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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Neuroleptic prescriptions for acutely ill geriatric patients.

BACKGROUND: Use of neuroleptic medication by the general population of acute care hospitals and in geriatric populations in long-term care has been described. This study examines the use of neuroleptics in acutely ill medical/surgical geriatric patients. METHODS: Chart review was performed for geriatric patients prescribed a neuroleptic drug during a 2-month study period. Patient characteristics, indications for drug use, and evaluations of cognitive or behavioral dysfunction were noted. For the patients who received only haloperidol, the type of order was described and prescription strategies were identified. RESULTS: Ninety-one (10.7%) of 848 patients received a neuroleptic order. They were older and stayed longer than the rest of the geriatric population. Fifty-eight percent were demented or delirious but 31.9% were simply described as agitated or had no reason identified for drug use. Haloperidol was the sole neuroleptic prescribed for 91.2% of patients. The rationale behind the strategies for drug prescription (loading, maintenance, sporadic) was not clear. CONCLUSION: This study raises concerns about the quality of documentation around drug use and the adequacy of diagnostic evaluation prior to drug prescription. The strategies of drug treatment do not consistently reflect a working knowledge of the pharmacology of the drug or a diagnosis-based plan of treatment. Future research should focus on physician education and the efficacy of diagnosis and management of the agitated elder.

Attitudinal stumbling blocks to geriatric rehabilitation.

Attitudes held by geriatric patients, their families, and hospital staff are frequent obstacles to successful rehabilitation following acute illness. These attitudes interfere with patients' motivation for increasing physical independence and result in patients' becoming stranded at a more dependent level of function. Three distinct attitudes frequently encountered in geriatric rehabilitation are identified: the prejudice of ageism, the right of dependency, and the apathy of fatigue. Recognition of these attitudinal syndromes permits effective treatment interventions to enable poorly motivated geriatric rehabilitation patients to progress towards functional independence.

Motivating the geriatric patient for rehabilitation.

Geriatric patients often appear unmotivated for rehabilitation, and "poor motivation" is frequently the reason given for excluding them from rehabilitation programs. However, these patients may actually be impeded by specific obstacles to the development of motivation. Appropriate intervention may enable them to make better use of rehabilitation opportunities. In this paper the authors review the concept of human motivation and what is known about aging and motivation. Specific age-related changes are examined and treatment interventions identified to maximize the patients' participation in rehabilitation toward improved functional ability.

The paraprofessional as a referral link in the mental health delivery system.

The role of the paraprofessional in the delivery of mental health services is often ambiguously defined. Even while performing the specific task of making a referral, the activities of the paraprofessional are subject to controversy. In this study the clients, the agency board members, and the community mental health agency workers all have different expectations of the qualifications, the knowledge, and the activities of the paraprofessional referral worker. It is suggested that the disparate views the participants bring to the referral situation make it unlikely that the paraprofessional will satisfy the expectations of all of them.

Meeting the psychosocial needs of pacemaker patients.

A review of the literature concerning patients who have received permanently implanted cardiac pacemakers indicates that a substantial number of these patients experience difficulties in adjusting to their medical condition. Common feelings among these patients are anxiety and depression. It is suggested that difficulties often arise from the patient's misconceptions about the pacemaker and inadequate psychosocial support. To assist such patients in their adjustment, the Pacemaker Support Program was developed to provide psychosocial counseling and pacemaker education from the preoperative phase through to the outpatient pacemaker follow-up clinic phase. In the year of the program's operation a marked decline in adjustment problems has been observed, the program has been readily integrated into the hospital routine, and it has been enthusiastically accepted by both the hospital staff and the patients.