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Terminal Care of the Very Old: Changes in the Way We Die

Terminal Care of the Very Old: Changes in the Way We Die Abstract Background: This study examines the use of advance directives, limitations of treatment, and medical interventions during the terminal hospitalization of the old-old. Study periods before and after the implementation of the Patient Self-Determination Act of 1990 were chosen to determine if there has been a change in terminal care. Methods: Chart review was performed for all patients 85 years and older who died in the hospital during 1988 and 1993. Patient characteristics, presence of advance directives, do-not-resuscitate orders, and other treatment limitations were noted as were interventions listed in the Medical Directive. Results: Less than 12% of the 167 study patients had an advance directive. Length of stay for these terminal admissions decreased from 18.5 to 9.6 days. Ninety-five percent of the patients were "do not resuscitate" by time of death, but orders were written sooner in 1993-75% within 24 hours of admission. Patients with early do-not-resuscitate orders had fewer high-intensity interventions. More patients had "comfort measures only" during the study period. An overall decrease in high-intensity interventions and a specific decrease in the use of transfusions, invasive tests, minor surgery, and cardiopulmonary resuscitation was seen. Conclusion: Patients 85 years and older are receiving fewer high-intensity interventions during their terminal hospitalizations. More attention is being paid to comfort and few are receiving cardiopulmonary resuscitation. There is little reference to formal advance directives in decision making for these patients.(Arch Intern Med. 1995;155:1513-1518) References 1. Ginzberg E. The high costs of dying. Inquiry . 1980;17:293-295. 2. Schroeder SA, Showstack JA, Schwartz J. Survival of adult high cost patients: report of a follow-up study from nine acute-care hospitals. JAMA . 1981;245: 1446-1449.Crossref 3. Bayer R, Callahan D, Fletcher J, et al. The care of the terminally ill: mortality and economics. N Engl JMed . 1983;309:1490-1494.Crossref 4. Scitovsky AA. The high cost of dying. What do the data banks show? Milbank Q . 1984;62:591-608.Crossref 5. Emanuel EJ, Emanuel LL. The economics of dying: the illusion of cost savings at the end of life. N Engl J Med . 1994;330:540-544.Crossref 6. Volicer L, Rheaume Y, Brown J, Fabiszewski K, Brady R. Hospice approach to the treatment of patients with advanced dementia of the Alzheimer type. JAMA . 1986;256:2210-2213.Crossref 7. Mor V, Kidder D. Cost savings in hospice: final results of National Hospice Study. Health Serv Res . 1985;20:407-422. 8. Lind SE. Transferring the terminally ill. N Engl J Med . 1984;311:1181-1182.Crossref 9. Singer PA, Lowy FH. Rationing, patient preferences and cost of care at the end of life. Arch Intern Med . 1992;152:478-480.Crossref 10. Maksoud A, Jahnigen DW, Skibinski CK. Do-not-resuscitate orders and the cost of death. Arch Intern Med . 1993;153:1249-1253.Crossref 11. Chamber CV, Diamond JJ, Perkel RL, Lasch LA. Relationship of advanced directives to hospital charges in a Medicare population. Arch Intern Med . 1994; 154:541-547.Crossref 12. Murphy DJ, Finucane TE. New do-not-resuscitate policies: a first step in cost control. Arch Intern Med . 1993;153:1641-1648.Crossref 13. Callahan D. Terminating treatment: age as a standard. Hastings Cent Rep . 1987; 17:21-25.Crossref 14. Murphy DJ. Do-not-resuscitate orders: time for reappraisal in long-term care institutions. JAMA . 1988;260:2098-2101.Crossref 15. McIntyre KM. Loosening criteria for witholding prehospital cardiopulmonary resuscitation: futility of prehospital cardiopulmonary resuscitation: like beauty, in the eyes of the beholder. Arch Intern Med . 