Calculation: A Hidden Problem Understanding Food Labels You drink this whole bottle of soda. How many grams of total carbohydrates does it contain? 67.5 grams 32% answered correctly 200 primary care patients – 73% private insurance – 67% at least some college – 78% read > 9 th grade – 37% math > 9 th grade Rothman R, Am J Prev Med, 2006
Red Flags For Limited Literacy “You Can’t Tell By Looking” • May say “I forgot my glasses.” • Incomplete intake forms • Frequently missed appointments • Unable to give coherent, sequential history • Not taking medications correctly • Ask fewer questions • Lack of follow-through with referrals • May be hesitant to sign forms * Health Literacy and Patient Safety: Help Patients Understand – A Manual for Clinicians. 2 nd edition. Chicago: AMA Foundation and AMA, 2007. www.ama-assn.org/ama1/pub/upload/mm/367/healthclinicians.pdf
Medication Error Most Common Medical Mistake 1.5 M adverse events (patient error >700,000) 2 out of 3 patients leave MD visit with Rx 3.9 Billion Rx filled in 2010 Up 50% - 60% in 10 years 82% adults take at least one med Elderly fill 20 Rx/year, see 8 physicians 1 in 6 pediatric Rx not dosed correctly >300,000 OTC meds (>600 contain acetaminophen) Most labels and inserts are in English only U.S. Census Bureau, 2009; PDR for Non-Prescription Drugs, Dietary Supplements and Herbs (2007); IMS Health 2005; IOM 2006.
Do Patients Understand How To Safely Take Their Medication?
What Does This Picture Mean? • “Somebody is dizzy” • “Don’t touch this stuff” • “Take anywhere” • “Chills or shaking” • “Having an experience with God”
1 in 10 Adults Struggle With Decoding • “Use extreme caution in how you take it” • “Medicine will make you feel dizzy” • “Take only if you need it” 8% of patients with low literacy understood this instruction
Rx Label Instructions Can patients understand how to take meds after reviewing instructions on pill bottles? Davis, Wolf, Bass, Parker. Ann Intern Med, 2006.
“How would you take this medicine?” 395 medicine clinic patients in 3 states 48% <9 th grade reading, averaged 1.4 meds • 46% did not understand instructions ≥ 1 labels • 38% with adequate literacy missed at least 1 label • <10 % attended to warning labels Davis, Wolf, Bass, Parker. Ann Intern Med, 2006.
“Show Me How Many Pills You Would Take in 1 Day” Rates of Correct Understanding vs. Demonstration “Take Two Tablets by Mouth Twice Daily” 100 100 89 84 80 80 80 71 63 t (%) 60 60 Under erstandi anding ng Correct Demons onstrat ation on 40 40 35 John Smith Dr. Red 20 20 Take two tablets by mouth twice daily. 0 Humibid LA 600MG Low Low Mar argi ginal al Adequ dequate 1 refill Patien ent Liter erac acy Level
Patient Centered Label Can Improve Understanding and Adherence RCT in 11 FQHCs. Sta nda r d L a be l PC L a be l 429 pts w DM and/or HTN. Unde r sta nding 59% 74% Average 5 meds Mean age 52, 28% W, Adhe r e nc e (3 mo nths) 30% 49% 39% low literacy State Board of Pharmacy in CA passed legislation for this label
The Problems With Food Labels Difficult to navigate and interpret What is the essential info? How and where should it be displayed?
Efforts to Clarify Label May Add Complexity 37
Why Integrate Health Literacy Assessment in Disparities Research Years of schooling is NOT a good measure of literacy level ( reading comprehension may be 2-5 grade levels < education level ). In research, literacy is an easy, yet informative variable to add. Several tests measure literacy in healthcare research. Some have math sections. All existing tests measure literacy in health context (i.e. not health literacy). These formal assessments provide a proxy measure of health literacy and can be used to compare results in the literature. Patient’s score on literacy test is an indication they may struggle to understand and act on oral or written health information.
