The decision to execute a durable power of attorney for health care and preferences regarding the utilization of life-sustaining treatments in nursing home residents

Article Abstract:

The right of elderly nursing home residents to decide about their own care has traditionally been taken over by family, nurses, physicians and administrators. This is beginning to change. One way to promote autonomous decision making is through a durable power of attorney for health care, by which one or more persons can be designated to make decisions if the signer becomes incapable of doing so. In spite of agreement on their usefulness, these documents are not widely used. Previous research has recorded wide disparities between what study participants wanted and what their doctors or relatives thought they wanted. The views were opposite 24 percent of the time for tube feeding, and 50 percent for chemotherapy. One hundred three nursing home residents were interviewed about their preferences for choosing an agent for health care decisions while being offered an opportunity to execute a durable power of attorney, which only 25 percent agreed to do. Although most participants had definite preferences about life-sustaining treatments and an agent, they had not discussed this with the agent or anyone else. It seems that the elderly believe that health care decisions will be made by family consensus. They seemed to assume that treatment is the norm, and that the legal document is required for deviations from that norm. Most chose to forego life-sustaining treatment, but there was variability in preferences, and the type of treatment was less important to them than the level of mental impairment and the permanence of the procedure. Preferences were not affected by mood, mental functioning, religiosity, demographics, or previous experience with life-sustaining treatment. The answers to questions regarding health care preferences are extremely important for the development of legal and ethical guidelines, and they also have implications for health care costs. (Consumer Summary produced by Reliance Medical Information, Inc.)

Durable power of attorney

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Resuscitation of patients with metastatic cancer: is transient benefit still futile?

Article Abstract:

Opinion about the use of cardiopulmonary resuscitation (CPR) has changed over the years. In 1974 the guidelines published by the National Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care stated CPR was to be used to prevent sudden, unexpected death. When it was not to be used, this was to be noted on the patient's medical record. No discussion with the patient or family was mentioned. By 1980 major changes in the physician-patient relationship had occurred, although the National Conference reiterated that CPR should not be used in the case of terminal illness. The patient's wishes were still overlooked, but the family's agreement was to be sought, although their ''opinion need not be controlling.'' The most recent guidelines, published in 1986, exhibit less confidence about when CPR should be used. The patient has the right to decide to forego resuscitation, and a ''do not resuscitate'' (DNR) order should be noted on the chart. Two other factors must also be considered: the patient's diagnosis before heart failure and the outcome after CPR. Statistics on survival after CPR show when it is useful. Several studies reviewed here indicate that CPR for patients with metastatic cancer is futile, that few patients survive the attempt, and almost no patients survive long enough to be discharged from the hospital. In spite of this, there are hospital policies and ethics manuals that suggest that all patients, regardless of the outcome, should be offered CPR. The conclusion is that patients dying from metastatic cancer should not ordinarily be offered CPR, but some people still expect that resuscitation will be attempted in all cases when a patient has not explicitly asked otherwise. Communication between patient and physician, and patient autonomy, are fundamental, but the physician must not propose treatments that do not work. (Consumer Summary produced by Reliance Medical Information, Inc.)

Care and treatment, Patient outcomes, Mortality, Ethical aspects, Cancer, Metastasis, Cancer metastasis, CPR (First aid), Cardiopulmonary resuscitation, Resuscitation, editorial

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Knowledge, attitudes, and behavior of elderly persons regarding living wills

Article Abstract:

Although most states have enacted living will legislation, and many people have strong beliefs regarding medical intervention during terminal illness, only 15 percent of the people in a recent survey had actually signed a living will. Questions about end-of-life care too often arise after the patient is incapacitated, limiting patient autonomy. Such autonomy could be better assured if patients were counseled to make their wishes explicit beforehand. Little is known about how the elderly feel about living wills, and therefore this study of 75 elderly people was undertaken to study the knowledge, attitudes and behavior of the elderly concerning living wills. Most of these people wanted medical care limited during terminal illness, but none had signed a living will, even though just over half said they were familiar with state legislation. However, many had misconceptions about the law, which contained a great deal of technical language. When they were read the actual text, 60 percent said they were not aware they could sign such a document. The respondents did not fully understand such terms as ''extraordinary means'' and ''terminal and incurable,'' and these terms were not defined in the statute. Three out of four people surveyed wanted only basic medical care, such as antibiotics and intravenous fluids, during terminal illness, and 13 percent wanted comfort care only; however, 11 percent wanted all possible means of treatment. Physicians were not effective in pursuing this subject with patients, and only eight of the participants had discussed the topic with their doctors. Most felt that their physicians were unaware of their wishes. Educational efforts should be directed at elderly populations to explain the function of living wills. (Consumer Summary produced by Reliance Medical Information, Inc.)

Living wills

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