1993;153:2189-2192.Crossref 16. Council on Ethical and Judicial Affairs, American Medical Association. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA . 1991;265: 1868-1871.Crossref 17. Applebaum GE, King JE, Finucane TE. The outcome of CPR initiated in nursing homes. J Am Geriatr Soc . 1990;38:197-200. 18. Longstreth WT, Cobb LA, Fahrenbruch CE, Copass MK. Does age affect outcomes of out-of-hospital cardiopulmonary resuscitation? JAMA . 1990;264: 2109-2110.Crossref 19. Landey FJ, Parker JM, Phillips YY. Outcome of cardiopulmonary resuscitation in the intensive care setting. Arch Intern Med . 1992;152:2305-2308.Crossref 20. Heuser MD, Case LD, Ettinger WH. Mortality in intensive care patients with respiratory disease: is age important? Arch Intern Med . 1992;152:1683-1688.Crossref 21. Cohen IL, Lambrinos J, Fein IA. Mechanical ventilation for the elderly patient in intensive care: incremental charges and benefits. JAMA . 1993;269:1025-1029.Crossref 22. Emanuel LL, Emanuel EJ. The Medical Directive: a new comprehensive advance care document. JAMA . 1989;261:3288-3293.Crossref 23. Hanson LC, Danis M. Use of life-sustaining care for the elderly. J Am Geriatr Soc . 1991;39:772-777. 24. Gillick M. Limiting medical care: physicians' beliefs, physicians' behavior. J Am Geriatr Soc . 1988;36:747-752. 25. Goetzler RM, Moskowitz MA. Changes in physician attitude toward limiting care of critically ill patients. Arch Intern Med . 1991;151:1537-1540.Crossref 26. Wennberg JE, Freeman JL, Shelton RM, Bubolz TA. Hospital use and mortality among Medicare beneficiaries in Boston and New Haven. N Engl J Med . 1989; 321:1168-1173.Crossref 27. Jayes RL, Zimmerman JE, Wagner DP, Draper EA, Knaus WA. Do-not-resuscitate orders in intensive care units: current practices and recent changes. JAMA . 1993;270:2213-2217.Crossref 28. La Puma J, Orentlicher D, Moss RJ. Advance directives on admission: clinical implications and analysis of the Patient Self-Determination Act of 1990. JAMA . 1991;266:402-405.Crossref 29. Broadwell AW, Bousaubin EV, Dunn JK, Engelhardt HT. Advance directives on hospital admission: a survey of patient attitudes. South Med J . 1993;86:165-168.Crossref 30. Sachs GA, Stocking CB, Miles SH. Empowerment of the older patient? a randomized, controlled trial to increase discussion and use of advance directives. J Am Geriatr Soc . 1992;40:269-273. 31. Fitten LJ, Waite MS. Impact of medical hospitalization on treatment decision-making capacity in the elderly. Arch Intern Med . 1990;150:1717-1721.Crossref 32. Cohen LM, McCue JD, Green GM. Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree? Arch Intern Med . 1993;153:2481-2485.Crossref 33. Gleeson K, Wise S. The do-not-resuscitate order: still too little too late. Arch Intern Med . 1990;150:1057-1060.Crossref 34. Evans DA, Funkenstein H, Albert MS, et al. Prevalence of Alzheimer's disease in a community population of older persons: higher than previously reported. JAMA . 1989;262:2551-2556.Crossref 35. Skoog I, Nilsson L, Palmertz B, Andreasson LA, Svanborg A. A population-based study of dementia in 85-year-olds. N Engl J Med . 1993;328:153-158.Crossref 36. Levkoff SE, Evans DA, Liptzin B, et al. Delirium: the occurrence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med . 1992; 152:334-340.Crossref 37. Fried T, Gillick M. Medical decision making in the last 6 months of life: choices about limitation of care. J Am Geriatr Soc . 1994;42:303-307. 38. Emanuel LL, Emanuel EJ, Stoeckle J, Hummel LR, Barry MJ. Advance directives: stability of patients' treatment choices. Arch Intern Med . 