Health Literacy Assessment Mediates Racial Disparities in Research Prostate Cancer Stage of Presentation African American men 2x more likely to present with stage D prostate cancer than whites, but after adjusting for literacy, race was no longer a factor 1 HIV Medication Adherence African Americans 2.4x more likely to be non-adherent to HIV medication than whites, but when health literacy was included in analysis, there was NO difference in adherence by race 2 Diabetes Medication Adherence African Americans are less adherent to diabetes medicines compared to whites (controlling for SES), but when health literacy is added to analysis, race is no longer directly associated with adherence 4 End of Life African American patients preferred more aggressive care at end of life, but when health literacy was included in analysis, health literacy, NOT race, predicted preferences for care 3 1) Bennett, Davis, J Clin Oncol, 1998. 2) Osborn, Davis, Wolf, Am J Prev Med, 2007. 3) Volandes , J Palliative Med, 2005. 4) Osborn C, J Health Comm, 2011
Literacy Tests Used in Healthcare Research • The most commonly used • REALM (Rapid Estimate of Literacy Medicine) • TOFHLA (Test of Functional Health Literacy) • NVS (Newest Vital Sign) • These are sometimes referred to as tests of health literacy Qualitative : How confident are you filling out medical forms by yourself? Extremely – Quite A Bit – Somewhat – A Little Bit – Not At All ( 0 ) ( 1 ) ( 2 ) ( 3 ) ( 4 ) Tests and ordering instructions are in resources at the end of the presentation.
Cautions About Assessing Health Literacy Clinically • Testing patient literacy level alone will NOT confirm ability to understand and act on health information. • No evidence that literacy testing improves health care delivery or outcomes when testing is done strictly for clinical use. • To get the most accurate measure of patient’s specific health literacy clinically use “teach back.” • “Universal precautions” (plain language) are recommended to make materials user-friendly.
Strategies to Improve Health Communication, Patient Education & Consent Put yourself in patient’s shoes
3 Problems with Face to Face Communication 1. Patients don’t understand unfamiliar medical terms. Those with low literacy rarely ask for clarification. • Transcripts of 150 genetic counseling sessions found key terms (that were jargon) were typically repeated 20 times. • In study of 800 pediatric visits only 1 mother asked for clarification. • In a study of 250 orthopedic patients at 1st post-op visit, 45% knew bone fractured, 19% knew expected healing time, 45% knew weight bearing status. 2. Many have difficulty understanding and recalling complex information, less satisfied with visit. • In a study of 100 surgery patients, 95% of surgeons believed patients understood when to resume normal activities vs. only 58% of patients. 3. Those with low literacy are less likely to actively participate in healthcare dialogue and decision making. Roter, D. 2011 Nursing Outlook; Korsch, B. Pediatrics 1968; Castro C 2007 Am J Health Behav; Kadakia, J Ortho Trauma, 2013; Calkins Arch Intern Med, 1997.
Solution : “Strip it down, bring it home, mix it up ” Easy ways to reduce ‘literacy burden’ in ‘face-to-face’ communication Strip it down. Limit unnecessary use of jargon and complex language. Goal - engage patient in conversation that facilitates understanding, establishes rapport and diminishes social distance. Bring it home. Make health information personally relevant. Make it concrete by grounding it in the patient’s life. Begin by asking patients what they know. Mix it up Cut the ‘mini lectures’/monologues. Increase “the back and forth”. Talk less - listen more. Check for understanding, buy in, or questions. Have normal conversation. Roter, D. 2011 Nursing Outlook
7 Health Literacy Steps to Improve Patient Education 1. Slow down 2. Avoid medical jargon, use living room language 3. Use pictures, teaching tools (pamphlets, brown bag meds) 4. Limit information – write brief take home information 5. Focus on need to know and do 6. Repeat and summarize info 7. ‘Teach back’/’show back’ to confirm understanding
What Words Are Clearer, More Culturally Appropriate? • High blood pressure • Low blood sugar • Diabetes • Poultry • Obesity • Dairy product • Fat (low fat, no fat, • Carbohydrates fat free) • Proteins • Sodium • Exercise • Cholesterol
Strategy for Limiting Information Lessons learned from patients Tell me 3 • What’s wrong? ( briefly ) (Diagnosis) • What do I need to do? (Treatment) • Why is it important that I do this? (Benefit/Context) If meds – “break it down” for me • What’s it for? ( indication ) • When to take? How many pills at a time, how long? ( duration ) • Why? ( benefit ) • What to expect? ( side effects )
Pictures Can be Good Teaching Tools Patients may not understand or use measurements Fruits and Veggies Proteins Healthy Carbs
Confirm Patient Understanding ‘Teach back’ Improves Outcomes • Ask patients to “teach back/ show back” key messages • Avoid asking: – Do you understand? – Do you have any questions? Remember - what’s clear to you is clear to you! Schilinger, D. Arch Int Med, 2003
Also consider What Its Like Being A Client In Your Setting? • Are signs easy to follow? • Are check-in personnel calm, friendly? • Are forms easy to read and answer? (Spanish?) • Is environment welcoming?
