Terminal care of the very old. Changes in the way we die

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.

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.

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.

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.