[SUCCESSFUL AGING-A MULTI-FUNCTIONAL DIMENSION CONCEPT AN EMPHASIS ON THE END OF LIFE].

INTRODUCTION: The concept of "successful aging" as coined by Rowe and Kahan in the late nineties of the last century, came to describe a period of old age with multi-functional abilities. The functions are physical, cognitive and social, without progressive chronic diseases and without disabilities. There is a change in the concept of successful aging beyond the physical dimension (daily function (ADL) and cognitive function) which is based on objective performance indicators towards subjective indicators based on the patients' feelings and their quality of life. Successful aging moves from the limited bio-physical aspect to an overall view of bio-psycho-socio which means mental-emotional-behavioral aspects, social involvement, and also an element of spirituality and even end-of-life decisions. Successful aging will be measured by objective and subjective measures that include the patient's feelings and experiences. The idea is to include and see in successful aging not only the absence of morbidity and disability as seen by Rowe and Kahan, but to a multidimensional function that includes physical and cognitive, mental and emotional, social and spiritual parameters and a dimension of the end of life in making decisions according to the wishes and preferences of the person himself and his family.

Left-prefrontal alpha-dynamics predict executive working-memory functioning in elderly people.

Recent findings suggest that electroencephalography (EEG) oscillations in the theta and alpha frequency-bands reflect synchronized interregional neuronal activity and are considered to reflect cognitive-control, and executive working memory mechanisms in humans. Above the age of 50 years, hypothesized pronounced alterations in alpha and theta-band power at resting or across different WM-functioning brain states may well be due to pre-dementia cognitive impairments, or increasing severity of age-related neurological disorders. Executive working memory (EWM) functioning was assessed in older-adult participants (54 to 83 years old) by obtaining their WM-related EEG oscillations and WM performance scores. WM performance and WM brain-state EEG were recorded during online-WM periods as well as during specific online WM events within EWM periods, and during resting offline-WM periods that preceded online-WM periods. Left-prefrontal alpha-power was enhanced during offline-WM periods versus online-WM periods and was significantly related to WM accuracy. Left-prefrontal alpha power and left prefrontal-parietal theta power anterior-posterior difference-gradient during online WM activity were related to reaction times (RT's). Importantly, during active-storage events, WM-offset offline-periods, and preparatory pre-retrieval events, excessive left-prefrontal alpha activity was related to poor EWM performance. The potential for developing targeted noninvasive cognition-enhancing interventions and developing clinical-monitoring EEG-based biomarkers of pathological cognitive-decline in elderly people is discussed.

Characterizing the Heterogeneity of Aging: A Vision for a Staging System for Aging.

Introduction: Older adulthood encompasses several decades of change and heterogeneity. Primary care providers need a geriatric comprehensive vision for defining older adult subpopulations. Methods: Using PubMed and Google searches, we reviewed the literature on epidemiology of age-related physiological changes, age-related diseases and geriatric syndromes, functional state, and emotional and social changes. We divided old age into strata based on chronological age and strata based on functional state, disease burden, and geriatric syndromes. Results: We describe 4 chronological-age strata beginning at age 60, and 4 functional-age strata based on frailty according to a modified clinical frailty scale. We provide clinical considerations and anticipatory guidance topics for each of the age strata and functional strata. Conclusion: Chronological age, functional status, chronic disease burden and geriatric syndromes, and life expectancy are all important domains that impact clinical care and appropriate anticipatory guidance for individual older adults. Better knowledge for differentiating subpopulations of older adults may improve clinical care, reduce medical overuse, improve personalized anticipatory guidance, and focus on the impact of functional state on the quality of life.

[PREDICTING PARAMETERS WITH FOCUS ON PRESSURE ULCERS IN IDENTIFYING ADVANCED DEMENTIA MORTALITY].

