Medical care in old age: what do nurses in long-term care consider appropriate?

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.

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.

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.

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.

The unit of analysis is the refusal rate, defined as the mean number of refusals of interventions for each respondent.

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).

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.