Effect of cognitive impairment and premorbid intelligence on treatment preferences for life-sustaining medical therapy

Goals of Care Discussions in Orthopaedic Surgery: Geriatric Hip Fractures

BACKGROUND

Due to the severity of hip fracture complications in the geriatric population, including major morbidity and mortality, it is crucial to establish treatment goals and manage expectations as a patient-centered multidisciplinary team. Goals of care (GOC) are personalized treatment programs designed to align with the individual patient's values and preferences. There is a paucity of literature on the topic of GOC discussions, especially regarding orthopaedic injuries. Therefore, this narrative review aims to provide an account of GOC discussions related to geriatric hip fractures.

METHODS

We reviewed articles published on GOC between 1978 and 2024. The articles were identified by searching PubMed and Google Scholar. We utilized the search terms GOC discussions and hip fracture, with additional descriptors including arthroplasty and geriatric.

RESULTS

There were 11 articles that met the selection criteria and were published between 1978 and 2024. Five articles were published on GOC discussions in orthopaedic surgery, while the remaining 6 articles were published in non-orthopaedic fields. There was one systematic review, 2 narrative reviews, 6 observational studies, and 2 descriptive studies. Supplemental commentary from non-orthopaedic specialties and the fields of law and medical ethics was included to assist in highlighting barriers to GOC discussions and to explore potential strategies to enhance GOC discussions.

CONCLUSIONS

Goals of care discussions provide a framework for treatment decisions based on an individual patient's values and cultural beliefs; however, these conversations may be limited by perceived time constraints, patient health care literacy, and physicians' misconceptions of what is most important to discuss. While no clear consensus was identified regarding strategies for improving GOC discussions in geriatric patients who have hip fractures, the authors recommend standardized training programs, expedited family meetings, multidisciplinary team involvement, assistive technology such as Outcome Prioritization Tool, and the incorporation of GOC discussions into institutional hip fracture pathways.

The effect of a family-centered advance care planning intervention for persons with cognitive impairment and their family caregivers on end-of-life care discussions and decisions

Advanced care planning (ACP) includes advance directives (AD), which can specify provisions for palliative care and types of life-sustaining treatments for an individual requiring end-of-life (EoL) care. ACP for persons in the early stages of cognitive decline can decrease anxiety and conflict for family members needing to make decisions about EoL-care, which is especially critical for family caregivers (FCGs) if they play a role as a surrogate regarding healthcare decisions. However, ACP for persons with cognitive impairment (PWCIs) is often overlooked. This study explored the effects of a family-centered ACP intervention on decisions about EoL-care, life-sustaining treatment decisions, and discussions of related topics among PWCIs and FCGs. The study was conducted in outpatient clinics of regional teaching hospitals in northern Taiwan. Participants were dyads consisting of persons diagnosed with mild cognitive impairment or mild dementia and their FCGs. The family-centered ACP intervention was provided by an ACP-trained senior registered nurse. A one-group, pretest–posttest design was used to evaluate the effect of the intervention on 44 dyads. Four structured questionnaires collected data regarding familiarity with ACP, intention to engage in ACP, participation in personal discussions between the dyads about ACP, and consistency between PWCIs and FCGs for decisions about life-sustaining treatments at EoL. Paired t, Kappa, and McNemar tests were used to compare differences between pre-intervention data (pretest) and post-intervention data (posttest). There were significant increases in familiarity with ACP, components of ACP, and the number of topics PWCIs and FCGs personally discussed surrounding EoL-care decisions. There was no change for either group in wanting to have a formal ACP consultation and only modest increases in consistency between PWCIs and FCGs for life-sustaining treatment decisions after completion of the family-centered ACP intervention. Clinicians caring for PWCIs should incorporate family-centered ACP interventions and support ongoing discussions about life-sustaining medical treatments to ensure their preferences regarding EoL-care are respected. The accessibility and availability of consultations about ACP should also be provided.