INTRODUCTION: Longer life expectancy exposes the older person to vulnerability, morbidity and disability and increases the risk of developing dementia. The number of elderly patients with dementia reaching the advanced stage is increasing in entire settings. This condition of poor quality of life existing over months and years, when the time of death cannot be predicted, raises dilemmas in medical and ethical decisions. Dementia is an incurable disease at the last stage of life, highlighting a therapeutic approach in the provision of palliative care with emphasis on the quality of life as a primary goal. In older age, any advanced chronic disease is incurable and palliative care includes life-long therapies with hospice-type supportive care. Advanced dementia stresses an aggravated approach, and the recommendation is to provide only hospice type palliative care. The purpose of this survey is to review the existing evidence in base evidence literature containing prognostic parameters indicating mortality at six months including cognitive, functional, nutrition and morbidity factors, and focusing on pressure ulcers. Thus, the goal is to allow the attending team and the families to make appropriate evidence based medical-ethical decisions. A systematic review of the medical literature found seven articles with indices predicting mortality within six months in patients with advanced dementia (5 studies originated in the USA, 2 from Israel). The most common predictor variable in 100% of studies is eating and swallowing problems associated with the consequences of malnutrition and indigestion, weight loss and loss of appetite. The variable in 80% of the studies is background diseases including: cancer, heart failure, second-degree pressure ulcers, and lack of control of the sphincters. In 75% of cases, functional decline in personal care, level of consciousness and alertness are identified as variables, and in 60% of cases, mobility impairment unstable medical conditions and demographic conditions are diagnosed.

Advanced Dementia: Brain-State Characteristics and Clinical Indicators of Early Mortality.

There is an urgent need in advanced dementia for evidence-based clinical prognostic predictors that could positively influence ethical decisions allowing health provider and family preparation for early mortality. Accordingly, the authors review and discuss the prognostic utility of clinical assessments and objective measures of pathological brain states in advanced dementia patients associated with accelerated mortality. Overall, due to the paucity of brain-activity and clinical-comorbidity predictors of survival in advanced dementia, authors outline the potential prognostic value of brain-state electroencephalography (EEG) measures and reliable clinical indicators for forecasting early mortality in advanced dementia patients. In conclusion, two consistent risk-factors for predicting accelerated mortality in terminal-stage patients with advanced dementia were identified: pressure ulcers and paroxysmal slow-wave EEG parameters associated with cognitive impairment severity and organic disease progression. In parallel, immobility, malnutrition, and co-morbid systemic diseases are highly associated with the risk for early mortality in advanced dementia patients. Importantly, the authors' conclusions suggest utilizing reliable quantitative-parameters of disease progression for estimating accelerated mortality in dementia patients entering the terminal disease-stages characterized by severe intellectual deficits and functional disability.

Neural reactivity parameters of awareness predetermine one-year survival in patients with disorders of consciousness.

Objective: The current investigation evaluated the sensitivity of neural-reactivity markers of awareness versus standard clinical assessments in predicting 1-year survival in nonresponsive-awake patients with disorders of consciousness (DOC).Methods: Pre-attentive auditory mismatch-negativity (MMN) event-related potentials (ERP's), globally induced electroencephalography (EEG) spectral power following verbal command, and clinical parameters were assessed. The study included 10 patients with DOC with mixed etiology and 10 healthy controls (HC) at baseline. The clinical status of patients with DOC was reassessed after 1 year.Results: Unlike baseline clinical assessment scores, baseline MMN amplitudes of non-survivors and induced theta-power following verbal-command clearly distinguished the non-surviving patients versus surviving patients. Baseline MMN peak-amplitude latencies in survivors with DOC were significantly related to clinical outcome over a 1-year period.Conclusion: Current findings underscore the increased sensitivity of EEG-reactivity markers of awareness versus standard clinical scores in predicting 1-year clinical outcome and survival in patients with DOC. Further longitudinal research in larger DOC samples is needed to confirm the prognostic-reliability, and validity of neural reactivity parameters of awareness in patients with DOC. Current finding may have implications for clinical care and medical-legal decisions in unresponsive-awake patients, and could assist clinicians to predict their survival up to 1 year from admission.

Integrated Development Environment for EEG-Driven Cognitive-Neuropsychological Research.

Background: EEG-driven research is paramount in cognitive-neuropsychological studies, as it provides a non-invasive window to the underlying neural mechanisms of cognition and behavior. A myriad collection of software and hardware frameworks has been developed to alleviate some of the technical barriers involved in EEG-driven research. Methods: we propose an integrated development environment which encompasses the entire technical "data-collection pipeline" of cognitive-neuropsychological research, including experiment design, data acquisition, data exploration and analysis in a state-of-the-art user interface. Our framework is based on a unique integration between a python-based web framework, time-oriented databases and object-based data schemes. Results: we demonstrated our framework with the recording and analysis of an n-Back task completed by 15 elderly (ages 50 to 80) participants. This case study demonstrates the highly utilized nature of our integrated framework with a challenging target population. Furthermore, our results may provide new insights into the correlation between brain activity and working memory performance in elderly people, who are prone to experience accelerated decline in executive prefrontal cortex functioning. Conclusion: our framework extends the range of EEG-driven experimental methods for assessing cognition available for cognitive-neuroscientists, allowing them to concentrate on the creative part of their work instead of technical aspects.