Telephone Help: What We Need to Consider • Who answers phone – person or computer? • Are computer options simple, short? • How long is person on hold? • Is voice tone friendly, conversational? • Is system pilot tested with target audience?
Hidden Problems with Health Information • Organized using medical model not patient -centered • Scientific/bureaucratic not personal/conversational • Often too long, too much information • Illustrations complex, confusing or “don’t look like me” • Lack of attention to ‘tone,’ patient emotions & culture • Lack of patient and provider input and evaluation • Distribution and sustainability not thought out – How and when will patients get the information? Who gives it to them? When is teachable moment? Plan to update? • Lack of awareness of what’s on Google/blogs
Nuts and Bolts of Easy to Read Materials • Familiar words (ideally < 3 syllables) • Short sentences (8-10 words) • Short paragraphs (3-4 lines, 1 idea) • Avoid ALL CAPS and cutesy font • Use simple headers, bolding, boxes (lump and clump info) • Use lots of white space • Use fonts > 12 point – Arial, Times New Roman
User Friendly Does Not Mean “Dumbed Down” • Adults with high education and income still prefer brief, to-the- point materials. • Most patients looking for “what I need to know and do”. Patients who want more detailed • information appreciate links to websites. • Web sites need to be user-friendly, easy to navigate and understand.
Templates Provide Useful Framework • Uniform look, consistent message • Makes development easier • Easily reproducible • Standard structure helps patients navigate the material
Cincinnati Children’s Materials Focused on Behavior 1 page handout “voice of the child” What I can do & parent can do to help me Cincinnati Children’s Hospital Medical Center, 2012
American College of Physician’s Patient Self-Management Guides: A good model to engage people in their health Guides focused on: • Patient not disease • ‘Need to know and do’ Help patients change health behavior: • Increase knowledge and confidence managing disease • Help patients solve self-care problems 57
Focus Is On Doing • ‘You Can Do It’ checklist at end of each chapter • Concrete examples of successful action plans • Emphasis on small steps and patient choice
When Evaluating Materials: Ask 7 Questions 1. Is title patient centered? 2. Is layout user-friendly? 3. Do illustrations tell the story? 4. Is key message clear, easy to pick out? 5. What is behavioral objective? 6. Is information manageable? 7. Is it culturally appropriate?
Is This Pamphlet Patient Centered?
Evidence Based Strategies & Considerations in Helping Patients Change Behavior & Improve Health
Why Focus on Diabetes Self-Management? Diabetes is Prevalent and Increasing • >11% adults have diabetes; 27% adults > 65 years, • African Americans and Hispanics almost 2X more likely to have diabetes ( 19% vs. 10% for whites ) • 35% adults > 20 yrs have pre-diabetes, 50% adults > 65yrs www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf • www.minorityhealth.hhs.gov , NIDDK 201
What About Obesity? • Over 36% U.S. adults are obese. ( 34% ,whites ; 39%, Hispanic 50% African Americans). 18% of children are obese. • Louisiana ranks 50 th in obesity and rates are increasing. • No state has an obesity rate <15% (the national goal) • Obesity contributes to major causes of death in the US www.americashealthrankings.org/OR , CDC 2012
1 st Beware of Faulty Assumptions About Patient’s Need to Change Behavior • The patient – ought to change – wants to change – knows how to change • If patient does not change – visit has failed • Patients are either motivated to change or not • Now is the right time to change • I’m the expert – patient must follow my advice
Consider the Spirit of Motivational Interviewing • Behavior change is most effective if patient, not doctor, chooses area to work on • Motivation to change should be elicited from patient , not imposed by provider • Relationship functions best as partnership , not expert/recipient • It is patient’s task – not provider’s – to articulate and resolve resistance to change • Rational arguments not effective in resolving resistance Hecht, J Am Behav Med, 2005
Bunny or Duck? What problem does the patient need to work on?