'What matters to you?' Health outcome prioritisation in treatment decision-making for older patients

Background

for shared decision-making, it is important to discuss of the patients’ priorities in order to align treatment decisions with these priorities.

Objective

to assess the most important health outcome for older patients on the verge of making a treatment decision, using the Outcome Prioritization Tool (OPT). Secondary objectives were the feasibility of the OPT and patient variables associated with prioritising different health outcomes.

Design

retrospective cohort study.

Setting and subjects

at the University Medical Hospital Groningen, the Netherlands, 350 patients were included who visited the geriatric outpatient clinic during the work-up regarding a complex treatment decision (such as cancer treatment or heart valve replacement).

Methods

during geriatric assessment, patients prioritised between four health outcomes, using the OPT.

Results

median age was 78.5 years, 172 (49.1%) were referred regarding a treatment decision for a malignant disease. Cognitive impairment was present in 23.6%. Most patients (55.2%) prioritised maintaining independence as their most important goal, followed by extending life in 21.1%. Only cognitive impairment was significantly associated with prioritising extending life as the most important health outcome. For 107 patients (30.6%), the OPT was not feasible; these patients more often had malnutrition and assisted living.

Conclusions

the main health outcome of older patients on the verge of making a treatment decision was maintaining independence, followed by extending life. Patients with cognitive impairment more often prioritised extending life. The OPT was feasible as a decision aid for most patients. For optimal shared decision-making, it is crucial to take patient preferences into account.

Integration of a Palliative Approach in the Care of Older Adults with Dementia in Primary Care Settings: A Scoping Review

A palliative approach to care aims to meet the needs of patients and caregivers throughout a chronic disease trajectory and can be delivered by non-palliative specialists. There is an important gap in understanding the perspectives and experiences of primary care providers on an integrated palliative approach in dementia care and the impact of existing programs and models to this end. To address these, we undertook a scoping review. We searched five databases; and used descriptive numerical summary and narrative synthesizing approaches for data analysis. We found that: (1) difficulty with prognostication and a lack of interdisciplinary and intersectoral collaboration are obstacles to using a palliative approach in primary care; and (2) a palliative approach results in statistically and clinically significant impacts on community-dwelling individuals, specifically those with later stages of dementia. There is a need for high-quality research studies examining the integrated palliative approach models and initiation of these models sooner in the care trajectory for persons living with mild and moderate stages of dementia in the community.

The Seven Selves of Dementia

The self is a complex and multifaceted phenomenon, encompassing a variety of cognitive processes and psychosocial influences. Considering this, there is a multiplicity of "selves," the current review suggesting that seven fundamental self-processes can be identified that further our understanding of the experience of dementia. These include (1) an embodied self, manifest as corporeal awareness; (2) an agentic self, related to being an agent and influencing life circumstances; (3) an implicit self, linked to non-conscious self-processing; (4) a critical self, which defines the core of self-identity; (5) a surrogate self, based on third-person perspective information; (6) an extended self, including external objects or existences that are incorporated into the self; and, finally, (7) an emergent self, a property of the self-processes that give rise to the sense of a unified self. These are discussed in relation to self-awareness and their use in making sense of the experience of dementia.

Perspectives and Experiences of Persons With Dementia With Advance Care Planning: An Integrative Literature Review

OBJECTIVE

An integrative review of the literature on advance care planning (ACP) preferences and practices from the perspective of persons with dementia (PWDs) was conducted, both to learn how health-care providers might engage and empower PWDs in ACP during the early stages of dementia and to identify where researchers should focus future work to improve ACP in this population.

METHODS

In November 2017, CINAHL, Legal Collection, PsycINFO, PubMed, and SocIndex were searched for empirical studies with PWDs as participants and ACP as a topic of interest.

RESULTS

Eighteen articles, which sampled 1304 PWDs, were found, focusing on 4 domains: engagement in and correlates of ACP participation; ability and attitudes toward ACP participation; ACP interventions; and values and preferences for end of life (EOL). Demographics were reported for correlates of participation. Many PWDs held a neutral to negative view toward ACP, although values exploration exercises in interventions were well received. No intervention study reported significant findings for ACP participation. Most PWDs emphasized the importance of family at EOL.

