Hospice approach to the treatment of patients with advanced dementia of the Alzheimer type

Abstract

A program that limits the extent of medical treatment in patients with advanced dementia of the Alzheimer type was initiated on an intermediate medical ward. Five levels of care were designed to define options that stress maintenance of patient comfort without striving for a maximal period of survival (hospice approach). An optimal care level for each patient recommended by the staff correlated highly with the severity of dementia, but care levels assigned during meetings of family members with the multidisciplinary team for 40 patients correlated poorly with the staff recommendations and the severity of dementia. Intensive nursing care and comfort measures, which included antipyretics, analgesics, and (if necessary) oxygen and anticholinergics, were provided during the terminal phase. Preliminary results indicate that the mortality did not increase significantly during the first year of this program, although the extent of medical care was limited in all patients, and 62% were not treated with antibiotics if they developed symptoms of pneumonia or urinary tract infection.

KIE: The authors describe the implementation of a program that provides a decision making mechanism for limiting treatment of patients with advanced Alzheimer's disease. The nursing staff and attending physician propose a treatment plan, which is approved or revised at a multidisciplinary team conference with family members. Each decision about patient care is reviewed monthly. During the first year of the program's operation, 40 patients were assigned to treatment options that ranged from withholding resuscitation to withholding non-oral feeding and hydration. Assignment of care levels did not correlate well with the severity of dementia or with staff recommendations. The authors discuss staff reaction, team-family interactions, and the rationale for the various treatments provided. Their preliminary findings indicate that the hospice approach did not significantly increase mortality.