Spasticity and dementia increase the risk of pressure ulcers.

The aim of this study was to identify and characterise the association between the prevalence of pressure ulcers, spasticity levels, and advanced dementia in disable elderly patients. Data were obtained from the patient medical files. Patients were hospitalised in the geriatric skilled nursing department. A total of 40 frail elderly patients, bedbound and suffering from advanced chronic diseases, advanced dementia, and high-grade pressure ulcers, were examined. Pressure ulcer grades and spasticity in advanced dementia versus non-dementia patients were evaluated. Logistic regression indicated that only advanced dementia and spasticity were significantly associated with the development of pressure ulcers versus those without dementia or without spasticity. Patients with advanced dementia displayed a significantly higher prevalence of severe spasticity. In multivariate logistic regression analyses, spasticity was significantly associated with pressure ulcers. The strong association of spasticity with the onset of pressure ulcers in advanced dementia should encourage clinicians to implement preventative measures to delay the onset of pressure ulcers.

An overview of co-morbidities and the development of pressure ulcers among older adults.

BACKGROUND: The prevalence of pressure ulcers particularly in the frail older adult population continues to be high and very costly especially in those suffering from chronic diseases and has brought a higher awareness to comprehensive, preventive and therapeutic measures for treatment of pressure ulcers. Internal risk factors highlighted by comorbidities play a crucial role in the pathogenesis of pressure ulcers. MAIN BODY: Focusing on the impact of common chronic diseases (comorbidities) in aging on pressure ulcers (e.g., cardiovascular diseases, diabetes, chronic pulmonary diseases, renal diseases and neurodegenerative disorders) and the significant complicating conditions e.g., anemia, infectious diseases, malnutrition, hospitalization, incontinence and polypharmacy, frailty and disability becomes important in developing a more complete, inclusive and multidisciplinary approach to prevention of PU in older patients. OBJECTIVE: To describe chronic and acute conditions which are risk factors in elderly patients for developing PU. METHODS: We present an overview of comorbidities seen with PU in three diverse patient locations. The inclusion criteria are sites (community, acute hospital and long term facilities), older patients, chronic diseases and pressure ulcers grade 2 and over. Using a recently developed conceptual framework accepted by European and National Pressure Ulcer Advisory Panels, we examined chronic diseases to identify the risk factors of chronic conditions and complicating conditions which potentially influence risk for PU development. CONCLUSION: Multiple chronic diseases and complicating factors which associated with immobility, tissue ischemia, and undernutrition are caused to PU in community settings, hospitals, and nursing facilities.

Systemic and Disease-Specific Risk Factors in Vascular Dementia: Diagnosis and Prevention.

In order to prevent the onset of vascular dementia (VaD) in aging individuals, it is critical to detect clinically relevant vascular and systemic pathophysiological changes to signal the onset of its preceding prodromal stages. Identifying behavioral and neurobiological markers that are highly sensitive to VaD classification vs. other dementias is likely to assist in developing novel preventive treatment strategies that could delay the onset of disruptive psychomotor symptoms, decrease hospitalizations, and increase the quality of life in clinically-high-risk aging individuals. In light of empirical diagnostic and clinical findings associated with VaD pathophysiology, the current investigation will suggest a few clinically-validated biomarker measures of prodromal VaD cognitive impairments that are correlated with vascular symptomology, and VaD endophenotypes in non-demented aging people. In prodromal VaD individuals, distinguishing VaD from other dementias (e.g., Alzheimer's disease) could facilitate specific early preventive interventions that significantly delay more severe cognitive deterioration or indirectly suppress the onset of dementia with vascular etiology. Importantly, the authors conclude that primary prevention strategies should examine aging individuals by employing comprehensive geriatric assessment approach, taking into account their medical history, and longitudinally noting their vascular, systemic, cognitive, behavioral, and clinical functional status. Secondary prevention strategies may include monitoring chronic medication as well as promoting programs that facilitate social interaction and every-day activities.

A Retrospective Study of the Impact of Pressure Ulcers on Survival in Elderly Persons With Chronic Diseases.