CONCLUSION

Research is needed with methodologically rigorous designs and theoretical frameworks that examine cognitive, psychosocial, and environmental factors influencing ACP attitudes, preferences, and behaviors among PWDs in order to improve engagement among this population.

Advanced Care Planning for Persons With Dementia in Primary Care: Attitudes and Barriers Among Health-Care Professionals

BACKGROUND

Advance care planning (ACP) provides clarity on goals and preferences for future health-care decisions, the timeliness of which is critical for persons with dementia.

AIM

This study assessed Primary Care Collaborative Memory Clinic (PCCMC) health-care practitioners' desire for more education on ACP, capacity for and attitudes toward ACP, and current ACP practices in their regular family practice and in their PCCMC.

METHODS

Primary Care Collaborative Memory Clinic health-care professionals completed a questionnaire in which they rated their interest in learning various ACP-related topics (5-point scale: not at all to very much so), attitudes toward ACP, and the importance of and perceived degree of responsibility for ACP (5-point scale: not at all to extremely). Respondents estimated ACP completion in regular family practice and PCCMC.

RESULTS

Two hundred and sixty one surveys were completed. Mean knowledge ratings were moderate (M = 3.0) and mean ratings of interest in ACP topics were all high (median ≥ 4). Despite the perception that ACP is very important (M = 4.9) and the responsibility of PCCMCs (M = 3.7), the majority of respondents estimated that 40% or fewer patients have had ACP. Ratings of willingness to conduct ACP (M = 3.7) and comfort level (M = 3.4) were moderate but significantly exceeded ratings of ability (M = 2.9), comfort (M = 3.5), and confidence (M = 2.8).

CONCLUSION

There was a striking disconnect between perceptions of the importance of completing ACP for persons with dementia and actual ACP completion rates. Primary Care Collaborative Memory Clinics may be in an ideal position to support ACP discussions; however, there is a need to improve health-care professionals' knowledge and attitudes toward ACP.

SPIRIT advance care planning intervention in early stage dementias: An NIH stage I behavioral intervention development trial

People in the early stages of Alzheimer's disease and related dementias (ADRD) are encouraged to engage in advance care planning (ACP) while they are still competent to appoint a surrogate decision maker and meaningfully participate in ACP discussions with the surrogate. In this NIH Stage I behavioral intervention development trial, we will adapt and test an efficacious ACP intervention, SPIRIT (Sharing Patient's Illness Representation to Increase Trust), with people with mild dementia and their surrogates to promote open, honest discussions while such discussions about end-of-life care are possible. We will first adapt SPIRIT (in person) to target people with mild dementia and their surrogates through a process of modification-pretesting-refinement using stakeholders (persons with mild dementia, family caregivers, and clinicians) and experts, including adapting the delivery mode to interactive web-based videoconference format (SPIRIT-remote). Then in a 3-group RCT with 120 patient-surrogate dyads, we will evaluate the feasibility and acceptability of SPIRIT in-person and SPIRIT remote, and preliminary efficacy of SPIRIT compared to usual care on preparedness outcomes for end-of-life decision making (dyad congruence on goals of care, patient decisional conflict, and surrogate decision-making confidence) shortly after the intervention. This Stage I research of SPIRIT will generate valuable insights regarding how to improve ACP for people with mild dementia who will progress to an advanced stage of the disease in the foreseeable future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03311711, Registered 10/12/2017.

End-of-life decision making in dementia

Family caregivers are often required to make treatment decisions on behalf of institutionalized loved ones with advanced-stage dementia. Deciding on appropriate treatment is a complex process which can be difficult for families. This grounded theory study examined the concerns of family caregivers regarding their relative’s care and explored how end-of-life treatment decisions are made. Data were collected from in-depth interviews with 24 caregivers and analysed using constant comparison and dimensional analysis, resulting in a substantive theory of decision making. The role of decision maker from the perspective of family caregivers is described. The relative’s level of quality of life emerged as central to decision making. Four end-of-life phases were identified in which treatment intensity was influenced by the caregivers’ evaluation of quality of life. The results highlight the importance of including family caregivers’ experiences in working toward caregiver/medical team consensus around treatment decisions at the end of life in dementia.

