Preferences versus practice: life-sustaining treatments in last months of life in long-term care

Abstract

Purpose: To determine prevalence and correlates of decisions made about specific life-sustaining treatments (LSTs) among residents in long-term care (LTC) settings, including characteristics associated with having an LST performed when the resident reportedly did not desire the LST.

Design and participants: After-death interviews with 1 family caregiver and 1 staff caregiver for each of 327 LTC residents who died in the facility.

Setting: The setting included 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in 4 states.

Measurements: Decedent demographics, facility characteristics, prevalence of decisions made about specific LSTs, percentage of time LSTs were performed when reportedly not desired, and characteristics associated with that.

Results: Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in 5 of 7 (71.4%) resuscitations, 1 of 7 feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, P=.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared with 32.8% of those whose decisions were concordant (P=.034).

Conclusion: Most respondents reported decision making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded.

Figure 1

Prior decision status of residents who received a life-sustaining treatment