Medical advancements are extending the lives of persons with chronic diseases, increasing their risk for pressure ulcer (PU) development. A retrospective chart review of 192 patients (49.48% male, mean age 9.7 ± 10.9 years) admitted to a skilled nursing department between 2008 and 2013 was performed to determine whether PUs and comorbidities, singly and combined, affect patient survival. Characteristics abstracted and assessed included sociodemographic factors (age, gender), diseases/comorbidities (eg, chronic renal failure, dementia, Parkinson's disease [PD], ischemic heart disease, and diabetes mellitus), persistent vegetative state (PVS), type and quantity of PUs (excluding Stage I and PUs that developed during the study), body mass index (BMI) <22, and laboratory data (serum albumin, total protein level, and hemoglobin [Hg] <10). Results were expressed as proportion or mean ± standard deviation. All statistical tests were 2-sided. A P value <.05 was considered significant. Hazard ratios (HR) and statistical significance for survival by risk factors were calculated by the Cox proportional hazards model. Univariate survival models were fitted for all risk factors. Statistical and clinical considerations were used to choose a subset of significant factors to include in a multivariate survival model; all chosen factors were fitted at the first step of the univariate survival models. Age, gender, and BMI were included in the model due to their known clinical effects on survival and their influence on other prognostic factors. In assessing anemia and Hg, only anemia was included due to multicollinearity. From the chosen factors fitted at the first step, a backward elimination was used to successively remove nonsignificant factors until all factors were significant at the 0.10 level. Patients were followed from hospitalization date until death or censoring of study. Median survival time was 122 days (CI: 82-192 days). The median survival time of patients with PUs was 72 days. Every increase in the number of PUs increased mortality by 14% (P <.001, HR = 1.14, CI: 1.07-1.20). In univariate analysis, PUs, anemia, dementia, and PD were found to have a significant association with decreased survival (P = .0001, .003, .001, and .004, respectively). In multivariate analysis, significant risk factors for decreasing survival time were the presence of PUs (HR = 1.14, P = .0001) and dementia (HR = 1.585, P = .009). Anemia (HR = 1.345, P = .09) and PVS (HR = 0.51, P = .09) were determined not to be significant. Anemia was found to decrease survival time and PVS was found to increase survival time. When number of PUs was combined with anemia, advanced dementia, or BMI, the median survival decreased from 72 days to 52, 63, and 63 days, respectively. These findings suggest that PUs in this population are not an isolated health problem but are 1 indicator of systemic deterioration and decreased survival time. The significance of knowing the survival time of patients with PUs has clinical and ethical implications for the comprehensive treatment of elderly patients, particularly those with advanced dementia and other associated medical conditions.

Age-Related Diseases and Clinical and Public Health Implications for the 85 Years Old and Over Population.

By 2050, the American 85 years old and over population will triple. Clinicians and the public health community need to develop a culture of sensitivity to the needs of this population and its subgroups. Sensory changes, cognitive changes, and weakness may be subtle or may be severe in the heterogeneous population of people over age 85. Falls, cardiovascular disease, and difficulty with activities of daily living are common but not universal. This paper reviews relevant changes of normal aging, diseases, and syndromes common in people over age 85, cognitive and psychological changes, social and environmental changes, and then reviews common discussions which clinicians routinely have with these patients and their families. Some hearing and vision loss are a part of normal aging as is decline in immune function. Cardiovascular disease and osteoporosis and dementia are common chronic conditions at age 85. Osteoarthritis, diabetes, and related mobility disability will increase in prevalence as the population ages and becomes more overweight. These population changes have considerable public health importance. Caregiver support, services in the home, assistive technologies, and promotion of home exercise programs as well as consideration of transportation and housing policies are recommended. For clinicians, judicious prescribing and ordering of tests includes a consideration of life expectancy, lag time to benefit, and patient goals. Furthermore, healthy behaviors starting in early childhood can optimize quality of life among the oldest-old.

Dementia and Pressure Ulcers: Is There a Close Pathophysiological Interrelation?

The current theoretical investigation aimed to explore common pathophysiological mechanisms underlying dementia and pressure ulcers (PU). Along with the increased longevity, especially in frail elderly patients, there is a higher rate of functional and cognitive impairment with dementia coinciding with immobility, which results in a higher rate of PU. Understanding common etiological paths resulting in pressure ulcers and dementia is likely to produce new treatment strategies that could lead to the prevention of comorbid complications. Data collected from elderly dementia patients indicate a deterioration of several neurophysiological subsystems associated with motor, sensory, autonomic, cognitive, or behavioral pathways, supporting a "close pathophysiological interrelation" perspective linking PU with dementia progression. Overall, the authors' theoretical systemic-model of disease progression and PU comorbidity proposes that increased clinician awareness to PU in mild to moderate dementia may suppress the accelerated development of PU, resulting in less patient suffering, reduced long-term care hospitalization, and hopefully PU prevention.

