Which signs and symptoms warrant involvement of medical staff? The definition and identification of status-change events in the nursing home

Which Advance Directive Matters? An Analysis of End-of-Life Decisions Made in Nursing Homes

This study clarifies the role of advance directives in the process of decision making in nursing homes. Physicians reported on the actual use of advance directives in a medical decision-making process related to status changes in 70 nursing home residents (mean age = 89 years). Charts were also reviewed to assess the specifics of the advance directives. Despite a high prevalence of advance directives, the directives themselves had a very limited role in affecting treatments. The physicians surveyed viewed directives related to hospitalization as the most useful, though these were not the most available directives. The attention and format given to advance directives in the nursing home may need to be reevaluated.

Medical Decision-Making in the Nursing Home: A Comparison of Physician and Nurse Perspectives

The purpose of this study is to clarify the perspectives of physicians and nurses in the medical decision-making process at the time of status change events in nursing home residents. The decision-making processes studied involved 28 cognitively impaired nursing home residents in a large suburban nursing home. In interviews, the authors ascertained the personal opinions of physicians and the nurses related to the status change event and the decision-making process using the Medical Decision-Making During a Status Change Event Questionnaire. Nurses reported a greater degree of familiarity with the family's and resident's wishes than did physicians. Physicians reported considering more treatment options and choosing more treatments for residents than nurses. Both physicians and nurses reported that the physicians had a major role in decision-making and that nurses did not, yet the gap in reported roles was greater based on physicians' reports in comparison to nurse reports. In a third of the reported cases, physicians and nurses disagreed about whether advance directives had been followed. These findings reflect a division of roles and perspectives of nurses versus physicians in the medical decision-making process. This study demonstrates the ability of the questionnaire to reveal several key differences in perceptions of care. This information could be useful in developing forums for communication among the professionals to enhance mutual understanding.