Easy Framework to Help Patients Manage Their Diabetes, Lose Weight 1. INTRODUCE Diabetes Guide (briefly review). 2. ASK : Is there anything you are willing to do this week to improve your health? Then wait, don’t jump in. 3. COACH patients to set goals and create action plan to change behavior. 4. ASSESS confidence . 5. TEACH BACK & then write plan down in guide 6. SET TIME to call patient to check progress (maintain, modify, new AP) Provider serves as partner, not expert, in helping patient change behavior Seligman H, Davis T, Am J Health Behav, 2007
Action Plans (Baby Steps) Engage Patients in Improving Health Behavior • Provider coaches patient to narrow a long term goal (patients choose) to a specific, easy-to-achieve, short term “ baby step ” behavior. – Long-term goal: lose weight – Patient decides: to walk – Baby step : I will walk around the block after dinner 3 times next week. – Encourages “buy-in”. – Teaches problem-solving. – Increases confidence. Davis, J Prim Care Comm Health, 2012; Seligman H, Davis T, Am J Health Behav, 2007, Lorig, Am Behav Fam Med, 2006
“Baby Step Coaching” The Patient is in Charge Patients choose areas – motivated to work on – Patients need a few minutes to come up with a plan . – At first confused by doctor asking what they want to work on. – Avoid telling them what they need to work on or giving unsolicited advice
Baby Step Action Plans are Easy-to-Achieve – Too often patients feel they are unable to do what doctors tell them to do – Goal: make your patients feel good about their ability to make behavior changes – Check confidence on a scale from 1-10. – If < 10 — rework
Action Plans are Very Specific Help patient turn goal – lose 10 lbs – into Action Plan – I will walk 2 blocks with my family after work 3 times next week • What Walk • How much 2 blocks • When (time of day) After work • How often 3 times
Examples of Actual Baby Steps • “I will dance like I saw in the book everyday for 2-3 songs on the radio.” “ I will eat ½ of a candy bar instead • of a whole one for my afternoon snack.” • “Instead of eating fast food every night, I will start cooking one night a week.” • “Two days a week I will eat sugar free ice cream instead of the regular ice cream I normally eat every night.”
Baby Steps: Lessons Learned • Goal setting with a provider was not a familiar strategy • Patients 1 st goals too general. “ I want to lose weight ” – had to learn “baby step” plan • Many physicians expect too big a step or too many steps
Patients Recalled Action Plans Changed Behavior And Problem Solved 225 patients, LSU, UNC, UC-SF Med Clinics (76% minority; DM 9yrs; BMI 36; A1C 8.6) 2 Week Calls - Recall AP 96% - Behavior sustained 75% • Most patients (89%) - Other behavior 56% chose diet and exercise 17 Week Visits • Equally effective with - Recall AP 88% low and high literacy - Behavior sustained 67% patients - Other behavior 45% Wallace, Seligman, Davis, Schillinger, Arnold, DeWalt, et al. In press DeWalt, Davis, Schillinger, Seligman, Arnold, et al. In press.
Significant Improvement In 6 Months 9 FQHCs in Missouri, 666 patients, 30% African American, 33% low literacy,A1c 8.5, SBP 140 Self report ↑ knowledge ↑ self-efficacy ↓ diabetes distress ↑ taking ownership of health ↑ self-reported diabetes management Chart documentation ↓ HbA1c ( 7.7. p <.001) ↓ SBP (133, p=.02) *p<0.01 Wallace, Seligman, Davis, Schillinger, Arnold, DeWalt, et al. In press
Bottom Lines: Helping People Change Health Behavior • Changing behavior is a process • Information alone is not enough • Patients & providers need practical frameworks • “Baby Step” approach is effective, invites engagement, problem solving, empowerment • Ongoing support “touch points” are essential • Telephone outreach, particularly with groups, improves outcomes & satisfaction
Do Your Consent Forms Work? What problems have you encountered ? • • Can patients read and understand them? • Is the content meaningful to patients? • Do they help patients make a decision about whether or not to be in the study? Are they written in plain language? • • Are they formatted for reading ease? • Do they have a manageable amount of information? AHRQ, 2008
The challenge in writing consent forms: considering both IRB and Patients • Identify IRB requirements – what are they looking for? • What templates /standard wording is required? • What information do patients need & want? • Consider how their literacy, motivation, attention, and distractions may affect their comprehension. • What is your key message? • What is your behavioral objective? CDC Clear Communication Checklist
Starting Steps: Developing Consent Documents 1. Develop content from patient perspective Plain Language, key messages easy to pick up, personal “tone” 2. Attend to format and layout for reading ease 3. Evaluate content, design, readability 4. Get patient and provide input 5. Continue to tweak
Example of Buried vs. Clear Messages The goal of the tissue bank or repository is to support the LSUHSC-S Dept. of Surgery research in order to improve our understanding of those molecular factors that contribute to cancer and that may lead to prevention, early detection, and cure. vs. The goal of this research is to learn what makes cells turn into cancer .