The Effect of Pressure Ulcers on the Survival in Patients With Advanced Dementia and Comorbidities.

BACKGROUND/STUDY CONTEXT: The mortality rates for many leading causes of death have declined over the past decade. Advanced dementia with comorbidities has steadily increased to become one of the leading causes of death in the elderly population. Therefore, this study examined the effect of pressure ulcers on the survival time of patients with advanced dementia and comorbidities. METHODS: Data were reviewed from all the files of 147 patients hospitalized over a period of 3½ years. Ninety-nine tube-fed patients suffering from advanced dementia were assessed; 72 (66.5%) had pressure ulcers and 27 (33.5%) were without pressure ulcers at admission. Logistic regression analysis was used to estimate the odds ratio and 95% confidence intervals for pressure ulcers group versus non-pressure ulcers group. Unadjusted Cox model and Cox proportional hazards model were used to assess the hazard ratio for pressure ulcers and the association between pressure ulcers and survival time, respectively. Kaplan-Meier model was used to visually confirm the existence of proportional hazards of pressure ulcers on survival. RESULTS: The median survival of advanced dementia patients with pressure ulcers was significantly shorter, compared with those without pressure ulcers (96 vs. 863 days). Significant lower hemoglobin and serum albumin levels were found in the patients with pressure ulcers. CONCLUSION: Advance dementia and pressure ulcers in the same patient results in earlier mortality. Advanced dementia patients with pressure ulcers had significantly lower survival expectancy in comparison with similar patients without pressure ulcers. Clinical and ethical implications are discussed.

A comparative, descriptive study of systemic factors and survival in elderly patients with sacral pressure ulcers.

Sacral pressure ulcers (PUs) are a serious complication in frail elderly patients. Thin tissue in the sacral area, low body mass index, and anatomical location contribute to the development of sacral PUs. A comparative, descriptive study was conducted to identify patient systemic factors associated with sacral PUs and to compare survival time in patients with and without PU. All consecutive patients with PUs (n = 77) and without sacral PUs (n = 53) admitted to the skilled nursing department of a geriatric hospital in Jerusalem, Israel between July 1, 2008 and December 31, 2011 were eligible to participate. Charts of previously admitted patients were abstracted and patients were prospectively followed until discharge, death, or the end of the study. Patient demographics, comorbidities, nutritional status, physical and cognitive function (measured using the Reisberg's Functional Assessment Staging Tool [FAST], Stages of Dementia of Alzheimer Scale, and the Glasgow Coma Scale), PU status, number of courses of antibiotic treatment during admission, length of hospitalization, and mortality were compared between patients admitted with and without a sacral PU using descriptive and univariate statistics. Logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals (CI) for sacral PU versus without PU by study covariate. The association between sacral PU and survival time was assessed using Kaplan-Meier models. Patients with a sacral PU were significantly older (average age 81.60 ±10.78 versus 77.06±11.19 years old, P = 0.02) and had a higher prevalence of dementia (70% versus 30%, P = 0.007), Parkinson's disease (92.3% versus 7.7%, P = 0.03), and anemia (67.7% versus 32.3%, P = 0.06) than patients admitted without a PU. Patients with a sacral PU also had a lower body mass index (23.1 versus 25.4, P = 0.04), and lower hemoglobin (10.54 versus 11.11, P = 0.03), albumin (26.2 versus 29.7, P = 0.002), and total protein levels (61.3 versus 65.7, P = 0.04). In addition, antibiotic treatment was significantly higher in the patients with PU (50.6% versus 28.3%, P = 0.01). Patients with a sacral PU also had significantly lower physical and cognitive functioning scores and their median survival time was 70 days compared to 401 days in the non-PU group (P <0.001). These findings are generally consistent with the literature regarding risk factors for PU development and confirm the need for preventive measures. In addition, clinicians need to address the overall goal of patient care and patient quality of life when considering PU management interventions in this patient population.

Systemic factors and mortality in elderly patients with pressure ulcers.

