Health care decisions among elderly long-term care residents and their potential proxies

Seventy residents of the residential care section of a long-term care facility were asked to make health decisions after being presented four clinical vignettes. Two vignettes involved high-risk procedures (aortic valve replacement and carotid endarterectomy) and two were low risk (flu vaccination and psychotropic medication). Comparisons were made between decisions made by the elderly participants and predictions of those decisions by potential proxies, including the participant's closest relative and a nurse, a social worker, and a physician in the facility. There was a low rate of agreement between decisions made by the elderly participant and the decisions the potential proxies thought they would make. The highest agreement was found between the participants' actual decision and the decision predicted by their relatives. The lowest agreement occurred between what the physician thought the participant would choose for the two high-risk vignettes and what the participant actually chose. The quality of the elderly participant's decisions was also rated on a four-point scale by the potential proxy, as well as by a researcher. Highest ratings of the quality of the elderly person's decision-making ability were assigned by the relative. A significant negative correlation was obtained between the elderly person's age and the decision-making rating assigned by the physician, and significant positive correlations were obtained between mental status and decision-making ratings by the other raters. These data have important implications for designing and implementing strategies to maximize the ability of elderly people in long-term care settings to participate in decisions about their health care.