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. J Am Geriatr Soc 44:1322–1325, 1996 .