1994;154:209-217.Crossref 39. Pearlman R, Patrick D, Cain K, et al. Do treatment preferences remain stable when health status changes? J Am Geriatr Soc . 1993;415:SA17. Abstract. 40. Sehgal A, Galbraith A, Chesney M, Schoenfeld P, Charles G, Lo B. How strictly do dialysis patients want their advance directives followed? JAMA . 1992;267: 59-63.Crossref 41. Davis M, Southerland LI, Garrell JM. A prospective study of advance directives for life sustaining care. N Engl J Med . 1991;324:882-888.Crossref 42. Mower WR, Baraff LJ. Advance directives: effect of type of directive on physicians' therapeutic decisions. Arch Intern Med . 1993;153:375-381.Crossref 43. Paris Cammer BE, Carrion VG, Meditch JS, Capello CF, Mulvihill MN. Roadblocks to do-not-resuscitate orders: a study in policy implementation. Arch Intern Med . 1993;153:1689-1695.Crossref 44. Schneiderman LJ, Pearlman RA, Kaplan RM, Anderson JP, Rosenberg EM. Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness. Arch Intern Med . 1992;152:2114-2122.Crossref 45. Sulmasy DP, Geller G, Faden R, Levine DM. The quality of mercy: caring for patients with "do-not-resuscitate" orders. JAMA . 1992;267:682-686.Crossref 46. O'Toole EE, Younger SJ, Juknialis BW, Caly B, Bartlett ET, Landefeld CS. Evaluation of a treatment limitation policy with a specific treatment limiting order page. Arch Intern Med . 1944;154:425-432.Crossref 47. Schneiderman LJ, Kronick R, Kaplan RM, Anderson JP, Langer RD. Effects of offering advance directive on medical treatments and costs. Ann Intern Med . 1992;117:599-606.Crossref 48. Gorbein MJ, Miller DL, Jahnigen DW, Skibinski CI. High cost patients: an analysis of admission and outcome variables. J Am Geriatr Soc . 1993;41:SA4. 49. Truog RD, Brett AS, Frader J. The problem with futility. N Engl J Med . 1992; 326:1560-1564.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Terminal Care of the Very Old: Changes in the Way We Die

Archives of Internal Medicine , Volume 155 (14) – Jul 24, 1995

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430140086009
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Abstract

Abstract Background: This study examines the use of advance directives, limitations of treatment, and medical interventions during the terminal hospitalization of the old-old. Study periods before and after the implementation of the Patient Self-Determination Act of 1990 were chosen to determine if there has been a change in terminal care. Methods: Chart review was performed for all patients 85 years and older who died in the hospital during 1988 and 1993. Patient characteristics, presence of advance directives, do-not-resuscitate orders, and other treatment limitations were noted as were interventions listed in the Medical Directive. Results: Less than 12% of the 167 study patients had an advance directive. Length of stay for these terminal admissions decreased from 18.5 to 9.6 days. Ninety-five percent of the patients were "do not resuscitate" by time of death, but orders were written sooner in 1993-75% within 24 hours of admission. Patients with early do-not-resuscitate orders had fewer high-intensity interventions. More patients had "comfort measures only" during the study period. An overall decrease in high-intensity interventions and a specific decrease in the use of transfusions, invasive tests, minor surgery, and cardiopulmonary resuscitation was seen. Conclusion: Patients 85 years and older are receiving fewer high-intensity interventions during their terminal hospitalizations. More attention is being paid to comfort and few are receiving cardiopulmonary resuscitation. There is little reference to formal advance directives in decision making for these patients.(Arch Intern Med. 1995;155:1513-1518) References 1. Ginzberg E. The high costs of dying. Inquiry . 