Decisions to leave home

Improving advance directives for healthy older people

The quality and quantity of advance directives for healthy older people need to increase. Quality will improve with literal interpretations of do-not-resuscitate orders and more comprehensive directives. Changing the term "DNR" to "No ACLS (Advanced Cardiac Life Support)" should discourage health-care providers from subsuming other limitations under the directive to withhold resuscitation. Other aggressive medical and surgical interventions should be prospectively considered in addition to resuscitation. The quantity of advance directives will increase when physicians feel motivated to devote time and expertise to thorough discussions of advance directives. Although education and legislation will motivate physicians to some extent, their roles are limited. Fair reimbursement for this primary-care service is the most effective motive. The initial investment by Medicare may save large sums in the long run by reducing expensive, undesired care for older people.

Dangerous behavior in a demented patient. Preserving autonomy in a patient with diminished competence

When a cognitively-impaired elderly man nearly caused a serious fire at home through his inappropriate use of a gas oven, the incident raised questions about his capacity to live alone. Although he clearly wanted to preserve his independence, the health care team felt obligated to assure his safety. The following discussion of dangerous behavior in a demented elderly man elicits and portrays these conflicting values, and highlights the physician's obligations in such ethically and legally complex situations.

Decisions to leave home. What will the neighbors say?

This paper discusses two of the problems encountered when a decision not to institutionalize patients is made. When patient, physician, and family jointly decide to forego institutionalization, the family often subconsciously fears communal censure if it fails to call for help when the end is near. This may, at the last moment, prompt some families to call emergency teams and thwart the original purpose of the decision. Instances in which a previous decision not to institutionalize is justifiably interrupted, are discussed. Such an interruption does not necessarily foil the original plan if it is transient and one to provide comfort. An interactive model in which patients, health-care workers, families, and the community share is used. It is suggested that when a decision not to institutionalize is well-discussed, compassionately made, and carefully implemented, it may itself tend to reshape the communal ethos. As a result, communities, rather than expecting reflex action, are more prone to examine the appropriateness of institutionalization or emergency measures in particular cases and under particular circumstances.