Choosing appropriate medical care for the elderly

Decisions about what constitutes appropriate medical care are increasingly necessary in an aging society. Neither patient autonomy, physician beliefs, nor health services research alone can adequately define reasonable care for the individual patient. A new framework is proposed for determining reasonable medical care that involves 4 steps: (1) patients prioritize their goals of care (prolongation of life, maintenance of function, and maximization of comfort); (2) physicians assign a pathway of care based on the patient's prioritization of goals (longevous, ameliorative, or palliative); (3) expert panels define a range of feasible interventions for each pathway; and (4) medical problems are treated with interventions consistent with the pathway chosen. The pathway system has the potential for defining reasonable care by balancing the patient's view, the physician's view, and evidence from the clinical literature.

Artificial nutrition and hydration in the patient with advanced dementia: is withholding treatment compatible with traditional Judaism?

Several religious traditions are widely believed to advocate the use of life-sustaining treatment in all circumstances. Hence, many believe that these faiths would require the use of a feeding tube in patients with advanced dementia who have lost interest in or the capacity to swallow food. This article explores whether one such tradition--halachic Judaism--in fact demands the use of artificial nutrition and hydration in this setting. Traditional (halachic) arguments have been advanced holding that treatment can be withheld in persons who are dying, in individuals whose condition causes great suffering, or in the event that the treatment would produce suffering. Individuals with advanced dementia can be considered to be dying, often suffer as a result of their dementia, and are likely to suffer from the use of a feeding tube. Given these observations and the absence of a compelling case for distinguishing between tube feeding and other forms of medical treatment, traditional Judaism appears compatible with withholding artificial nutrition for individuals with advanced dementia.

Short-term functional outcomes of long-term care residents with pneumonia treated with and without hospital transfer

OBJECTIVE

To determine 2-month mortality and functional status outcomes after resolution of pneumonia in older long-term care facility (LTCF) patients treated with and without hospital transfer.

DESIGN

Retrospective cohort study.

SETTING

Hebrew Rehabilitation Center for Aged, a 725-bed LTCF affiliated with an academic medical center, whose residents are cared for by staff physicians and geriatric fellows.

PATIENTS

LTCF residents with an acute episode of pneumonia, defined as a new respiratory sign or symptom and a new infiltrate on chest radiograph.

MEASUREMENTS

Functional decline or death in the 2 months after the resolution of pneumonia.

RESULTS

Of 312 cases of pneumonia, 246 (79%) were treated in the LTCF and 66 (21%) were treated in the hospital. Equal proportions of patients died of their pneumonia (13% vs 12%), but a larger proportion of those hospitalized had either worsening in their functional status or had died at 2 months (P = .005, Mantel-Haenszel trend test). In a logistic regression model controlling for differences between patients treated at the two sites, hospital treatment remained associated with poorer 2-month outcome (AOR 3.02, 95% CI 1.32, 7.22), with a significant interaction between respiratory rate and treatment site. LTCF treatment was associated with better 2-month outcomes only among patients with a lower respiratory rate. For these patients, the difference in outcome between LTCF treatment and hospital treatment was greatest for patients who were independent or mildly dependent at baseline.

CONCLUSIONS

In this academic LTCF, treatment for pneumonia without hospital transfer resulted in better 2-month outcomes compared with hospital treatment. Although the difference in outcome may be explained in part by differences between patients treated with and without hospital transfer, it persisted after correcting for these differences. The benefits of LTCF treatment appear to be greatest for those with less severe pneumonia and more independent functional status.

Medical care in old age: what do nurses in long-term care consider appropriate?

OBJECTIVES

To determine whether nurses working in a long-term care institution, who are knowledgeable about the full range of conditions common among older people, favor limitations of treatment in old age; and to study whether the level of intensity of care they regard as appropriate varies with the overall health status of the older individual.

DESIGN

Participants were asked to complete an intervention-specific advance directive for themselves, with scenarios representing terminal illness, dementia plus chronic illness, chronic illness in a nursing home resident, chronic illness in a community-dwelling older person, and a robust, community-dwelling older person.