1980;17:293-295. 2. Schroeder SA, Showstack JA, Schwartz J. Survival of adult high cost patients: report of a follow-up study from nine acute-care hospitals. JAMA . 1981;245: 1446-1449.Crossref 3. Bayer R, Callahan D, Fletcher J, et al. The care of the terminally ill: mortality and economics. N Engl JMed . 1983;309:1490-1494.Crossref 4. Scitovsky AA. The high cost of dying. What do the data banks show? Milbank Q . 1984;62:591-608.Crossref 5. Emanuel EJ, Emanuel LL. The economics of dying: the illusion of cost savings at the end of life. N Engl J Med . 1994;330:540-544.Crossref 6. Volicer L, Rheaume Y, Brown J, Fabiszewski K, Brady R. Hospice approach to the treatment of patients with advanced dementia of the Alzheimer type. JAMA . 1986;256:2210-2213.Crossref 7. Mor V, Kidder D. Cost savings in hospice: final results of National Hospice Study. Health Serv Res . 1985;20:407-422. 8. Lind SE. Transferring the terminally ill. N Engl J Med . 1984;311:1181-1182.Crossref 9. Singer PA, Lowy FH. Rationing, patient preferences and cost of care at the end of life. Arch Intern Med . 1992;152:478-480.Crossref 10. Maksoud A, Jahnigen DW, Skibinski CK. Do-not-resuscitate orders and the cost of death. Arch Intern Med . 1993;153:1249-1253.Crossref 11. Chamber CV, Diamond JJ, Perkel RL, Lasch LA. Relationship of advanced directives to hospital charges in a Medicare population. Arch Intern Med . 1994; 154:541-547.Crossref 12. Murphy DJ, Finucane TE. New do-not-resuscitate policies: a first step in cost control. Arch Intern Med . 1993;153:1641-1648.Crossref 13. Callahan D. Terminating treatment: age as a standard. Hastings Cent Rep . 1987; 17:21-25.Crossref 14. Murphy DJ. Do-not-resuscitate orders: time for reappraisal in long-term care institutions. JAMA . 1988;260:2098-2101.Crossref 15. McIntyre KM. Loosening criteria for witholding prehospital cardiopulmonary resuscitation: futility of prehospital cardiopulmonary resuscitation: like beauty, in the eyes of the beholder. Arch Intern Med . 1993;153:2189-2192.Crossref 16. Council on Ethical and Judicial Affairs, American Medical Association. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA . 1991;265: 1868-1871.Crossref 17. Applebaum GE, King JE, Finucane TE. The outcome of CPR initiated in nursing homes. J Am Geriatr Soc . 1990;38:197-200. 18. Longstreth WT, Cobb LA, Fahrenbruch CE, Copass MK. Does age affect outcomes of out-of-hospital cardiopulmonary resuscitation? JAMA . 1990;264: 2109-2110.Crossref 19. Landey FJ, Parker JM, Phillips YY. Outcome of cardiopulmonary resuscitation in the intensive care setting. Arch Intern Med . 1992;152:2305-2308.Crossref 20. Heuser MD, Case LD, Ettinger WH. Mortality in intensive care patients with respiratory disease: is age important? Arch Intern Med . 1992;152:1683-1688.Crossref 21. Cohen IL, Lambrinos J, Fein IA. Mechanical ventilation for the elderly patient in intensive care: incremental charges and benefits. JAMA . 1993;269:1025-1029.Crossref 22. Emanuel LL, Emanuel EJ. The Medical Directive: a new comprehensive advance care document. JAMA . 1989;261:3288-3293.Crossref 23. Hanson LC, Danis M. Use of life-sustaining care for the elderly. J Am Geriatr Soc . 1991;39:772-777. 24. Gillick M. Limiting medical care: physicians' beliefs, physicians' behavior. J Am Geriatr Soc . 1988;36:747-752. 25. Goetzler RM, Moskowitz MA. Changes in physician attitude toward limiting care of critically ill patients. Arch Intern Med . 1991;151:1537-1540.Crossref 26. Wennberg JE, Freeman JL, Shelton RM, Bubolz TA. Hospital use and mortality among Medicare beneficiaries in Boston and New Haven. N Engl J Med . 1989; 321:1168-1173.Crossref 27. Jayes RL, Zimmerman JE, Wagner DP, Draper EA, Knaus WA. Do-not-resuscitate orders in intensive care units: current practices and recent changes. JAMA . 