Is Tone Bureaucratic or Patient-Centered? Does the document • Focus on study or consider the patient • Is it conversational, respectful? • Address the reader – use personal pronouns
Is The Information Manageable? Does the document • Get to the point Good Example • Avoid information overload • Focus on “ need to know & do ” vs. “ nice to know ” Bad Example
Paragraphs: Limit length. One idea per paragraph. Too much (14 lines): Researchers at x hope to learn if adding a targeted therapy, trastuzumab (Herceptin), to standard treatment with chemotherapy for early stage, HER2-low breast cancer from returning. Tastuzumab is called a targeted therapy because it targets the tumor cells by blocking the HER2 protein on the surface of the cancer cell to slow down or stop cancer growth. Trastuzumab is a standard treatment For HER2-positive breast cancer. In this study, trastuzumab is considered to be investigational because it has not been studied for use in treating HER2-low breast cancer. Studies that already have been done with trastuzumab focused on breast cancers that were strongly HER2-positive. However, in some of these studies, tumor samples were checked in a central laboratory to confirm the HER2 testing results. Some breast cancers that were thought to be HER2 –positive were actually HER2 – low. The researchers then looked at the results of treatment in patients with HER2-low tumors. They found that trastuzumab seemed to have benefit in keeping the cancer from returning even when the HER2 levels were in the normalrange. The B-47 study is being done to learn more about trastuzumab or treat HER2-low breast cancer. vs. Appropriate (3 lines): Another goal of this study is to find out how the drugs used in this study affect menstrual cycles (monthly periods) and if these changes in menstrual cycles have any effect on breast cancer. You will be asked to allow blood samples to be collected as part of the study.
Example of Overload vs. To-The-Point Overload The purpose of this study is to try to understand if production of BK virus, JC virus, Merkel Cell Polyomavirus and Cytomegalovirus vary with hormonal changes during the female menstrual cycle. The study will also test your immune response to BK virus, JC virus, Merkel Cell Polyomavirus and Cytomegalovirus, if present, and measure hormone levels in urine for correlation with your menstrual cycle. vs. To-the-point The purpose of the study is to find out more about how the body controls BK virus.
Attend to Format and Layout Which are you more likely to read?
Plain Language = Useable Language Unnecessary and complicated language You have been selected as a possible participant in this study because you have a moderate to very-high risk pulmonary embolism, and it is not known if retrievable vena cava filters reduce mortality or reduce recurrence of nonfatal pulmonary embolism or if complications of vena cava filters outweigh the benefits in such patients. vs. Plain Language You are invited to be in the study because you have had a pulmonary embolism (clot that goes from your legs to your lungs).
Plain Language = Understandable Language Unnecessary and complicated language In order to draw statistical conclusions about the study, data from your medical records may be shared among researchers and research staff involved in the study, both here at our hospital and with other members of the collaborative group. vs. Plain Language In order to get statistical results about the study, data from your medical records may be shared among the research staff.
Developing User-Friendly Forms • It’s not rocket science, but harder and more tedious than it seems. • User friendly does not mean ‘ dumbed down. ’ • Patients with high education and income still prefer brief, simple, easy to read materials.
Improving Informed Consent Process • Give patient time to go over the form BEFORE you talk about it • Talk about the form in a private place (let patient include who they wish) • Offer to read document with patient • Slow down • Use plain language – avoid jargon • Verify and document comprehension AHRQ, 2008
Practice Recommendations • Use plain language, consider culture Focus on patients’ ‘need to know and do’ • vs. ‘nice to know’ • Encourage ‘buy in’/collaboration • Use teaching tools (pictures, pamphlets) • Write precise Rx instructions state purpose Use patient materials that are • understandable and culturally appropriate • ‘Teach back’ to confirm understanding • Be positive, motivating, encouraging
A Perfect Storm is Approaching Intersection of declining literacy, increasing immigrant, minority & elderly populations, and the increasing demands of health care & society Are We Prepared?