The aim of this article was to identify specific systemic factors associated with existence of pressure ulcers (PUs) and the effect on survival from the time of admission. Patients admitted to the Skilled Nursing Department of the Herzog Hospital, Jerusalem, between 1 July 2008 and 31 December 2011. Of the 174 admitted patients (mean age: 77·4 ± 13·2 years), 107 (61·5%) had pre-existing PUs and 67 (38·5%) did not have PUs. Major systemic factors were assessed for each patient at the time of admission: sociodemographic characteristics, comorbidities, use of urinary catheter, tube feeding and tracheostomy; nutritional state; Global Deterioration Scale, Glasgow Coma Scale and Norton Scale. Complications such as the number of provided antibiotic courses, and length and outcomes of hospitalisation were identified at the end of the study. In the univariate analysis, patients in the PU group had significantly prevalent characteristics including advanced age, low cognitive and consciousness function, low Norton scale, Parkinson's disease and anaemia due to chronic diseases, low nutritional parameters and higher number of antibiotics provided. Conditions that were associated with PUs in multiple regression analyses included advanced dementia (OR = 3·0, 95% CI: 1·4-6·3; P = 0·002), urinary catheter usage (OR = 2·25, 95% CI: 1·06-4·7; P = 0·03), low body mass index, BMI (OR = 0·92, 95% CI: 0·86-0·99; P = 0·02) and anaemia level (OR = 0·7, 95% CI: 0·58-0·9; P = 0·004). The median survival time of patients with PUs was significantly lower than the non PUs group (94 versus 414 days, respectively) (P = 0·005, log rank test). Length of stay was also significantly lower in the PU group (166 versus 270 days, P = 0·02). The existence of PUs may indicate a final common pathway of various systemic factors (geriatric conditions, diseases and frailty dysfunction).

Cohort study of atypical pressure ulcers development.

Atypical pressure ulcers (APU) are distinguished from common pressure ulcers (PU) with both unusual location and different aetiology. The occurrence and attempts to characterise APU remain unrecognised. The purpose of this cohort study was to analyse the occurrence of atypical location and the circumstances of the causation, and draw attention to the prevention and treatment by a multidisciplinary team. The cohort study spanned three and a half years totalling 174 patients. The unit incorporates two weekly combined staff meetings. One concentrates on wound assessment with treatment decisions made by the physician and nurse, and the other, a multidisciplinary team reviewing all patients and coordinating treatment. The main finding of this study identified APU occurrence rate of 21% within acquired PU over a three and a half year period. Severe spasticity constituted the largest group in this study and the most difficult to cure wounds, located in medial aspects of knees, elbows and palms. Medical devices caused the second largest occurrence of atypical wounds, located in the nape of the neck, penis and nostrils. Bony deformities were the third recognisable atypical wound group located in shoulder blades and upper spine. These three categories are definable and time observable. APU are important to be recognisable, and can be healed as well as being prevented. The prominent role of the multidisciplinary team is primary in identification, prevention and treatment.

Spiritual background and its association with the medical decision of, DNR at terminal life stages.

In recent years personal and clinical dilemmas relating to terminally ill patient-care medical, decisions have increased significantly. Although understanding the patient's medical, nursing and, social background is important, a comprehensive appraisal essential for treating the "whole patient" is, incomplete without a spirituality assessment. Religious beliefs and practices affect medical and health, care decisions and require recognition as a dynamic in coping with suffering, loss, life, and death. Taking a spiritual background obtains information that is meaningful to the patient's life and may, influence the medical decision-making relating to health. A study was undertaken to determine, whether assessing the spiritual background influences medical decisions-making regarding the use of, DNR. The target population was 46 family-member caregivers of non-communicative patients in the Herzog, Hospital Skilled Nursing ward located in Jerusalem. The spiritual assessment questionnaire was the, acronym FICA (faith, importance, community and addressing). Two-thirds of the families were opposed to a determination utilizing do not resuscitate (DNR). Multivariate, analysis of the findings found that only religious affiliation was statistically significant (p=0.003). The doctors recommend DNR in 67% of the cases while the family caregiver accepted this decision in, only 33% of the cases. The hypothesis was verified. People who are perceived as being religious or as being greatly influenced, by faith/spirituality opposed the recommendation implementing DNR. Obtaining a spiritual background assists the physician to understand the patient or family spirituality, facilitates sensitivity to value frameworks and preferences in making medical and health-related, decisions.