SETTING

A 725-bed long-term care institution, with residents having a mean age of 88 years and a wide range of physical and cognitive deficits.

PARTICIPANTS

Full-time nurses at the long-term care facility were eligible and were given survey instruments; 102 of the 145 eligible nurses completed the questionnaire.

MEASUREMENTS

The unit of analysis is the refusal rate, defined as the mean number of refusals of interventions for each respondent.

MAIN RESULTS

The overall refusal rate for all five scenarios taken together was 72.1%. The refusal rate in the case of terminal illness was 90.9%, in the case of dementia plus chronic illness 81.8%, in the case of dementia in a nursing home 69.1%, for a homebound older person with chronic illness 70.9%, and for a previously healthy 85-year-old person living in the community, 50.0% (P < .001).

CONCLUSIONS

Nurses working in a long-term care institution have strong preferences about limiting a variety of interventions in old age. The greater the degree of physical and cognitive impairment, the more limitations they favor. This suggests the necessity of expanding advance planning to include a discussion of what constitutes appropriate treatment in a broad range of circumstances.

A broader role for advance medical planning

Advance planning for future illness should be broadened from medical care in the event of incompetence to all medical care for the elderly. To plan effectively, patients need an assessment of their overall medical condition: whether they are robust, frail, demented, or dying. They need to understand the kinds of complications often engendered by aggressive treatment, given their underlying status. Given information about their circumstances and their capacity to withstand medical interventions, patients, together with their physicians, need to formulate broad goals for medical care. There are significant barriers to implementing this scheme, but pressure from patients, structural changes in the practice of medicine that create incentives for planning, and educational strategies, including videotaped interviews and role-playing exercises, can facilitate this form of preventive medicine.

Whether to transfer? Factors associated with hospitalization and outcome of elderly long-term care patients with pneumonia

OBJECTIVE

To determine factors associated with the decision to treat elderly long-term care patients with pneumonia in the hospital vs in the long-term care facility (LTCF) and factors associated with patient outcomes.

DESIGN

Retrospective cohort study.

SETTING

Hebrew Rehabilitation Center for Aged.

PATIENTS

Nursing home residents who had an episode of pneumonia, defined as a new respiratory sign or symptom and a new infiltrate.

MEASUREMENTS AND MAIN RESULTS

The majority of the 316 pneumonia episodes (78%) were managed in the LTCF, most (77%) with oral antibiotics. Both patient-related factors, such as elevated respiratory rate, and non-patient-related factors, such as evening evaluation, were associated with hospitalization. No patient who had a do-not-hospitalize (DNH) order was hospitalized. Equal proportions of patients given LTCF therapy (87%) and hospital therapy (88%) survived. Elevated respiratory rate was associated with dying from pneumonia in the LTCF but not in the hospital. Dependent functional status was associated with dying from pneumonia in both sites.

CONCLUSIONS

Many episodes of pneumonia can be managed in the LTCF with oral antibiotics. Because, in the absence of DNH orders, both patient-related and non-patient-related factors are associated with hospital transfer, discussion regarding preferences for hospitalization should occur prior to the development of an acute illness. A high respiratory rate may be a good marker for those LTCF patients requiring hospitalization. Dependent functional status may be a good marker for those LTCF patients unlikely to benefit from hospital transfer.

The limits of proxy decision making: overtreatment

Traditionally, surrogates have been involved principally in making decisions about life-sustaining treatment for incompetent individuals. Today, surrogates are increasingly called upon to make everyday medical decisions for patients who are incompetent because they are demented. Some of the potential perils of proxy decision making under these circumstances have been identified, including the lack of concordance between patients and their proxies, demands by proxies for technically futile therapy, and actual abuse of patients. We found a significant number of cases in which healthcare providers at a long-term care facility came into conflict with surrogates because the treatment desired by the surrogate was viewed as excessively burdensome when evaluated by an experienced team of nurses, physicians, and social workers. Neither a court-appointed guardian nor an Institutional ethics committee were likely to be able to resolve these conflicts because of lack of clarity about what constitutes the best Interest of Impaired nursing home patients. The following case illustrates this increasingly common conflict.