What’s Our Bridge to Action? • How does this talk stimulate your thinking? • What strategies could Xavier develop and test to make health information/ services more user- friendly? • How can health literacy research help reduce health disparities? • What research ideas & collaborations does it spark?
Useful HL Resources
IOM Reports on Health Literacy • Health Literacy: Improving Health, Health Systems, and Health Policy, 07/13 • Oral Health Literacy, 02/13 • How Can Health Care Organizations Become More Health Literate? 07/12 • Promoting Health Literacy to Encourage Prevention and Wellness, 12/11 • Improving health Literacy Within a State, 11/11 • Health Literacy Implications for Health Care Reform, 07/11 Innovations in Health Literacy Research, 03/11 • The Safe Use Initiative and Health Literacy, 12/10 • • Measures of Health Literacy, 12/09 • Health Literacy, eHealth, and Communication: Putting the Consumer First, 03/09 • Toward Health Equity and Patient -Centeredness: Integrating Health Literacy, Disparity Reduction, and Quality Improvement, 02/09 Health Literacy: A Prescription to End Confusion, 04/04 • http://iom.edu/Reports.aspx
AHRQ Toolkits (Agency for Healthcare Research & Quality) • Patient Education Materials Assessment Tool (PEMAT) (2013) www.ahrq.gov/pemat • Hospital Discharge Project RED (ReEngineered Discharge) (2013) www.bu.edu/fammed/projectred/newtoolkit/ • Informed Consent (2009) www.ahrq.gov/fund/informedconsent • Health Literacy Universal Precautions (2010) (clinic based system) www.ahrq.gov/qual/literacy/
Pharmacy Assessment Tools and Training AHRQ (2007) Strategies to improve communication between pharmacy staff and patients training program www.ahrq.gov/qual/pharmlit/pharmtrain.htm Website Design • HHS (2010) Health literacy online a guide to writing and designing easy to use health web sites www.health.gov/healthliteracyonline/ Web_Guide_Health_Lit_Online.pdf
Resources For Healthcare Organizations Institute of Medicine (2012) Ten Attributes of Health Literacy Healthcare Organizations iom.edu/Global/Perspectives/2012/HealthLitAttributes.aspx Health Literacy Environment of Hospitals & Health Centers (2006 ) www.hsph.harvard.edu/healthliteracy/ The Joint Commission (2007) What did the doctor say? Improving health literacy to protect patient safety National Qualify Forum (2009) Health Literacy a linchpin in achieving national goals for health and healthcare. Communication Climate Assessment Tool (2010) Wynia M: American Journal of Medical Quality
Health Literacy Websites CDC • www.cdc.gov/healthliteracy • www.cdc.gov/healthliteracy/pdf/simply_put.pdf NIH • www.nih.gov/icd/od/ocpl/resources/healthliteracyresearch.htm UNC • www.nchealthliteracy.org/ Rima Rudd (Harvard School of Public Health) • www.hsph.harvard.edu/healthliteracy/ Helen Osborne • www.healthliteracy.com/
Patient Education Development CDC (2013) Clear Communication Index www. cdc .gov/health communication / ClearCommunicationIndex CMS (2011) Toolkit for making written materials clear and effective www.cms.gov/writtenmaterialstoolkit/ NCI (2003) Clear and simple developing effective print materials for low literacy readers www.cancer.gov/cancertopics/cancerlibrary/clear-and-simple/page1 Seligman HK, Wallace AS, DeWalt DA, et al: Developing low -literacy patient educational materials to facilitate behavior change. Am J Health Behav. 2007 Sep-Oct;31 Suppl 1:S69-78.
Patient Education Materials www.iha4health.org/default.aspx/MenuItemID/191/MenuGroup/_Home.htm American College of Physicians • Helpful Ways To Lose Weight • Living With Diabetes • Caring For Your Heart • Living With COPD • Live Better With Rheumatoid Arthritis www.acponline.org/patient_tools End of Life Decision Making Volandes AE (2010) Medical Decision Making. 30(1):29 -34
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