Identifying the components of clinical vignettes describing Alzheimer's disease or other dementias: a scoping review

Background

Clinical vignettes are often used to elicit information about health conditions in research studies. This review summarizes the components of clinical vignettes describing Alzheimer’s disease (AD) or other dementias. The purpose is to provide recommendations for the development of standardized vignettes that may be used in future studies.

Methods

MEDLINE, EMBASE, PsycINFO, ASSIA, CINAHL were searched from their inception to June 2014. Primary English-language studies employing vignettes to describe AD or similar disorders (including other dementias and Parkinson’s disease) were included in the review. Included studies had to describe the content of the vignettes in the published manuscripts. The characteristics of the included studies and the vignettes were extracted in tabular form and summarized qualitatively.

Results

Forty-two studies were included in the review. Twenty-four of the studies contained at least one AD vignette, 11 had vignettes focusing on non-AD dementias, and seven contained vignettes describing conditions other than dementia. In total, 58 vignettes were obtained from the 42 included studies.

Conclusions

Key aspects to consider when constructing vignettes for AD or other dementias include writing the vignettes from a third-person perspective and presenting hypothetical patients as being at least 65 years of age. Researchers should develop standardized vignettes for use across studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-015-0179-x) contains supplementary material, which is available to authorized users.

Care planning in dementia: tips for clinicians

Care planning in dementia is made more complicated by the increasing prevalence of multiple chronic comorbidities, also termed 'frailty'. Consideration of the reciprocal impact of dementia and other health issues is critical to appropriate care planning. This may be best achieved through an ordered process whereby the clinician first considers medical evidence and its limitations to the medical, physical and social determinants of the patient's health trajectory and quality of life. The next step is to provide information and recommendations to the patient and a second decision maker (who will become increasingly involved as dementia progresses). The end point of care planning is an informed and empowered decision maker who is able to dynamically apply skills to measure any treatment option that may be proposed, while having access to the decisional support of a health professional familiar with the patient's health status.

Advance care planning for people with dementia: benefits and challenges

Advance care planning (ACP) is a process being championed within health and social care, particularly since the publication of the UK Department of Health's 2008 End of Life Care Strategy. However, its implementation in dementia care is yet to be fully realised and can pose significant ethical and legal dilemmas for the generic and specialist workforce, the patient themselves, and their family or loved ones. Challenges may be attributable to inadequate communication, capacity issues, missed opportunities, and the perception that dementia is not a life-limiting illness. The aim of this paper is to highlight the benefits of ACP for individuals with dementia while appraising the recognised barriers to assist in developing some realistic recommendations for future practice.

Preferences for end-of-life care: a nominal group study of people with dementia and their family carers

BACKGROUND

The wishes and preferences of people with dementia should inform decisions on future care. However, such decisions are often left to family carers and may not reflect those the person with dementia would have made for themselves. We know little about what influences agreement between people with dementia and their carers.

AIM

To explore whether people with dementia and their carers were able to generate and prioritise preferences for end-of-life care. We examined whether carers influenced the choices made by the persons with dementia.

DESIGN

Nominal group technique.

SETTING/PARTICIPANTS

People with dementia (n = 6), carers (n = 5) and dyads of people with dementia and carers (n = 6) attending memory assessment services.

METHODS

Three modified nominal group technique groups were conducted in five stages: (1) silent generation of ideas, (2) discussion, (3) further generation of ideas, (4) discussion and themeing and (5) ranking. The discussions were recorded, transcribed and analysed for thematic content using NVIVO8.