The limits of proxy decision making: undertreatment

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential conflict of interest have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma.

Medical decision-making in the last six months of life: choices about limitation of care

OBJECTIVE

To characterize the limitation of care in routine geriatric practice in advance of and at the time of a patient's final episode of illness.

DESIGN

A descriptive study performed by retrospective chart review.

SETTING

An outpatient geriatric practice affiliated with a community teaching hospital.

PATIENTS

Fifty-nine recipients of primary care who were community-dwelling and older than 65, died in the years 1988-1991, and were enrolled in the practice for at least 6 months prior to death.

MEASUREMENTS

We recorded the type(s) of care patients (or, in the case of incompetence, their families) and their physicians chose to limit during the last episode of illness preceding death and during previous episodes of illness by examining those instances when therapy other than that considered "standard" was given. We also examined whether the presence of dementia, functional impairment, chronic disease, terminal illness, site of routine care (home vs hospital), and location of death were associated with the limitation of care.

RESULTS

A choice to limit diagnostic tests or treatment was made by the patient or surrogate in 40% of the 59 patients during the 6 months before the patient's final episode of illness. Most frequently limited were diagnostic tests, surgery, and hospitalization for purposes other than surgery. Terminal illness and location of death were associated with the limitation of care, but dementia, functional impairment, chronic illness, and location of care were not. By comparison, 89% of the patients had limitation of care during the final episode of illness, and more aggressive therapies such as cardiopulmonary resuscitation and intubation constituted the majority of therapies withheld.

CONCLUSIONS

In one geriatric practice, care is frequently limited before a patient's final illness in the course of routine practice. In contrast to recent discussion focusing on limitation of end-of-life interventions or interventions in the severely impaired, these results suggest that there are multiple points in the course of a community-dwelling elderly patient's illness at which choices about level of care can be made. Given this opportunity, a significant number of elderly patients of their surrogates will choose less intensive therapy.

Medical technology at the end of life. What would physicians and nurses want for themselves?

BACKGROUND

Advance directives assume that patients are able to decide what interventions they would wish in the event of catastrophic illness. This study examines the preferences of nurses and physicians, who have extensive exposure to sick patients, for care at the end of life.

METHODS

Nursing and medical staff of a community teaching hospital were asked to complete the medical directive, detailing which of 12 interventions they would wish for themselves in each of four scenarios. Two additional scenarios were added to ascertain preferences for care in the event of severe illness in a previously healthy 85-year-old subject and in a chronically ill 75-year-old subject.

RESULTS

Refusal rate among the 127 nurses and 115 physicians who completed the questionnaire, averaged over the four scenarios, was 78%. Nurses and physicians refused 31% of proposed therapies in the case of acute illness in a previously healthy 85-year-old subject and 57% of interventions in the case of major illness in a 75-year-old subject with multiple debilitating chronic illnesses. Nurses reported significantly higher refusal rates than physicians for the scenarios involving possible reversible coma, the healthy 85-year-old subject, and the chronically ill 75-year-old subject. Factors predicting refusal patterns were age and being a nurse.

CONCLUSION

We conclude that physicians and nurses, who have extensive exposure to hospitals and sick patients, are unlikely to wish aggressive treatment if they become terminally ill, demented, or are in a persistent vegetative state. Many would also decline aggressive care on the basis of age alone, especially in the presence of functional impairment. These findings call into question the utility of detailed advance directives and suggest a need to focus on the goals of treatment for all elderly patients.

Influenza vaccination. Are we doing better than we think?

Patients who were candidates for influenza vaccination seen in the primary care center of a community teaching hospital were studied to determine whether there is a differential immunization rate depending on risk level. The immunization rate was as follows: moderate risk group, 44%; high risk group, 59%; and very high risk group, 81%. The immunization rate was also closely associated with the frequency of clinic visits, ranging from 34% for those with low visit frequency to 73% for those with high visit frequency. The highest vaccination rates were thus found in the groups at highest risk for influenza-associated morbidity and mortality. Although influenza complication rates are lower in the healthy elderly, this group is so large that the public health impact of a low vaccination rate will be significant. The healthy elderly should be the special targets of future influenza vaccination campaigns.

