Impact of medical hospitalization on treatment decision-making capacity in the elderly

Article Abstract:

Elderly patients suffering from acute illness may be unable to understand key treatment issues. Informed consent is required in order to treat illnesses and these patients may be unable to make important treatment decisions. There is no widely acceptable method for determining the capacity of a patient to consent to or refuse medical treatment. Basic assumptions may not be valid in patients that are impaired due to their serious level of illness. The decision-making capacity of 25 acutely ill, hospitalized, elderly patients and 25 healthy matched subjects was studied to determine the status of these individuals in understanding treatment issues. Vignettes of medical conditions commonly found in the elderly were used to test the understanding of the patients. Healthy elderly controls were consistently able to understand and respond to each of the vignettes. Education did not seem to influence their scores. Both groups were unable to understand the complicated official consent form used to obtain consent for treatment. In the acutely ill group, 28 percent had decisional impairment and had difficulty understanding the nature of treatment or a specific procedure. They were unable to understand the risks, benefits, and alternatives of treatment. Patients are usually referred to as completely competent or totally incompetent to make treatment decisions. It is slowly being understood in medicine that patients can be competent in some areas while incompetent in others. There have been some attempts to describe the decisionally impaired older patient. Healthy elderly people living independently understood all key treatment issues and seemed able to make treatment decisions, while the medically ill patients more often failed to understand these same issues. The vignettes were used to identify patients that were marginally competent in making important decisions regarding their medical care. Instruments need to be developed to assist the physician in assessing patients' decisional capabilities, and additional instruction in the area of bioethics is needed in medical school and post-graduate curriculums. (Consumer Summary produced by Reliance Medical Information, Inc.)

Care and treatment, Demographic aspects, Hospitalization, Hospital patients, Hospital care

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The utilization of pneumococcal polysaccharide vaccine among elderly Medicare beneficiaries, 1985 through 1988

Article Abstract:

Pneumococcal pneumonia, which is caused by several strains of the organism Streptococcus pneumoniae, is a major cause of illness and death in the United States, particularly among the elderly. Between 15 and 30 percent of those hospitalized for pneumonia have pneumococcal pneumonia. Since the mid-1980s, a vaccine against many of these strains has been recommended for all people over 65 years. A survey of Medicare patients was performed to determine how many of those eligible for the vaccine actually received it during the years 1985 through 1988. The number of claims submitted to Medicare for reimbursement for the pneumococcal vaccine was evaluated. During the three-year period studied, nearly 1.4 million claims for reimbursement for the pneumococcal vaccine were submitted to Medicare. This translates to approximately 5.3 percent of those covered by Medicare, or 1.33 percent of Medicare beneficiaries per year. Whites were more than twice as likely to receive the vaccine as blacks. Regional differences were also observed, with New England having the lowest rate of immunization, and the mountain and west north central areas of the country having the highest rates. Nearly 80 percent of the vaccinations were administered in the months of September through December, which coincides with the period when the influenza vaccine is given. These findings demonstrate that few of the eligible elderly are being vaccinated with the pneumococcal vaccine. Some have suggested that one factor contributing to this is the low rate of reimbursement Medicare provides for administering pneumococcal vaccine. Some controversy exists over the efficacy of the vaccine, which could account for some of the reluctance to administer it. Large scale public health efforts have successfully provided vaccinations for large segments of the elderly in given communities. These mass vaccination programs might consider submitting claims to Medicare for those patients who are eligible for such coverage to fund the cost of the programs. (Consumer Summary produced by Reliance Medical Information, Inc.)

Economic aspects, Prevention, Pneumococcal vaccine, Pneumococcal vaccines, Vaccination, Insurance claims adjustment, Medicare, Pneumonia, Pneumococcal, Pneumococcal pneumonia

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Health care decisions among elderly long-term care residents and their potential proxies

Article Abstract:

Seventy residents of a residential long-term care facility were asked to make decisions about their health care after being shown two high-risk and two low-risk clinical vignettes. Comparisons were then made between the decisions that the elderly participants made in the made-up scenarios and the decisions made, in the participants' interest, by other persons who would be in a position to make such a health care decision for them. There was a low rate of agreement between decisions made by the elderly and decisions that others thought they would make. The highest agreement was found between the participants' decision and the decision predicted by their relatives. The highest value was placed on the elderly persons' ability to make health care decisions by the relatives who were most likely to consider the participants' mental status. The lowest agreement occurred between what the participants' physicians thought they would choose for the two high-risk vignettes and what the persons chose. The physicians were more likely to place a lower value of the elderly participants' ability to make a health care decision with advancing age. These findings have important implications for designing and implementing methods to maximize the ability of elderly people in long-term settings to make decisions about their health care.

Psychological aspects, Research, Decision-making, Decision making, Geriatrics, Long-term care of the sick, Long term care, Health services administration

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