1993;270:2213-2217.Crossref 28. La Puma J, Orentlicher D, Moss RJ. Advance directives on admission: clinical implications and analysis of the Patient Self-Determination Act of 1990. JAMA . 1991;266:402-405.Crossref 29. Broadwell AW, Bousaubin EV, Dunn JK, Engelhardt HT. Advance directives on hospital admission: a survey of patient attitudes. South Med J . 1993;86:165-168.Crossref 30. Sachs GA, Stocking CB, Miles SH. Empowerment of the older patient? a randomized, controlled trial to increase discussion and use of advance directives. J Am Geriatr Soc . 1992;40:269-273. 31. Fitten LJ, Waite MS. Impact of medical hospitalization on treatment decision-making capacity in the elderly. Arch Intern Med . 1990;150:1717-1721.Crossref 32. Cohen LM, McCue JD, Green GM. Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree? Arch Intern Med . 1993;153:2481-2485.Crossref 33. Gleeson K, Wise S. The do-not-resuscitate order: still too little too late. Arch Intern Med . 1990;150:1057-1060.Crossref 34. Evans DA, Funkenstein H, Albert MS, et al. Prevalence of Alzheimer's disease in a community population of older persons: higher than previously reported. JAMA . 1989;262:2551-2556.Crossref 35. Skoog I, Nilsson L, Palmertz B, Andreasson LA, Svanborg A. A population-based study of dementia in 85-year-olds. N Engl J Med . 1993;328:153-158.Crossref 36. Levkoff SE, Evans DA, Liptzin B, et al. Delirium: the occurrence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med . 1992; 152:334-340.Crossref 37. Fried T, Gillick M. Medical decision making in the last 6 months of life: choices about limitation of care. J Am Geriatr Soc . 1994;42:303-307. 38. Emanuel LL, Emanuel EJ, Stoeckle J, Hummel LR, Barry MJ. Advance directives: stability of patients' treatment choices. Arch Intern Med . 1994;154:209-217.Crossref 39. Pearlman R, Patrick D, Cain K, et al. Do treatment preferences remain stable when health status changes? J Am Geriatr Soc . 1993;415:SA17. Abstract. 40. Sehgal A, Galbraith A, Chesney M, Schoenfeld P, Charles G, Lo B. How strictly do dialysis patients want their advance directives followed? JAMA . 1992;267: 59-63.Crossref 41. Davis M, Southerland LI, Garrell JM. A prospective study of advance directives for life sustaining care. N Engl J Med . 1991;324:882-888.Crossref 42. Mower WR, Baraff LJ. Advance directives: effect of type of directive on physicians' therapeutic decisions. Arch Intern Med . 1993;153:375-381.Crossref 43. Paris Cammer BE, Carrion VG, Meditch JS, Capello CF, Mulvihill MN. Roadblocks to do-not-resuscitate orders: a study in policy implementation. Arch Intern Med . 1993;153:1689-1695.Crossref 44. Schneiderman LJ, Pearlman RA, Kaplan RM, Anderson JP, Rosenberg EM. Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness. Arch Intern Med . 1992;152:2114-2122.Crossref 45. Sulmasy DP, Geller G, Faden R, Levine DM. The quality of mercy: caring for patients with "do-not-resuscitate" orders. JAMA . 1992;267:682-686.Crossref 46. O'Toole EE, Younger SJ, Juknialis BW, Caly B, Bartlett ET, Landefeld CS. Evaluation of a treatment limitation policy with a specific treatment limiting order page. Arch Intern Med . 1944;154:425-432.Crossref 47. Schneiderman LJ, Kronick R, Kaplan RM, Anderson JP, Langer RD. Effects of offering advance directive on medical treatments and costs. Ann Intern Med . 1992;117:599-606.Crossref 48. Gorbein MJ, Miller DL, Jahnigen DW, Skibinski CI. High cost patients: an analysis of admission and outcome variables. J Am Geriatr Soc . 1993;41:SA4. 49. Truog RD, Brett AS, Frader J. The problem with futility. N Engl J Med . 1992; 326:1560-1564.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 24, 1995

References