RESULTS

Quality of care, family contact, dignity and respect were ranked as significant themes by all groups. The analysis of transcripts revealed three main themes: quality of care, independence and control and carer burden. People with dementia had difficulty considering their future selves. Carers wanted much control at the end of life, raising issues of assisted dying and euthanasia.

CONCLUSIONS

Wishes and preferences of people with dementia and their family carers may differ. To ensure the wishes of people with dementia are respected, their views should be ascertained early in the disease before their ability to consider the future is compromised.

Preferences for end-of-life treatment: concordance between older adults with dementia or mild cognitive impairment and their spouses

BACKGROUND

There is considerable debate about the ability of proxies to adequately reflect patients' preferences regarding end-of-life care, when patients are no longer capable of stating their preferences. This study evaluated concordance in end-of-life preferences between patients with mild cognitive impairment (MCI) or dementia and their spouses.

METHODS

A cross-sectional sample of 106 respondents (53 couples) was recruited in two psychogeriatric clinics. Bivariate analyses were conducted to evaluate the degree of agreement between the patients' preferences and those of their spouses.

RESULTS

Patients were more likely to opt for more treatment than their spouses. Moderate agreement between patients and spouses was evident for preferences regarding end-of-life decisions for the patients. There was little concordance between the wishes of spouses regarding their own preferences and what they wanted for the patient or what the patient wanted. When incorrectly predicting patients' preferences, spouses were more likely to ask for treatment.

CONCLUSIONS

Our results show that regarding end-of-life preferences for patients, there is moderate agreement between patients and their spouses, but limited evidence for projection of spouses' preferences on patients (i.e. spouse making a prediction based on own wishes). Potential differences in end-of-life preferences between older adults with MCI or mild dementia and their caregivers should be taken into consideration in the preparation of advance care planning.

Advance care planning for people with dementia: a review

BACKGROUND

Few people with dementia have made advance plans for their health care. Advance care planning (ACP) is a process of discussion between an individual and their care providers that takes account of wishes and preferences for future care. We aimed to examine the facilitators and inhibitors to ACP in people with dementia. We also aimed to identify key themes in the literature and critically review the methodologies used.

METHODS

We systematically searched the English language literature including PubMed, CINAHL, AMED, PsychINFO, EMBASE and BNI. We included empirical studies which reported the characteristics of the patient population, the type of advance care planning used and the study setting, and which involved people with dementia, family members or professional carers.

RESULTS

We identified 17 studies (11 quantitative methods, one qualitative and five mixed methods). We found one ACP intervention which changed outcomes for people with dementia. Key themes were identified: there is a point at which cognition decreases critically so that an advanced care plan can no longer be made; factors present in family carers and professionals can influence decision-making and the ACP process; ACPs are affected by preferences for life sustaining treatments; ACP in dementia may differ from other illness groups; and there is a need for education relating to ACP.

CONCLUSION

The current evidence base for ACP in dementia is limited. Since UK government policy recommends that all people should engage in ACP, more evidence is needed to understand the feasibility and acceptability of advanced care plans for people with dementia.

Cardiopulmonary resuscitation and do-not-resuscitate orders: a guide for clinicians

The do-not-resuscitate order, introduced nearly a half century ago, continues to raise questions and controversy among health care providers and patients. In today's society, the expectation and availability of medical interventions, including at the end of life, have rendered the do-not-resuscitate order particularly relevant. The do-not-resuscitate order is the only order that requires patient consent to prevent a medical procedure from being performed; therefore, informed code status discussions between physicians and patients are especially important. Epidemiologic studies have informed our understanding of resuscitation outcomes; however, patient, provider, and institutional characteristics account for great variability in the prevalence of do-not-resuscitate orders. Specific strategies can improve the quality of code status conversations and enhance end-of-life care planning. In this article, we review the history, epidemiology, and determinants of do-not-resuscitate orders, as well as frequently encountered questions and recommended strategies for discussing this important topic with patients.

