confer a healer phenotype on otherwise susceptible mice using altered peptides that differed by a single amino acid suggests limited diversity in the endogenous T cell repertoire recognizing this antigen.