Medicare HMOs. The new kid on the block

Medicare HMOs may not be the ultimate answer to geriatric care, but they continue to grow in number and are becoming increasingly popular among the elderly. Independent practice association (IPA) groups are the fastest growing type. Problems concerning quality of care and cost, exemplified in the extreme by the recent case of the International Medical Centers HMO in Florida, have illustrated the need for greater regulation of Medicare HMOs by the Health Care Financing Administration. The author outlines the advantages and disadvantages of a prepaid health plan for elderly patients, as well as for the physicians who are members. Three methods of creative geriatric programming are suggested; these would promote continuity of care and decrease hospitalization rates, yet pose no risk to patients.

The impact of health maintenance organizations on geriatric care

Increasing numbers of health maintenance organizations (HMOs) are contracting with the federal government to permit enrollment of Medicare beneficiaries, and increasing numbers of the elderly are joining HMOs. A review of past HMO performance suggests that, although these organizations will try to effect a decrease in the rate and duration of hospitalization to control costs, a high rate of functional disability and acute illness in elderly patients will make it impossible to accomplish this significantly. Also, although HMOs will attempt to provide more comprehensive coverage, the demand for prescription drugs, eyeglasses, and medical devices will make such coverage very expensive. Attempts to ration the services of primary-care physicians will impede case management and continuity of care. If HMOs are to provide high-quality medical care at a reasonable cost, they will need to consider making use of geriatric assessment units, geriatric consultants, geriatric nurse practitioners, and special geriatric hospital wards.

Health promotion, jogging, and the pursuit of the moral life

Individual lifestyle was held accountable for health and disease throughout much of American history. Since the advent of the germ theory of disease, the focus on the etiology of disease has shifted to factors beyond individual control. But in the past two decades, there has been a resurgence of interest in the role of personal habits in producing sickness. This paper examines the history of one facet of the health promotion movement--aerobic exercise, primarily jogging. Initially, concepts in exercise physiology were adapted from non-medical fields--such as competitive sports and the military--for use in cardiac rehabilitation. Subsequently, a few physicians generalized their experience with cardiac patients to the general population, concluding that aerobic exercise could prevent heart attacks. This idea of exercise as a prophylaxis was seized upon by the public, who were receptive because of the political climate of the sixties. Once the popular movement was underway, researchers began studying the role of exercise in preventing coronary heart disease, confirming that exercise does confer some benefit. In the seventies, exercise attracted a new, wider audience--not because of the justification for its use provided by the scientific community, but because of the appeal of upright living as a means to personal and social redemption. The case of aerobic exercise provides an instructive example to social scientists and policymakers seeking to understand or to encourage widespread behavioral change.

Adverse consequences of hospitalization in the elderly

This study prospectively examines 502 general medical patients for evidence of side-effect of hospitalization unrelated to diagnosis or therapy of acute illness. Symptoms of depressed psychophysiologic functioning (confusion, falling, not eating, and incontinence) unrelated to acute medical diagnoses were found in 8.8% of the patients under 70 and in 40.5% of the elderly population (P less than 0.0001). The rate of medical intervention secondary to these symptoms (psychotropic medications, restraints, nasogastric tubes, and foley catheters) was 37.9% among the young patients and 47.1% in the elderly group (P = 0.4). The sample was too small to permit adequate empirical determination of the complication rate from medical intervention (thrombophlebitis, pulmonary embolus, aspiration pneumonia, urinary tract infection, septic shock) but estimates from the literature indicate that each of the interventions studied entails a complication rate of 25-30%. Combining the observed rate of functional symptoms development and intervention, and the literature rates of complications, yields a risk of complications of 1.0% for the young and 5.7% for the elderly (P less than 0.0001). These data indicate that hospitalized elderly patients are at high risk of developing symptoms of depressed psychophysiology functioning and of sustaining medical intervention as a result of these symptoms, with attendant medical complications. We suggest that in incidence of depressed psychophysiologic function needs to be assessed in patients treated outside the hospital, along with efficacy of treatment outside the hospital, to determine whether there are patients for whom hospitalization is not optimal therapy.