The representation of healthcare end users' perspectives by surrogates in healthcare decisions: a literature review

BACKGROUND

The representation of end users' perspectives in healthcare decisions requires involvement of their surrogates when the end users, i.e. certain patients, elderly people, children and people with disabilities, are unable to present their views.

AIMS

To review critical issues, and the advantages and disadvantages of involving surrogates in representing end users' perspectives in healthcare decisions.

METHODS

A systematic review of literature published in peer-reviewed journals from 1990 to 2005.

RESULTS

Findings show that surrogates are used widely in health care and that they are necessary to represent end users' perspectives in healthcare decisions when the latter are unable to do so themselves. Critical issues in using surrogates include key ethical, social, cultural, legal and medico-technological factors; ascertaining the best interest of end users; potential conflict of interest; possible biased decisions and the burden on surrogates. The key advantage of surrogate involvement in healthcare decisions is their ability to represent end users' needs, values and wishes. The main disadvantages include potential discrepancies between the decisions and conclusions of surrogates and end users; the failure of surrogates to predict end users' preferences accurately and the lack of certainty that useful information will be obtained through the surrogacy process.

CONCLUSION

This systematic review has revealed that the involvement of surrogates is an additional vital way to represent end users' perspectives in healthcare decisions where for a range of reasons their opinions are unable to be effectively ascertained. However, because of the heterogeneity of surrogates and end users, the selection of appropriate surrogates and deploying surrogate decisions require particularly careful consideration of their value in individual cases; thus, subsequent decision-making must be reviewed on a case-to-case basis to seek to ensure that the best interests, needs and wishes of the end user are fully and accurately represented.

Cognitive, functional, and quality-of-life outcomes of patients aged 80 and older who survived at least 1 year after planned or unplanned surgery or medical intensive care treatment

OBJECTIVES

To investigate long-term cognitive, functional, and quality-of-life outcomes in very elderly survivors at least 1 year after planned or unplanned surgery or medical intensive care treatment.

DESIGN

Retrospective cohort study.

SETTING

General, 1,024-bed, tertiary university teaching hospital in The Netherlands.

PARTICIPANTS

Two hundred four survivors of a cohort of 578 patients admitted to the medical-surgical intensive care unit (ICU) between January 1997 and December 2002 and alive in December 2003. The majority of survivors underwent elective surgery.

MEASUREMENTS

From December 2003 until February 2004, data were collected from 190 patients and 169 relatives. The measures were: Informant Questionnaire on Cognitive Decline short form (IQCODE-SF) (cognition), modified Katz index of activities of daily living (ADLs) (functional status), and EuroQol (EQ-5D) (health-related quality of life). The patients themselves completed the modified Katz ADL index and EQ-5D forms; their caregivers completed the ADL caregiver version and IQCODE-SF.

RESULTS

The mean age at admission+/-standard deviation was 81.7+/-2.4, and the median time after discharge was 3.7 years (range 1-5.9 years). Of the ICU patients who had planned surgery, 57% survived, compared with 11% of the unplanned surgical admissions and 10% of the medical patients. Three-quarters (74.3%) of the patients who lived at home before ICU admission remained at home at follow-up. Eighty-three percent had no severe cognitive impairment, and 76% had no severe physical limitations (33% had moderate, 40% had mild, and 3% had no limitations). The perceived quality of life was similar to that of an age-matched general population.

CONCLUSION

Long-term survivors of ICU treatment received at the age of 80 and older showed fair-to-good cognitive and physical functioning and quality of life, although few patients who underwent unplanned surgery or who were admitted to the ICU for medical reasons survived.

Older people's reasoning for resuscitation preferences and their role in the decision-making process

OBJECTIVES

To investigate older patients' reasoning for their cardiopulmonary resuscitation (CPR) preferences and the related decision-making process (DMP).

METHODS AND SUBJECTS

In a descriptive study 220 elderly home-dwelling cardiovascular patients were interviewed and asked to justify their CPR preferences according to the given statements. Questions related to DMP were asked and their physical function, cognition, mood, and quality of life were assessed.

RESULTS

Resuscitation preferences were associated with several patient characteristics, such as age, mood and quality of life. Patients preferring CPR (114/220, 52%) estimated their prognosis of CPR to be better than those preferring to forgo CPR. They justified their view: "Life is precious and worth living for me" (92%), "Maintaining life is a value of its own" (92%), "I feel needed by my family and my closest" (81%). Participants preferring to forgo CPR (106/220, 48%) justified: "I have already gained old age and led a full life" (88%), "People cannot decide these things" (72%). Only 9% of patients had discussed, and 38% would like to discuss preferences for life-sustaining treatments (LSTs) with their physician. However, 80% of respondents felt that the patients should take some part in the DMP; either alone (9%), together with a physician (23%), or together with a physician and a close relative (48%).

CONCLUSIONS

Older people justify their resuscitation preferences highlighting their experiences of meaningful life or fulfillment of their life, interpersonal relationships with their loved ones and presumed outcome of CPR. Less than a half of the patients wished to discuss CPR and LSTs preferences in their current situation with their physician, but nevertheless wanted to participate in the DMP of end-of-life treatment. Physicians should assess patients' own preferences in-depth.

Information needs and decision-making processes in older cancer patients

The paper provides an overview of age-differences in patients' preferences for participation in cancer treatment decision-making and factors that relate to these age-differences. On average, older cancer patients prefer to receive less information about their illness and treatment and assume a less active role in making treatment decisions. They are also less likely to collect and analyze all relevant information in order to make an optimal decision. Observed age-differences are, in part, explained by age-associated cognitive decline. Age-differences are, on average, small to moderate, and most older patients prefer to be well-informed. Nonetheless, only a minority of them wishes to play an active role in decision-making. Given their lower preference for active participation in decision-making, older adults may show less positive psychological effects of active participation, but this question warrants research. Implications for working with older cancer patients are discussed.

The role of cognitive impairment in desire for hastened death: a study of patients with advanced AIDS

To examine the relationship between cognitive impairment and desire for death in patients with advanced AIDS we evaluated 128 patients with advanced AIDS consecutively admitted to three long-term care facilities. Participants completed a clinical assessment that included a self-report measure of desire for hastened death in the medically ill (Schedule of Attitudes toward Hastened Death), three measures of cognitive functioning designed to screen for cognitive impairment (Dementia Rating Scale, Mini-Mental State Exam, HIV Dementia Scale), and other measures of physical and psychological functioning. Participants who were classified as cognitively impaired obtained significantly higher scores on the measure of desire for death than did patients without cognitive impairment. This modest association between cognitive impairment and desire for death remained significant even after controlling for the impact of depression on desire for death. Specific aspect of cognitive functioning such as memory and psychomotor coordination appeared to be more salient than executive functioning or abstract reasoning. Cognitive impairment appears to have a modest, but significant impact on patients' desire for hastened death. Aggressive treatment of cognitive symptoms in the terminally ill is necessary in order to disentangle the various factors that may drive end-of-life treatment decisions.

End-of-life treatment preferences among older adults: a nurse practitioner initiated intervention

PURPOSE

To explore end-of-life treatment preferences (ELTP) among older adults and to test the impact of a nurse practitioner (NP) initiated intervention to facilitate the completion of ELTPs.

DATA SOURCES

A descriptive study including 135 older adults living in a continuing care retirement community.

CONCLUSIONS

The findings in this study suggest that the majority of older adults do not want life sustaining interventions at the end of life, but are willing to accept interventions that will keep them comfortable. ELTP can, however, change over time. An NP-initiated teaching intervention about advance directives and ELTP significantly increased the number of individuals who completed advance directive forms.

IMPLICATIONS FOR PRACTICE

With the advancement of medical technology, various life-sustaining treatments are available at the end of life. Older adults should be encouraged to establish their ELTPs while they are physically and mentally able to do so. Health care providers should initiate discussions about ELTP at regular intervals (yearly) to assist older adults in participating in decisions about their end-of-life care.