Life-sustaining Procedures Research Articles

Enabling Advance Directive Completion: Feasibility of a New Nurse-Supported Advance Care Planning Intervention.

Adults who complete an advance directive (AD) are not consistently offered information about the risks, benefits, or alternatives (RBA) of the life-sustaining medical procedures addressed on standardized forms. The current article describes a new patient-centered nurse-supported advance care planning (NSACP) intervention focused on providing information about RBA of life-sustaining procedures. Fifty participants (mean age = 50.26 years) at a Veterans Affairs medical center were randomized to the NSACP intervention or a comparison condition. Before randomization, 78% (n = 39) expressed interest in RBA information. Of participants in the NSACP group, 94% (n = 30) completed an AD. Participants who received NSACP made more decisions to decline life-sustaining treatment than those who were randomized to the comparison group. Promising feasibility data include brevity (mean = 46 minutes), high patient satisfaction, participant retention, and treatment fidelity. The NSACP holds promise as a brief, educational intervention to support patients in completing an AD. [Journal of Gerontological Nursing, 44(7), 31-42.].

Life-Sustaining Procedures, Palliative Care Consultation, and Do-Not Resuscitate Status in Dying Patients With COPD in US Hospitals: 2010-2014.

Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population. A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status. Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and -9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001). Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.

Abstract TMP90: Trends in Tracheostomy after Stroke: Analysis of the 1993-2013 Nationwide Inpatient Sample

Background: Tracheostomy is a potentially life-sustaining procedure for patients with severe stroke, yet trends in its use are not well known. Methods: Patients presenting with ischemic stroke (IS), intracerebral hemorrhage (ICH), or subarachnoid hemorrhage (SAH) were identified from the 1993 to 2013 Nationwide Inpatient Sample using previously validated ICD-9-CM codes. Our outcome was tracheostomy, also defined using previously validated procedure codes. Survey weights and descriptive statistics with exact confidence intervals [CI] were used to report rates of tracheostomy, stratified by stroke type. In a secondary analysis, we used multivariate logistic regression to assess rates of tracheostomy stratified by age, race, and sex. Results: From 1993-2013, 13,729,365 patients (95% CI, 13,103,569-14,355,160) were hospitalized in the U.S. with IS, ICH, or SAH. Among these patients, 230,555 (1.7%; 95% CI, 1.6-1.8%) received a tracheostomy. The mean age of patients undergoing tracheostomy was 58.9 (±19.8) years. Rates of tracheostomy use were 1.1% (95% CI, 1.0-1.5%) after IS, 3.8% (95% CI, 3.6-4.0%) after ICH, and 6.2% (95% CI, 5.8-6.6%) after SAH. Tracheostomy was more common in men (OR, 1.32; 95% CI, 1.30-1.35), non-whites (OR, 2.04; 95% CI, 2.00-2.09), and those ≤60 years of age (OR, 2.33; 95% CI, 2.30-2.37). The overall rate of tracheostomy use after any type of stroke increased from 1.2% in 1993 to 2.0% in 2013 (p &lt;0.001). This trend was more pronounced in patients with ICH and SAH than in patients with IS (Figure 1). Tracheostomy use increased annually by 0.9% (p &lt;0.001) among patients ≤60 years of age versus 1.7% (p &lt;0.001) among patients &gt;60 years of age, and by 2.7% (p &lt;0.001) among men versus 0.02% (p &lt;0.05) among women. Conclusion: Over the past two decades, the use of tracheostomy appears to be increasing among patients admitted with stroke.

The Use of Life-Sustaining Procedures in the Last Month of Life Is Associated With More Depressive Symptoms in Surviving Spouses

ContextFamily caregivers of individuals with serious illness who undergo intensive life-sustaining medical procedures at the end of life may be at risk of negative consequences including depression. ObjectivesThe objective of this study was to determine the association between patients' use of life-sustaining procedures at the end of life and depressive symptoms in their surviving spouses. MethodsWe used data from the Health and Retirement Study, a longitudinal survey of U.S. residents, linked to Medicare claims data. We included married Medicare beneficiaries aged 65 years and older who died between 2000 and 2011 (n = 1258) and their surviving spouses. The use of life-sustaining procedures (i.e., intubation/mechanical ventilation, tracheostomy, gastrostomy tube insertion, enteral/parenteral nutrition, and cardiopulmonary resuscitation) in the last month of life was measured via claims data. Using propensity score matching, we compared change in depressive symptoms of surviving spouses. ResultsEighteen percent of decedents underwent one or more life-sustaining procedures in the last month of life. Those whose spouses underwent life-sustaining procedures had a 0.32-point increase in depressive symptoms after death (scale range = 0–8) and a greater likelihood of clinically significant depression (odds ratio = 1.51) compared with a matched sample of spouses of those who did not have procedures (P < 0.05). ConclusionSurviving spouses of those who undergo intensive life-sustaining procedures at the end of life experience a greater magnitude of increase in depressive symptoms than those whose spouses do not undergo such procedures. Further study of the circumstances and decision making surrounding these procedures is needed to understand their relationship with survivors' negative mental health consequences and how best to provide appropriate support.

Patient Mortality Is Associated With Staff Resources and Workload in the ICU: A Multicenter Observational Study.

Matching healthcare staff resources to patient needs in the ICU is a key factor for quality of care. We aimed to assess the impact of the staffing-to-patient ratio and workload on ICU mortality. We performed a multicenter longitudinal study using routinely collected hospital data. Information pertaining to every patient in eight ICUs from four university hospitals from January to December 2013 was analyzed. A total of 5,718 inpatient stays were included. None. We used a shift-by-shift varying measure of the patient-to-caregiver ratio in combination with workload to establish their relationships with ICU mortality over time, excluding patients with decision to forego life-sustaining therapy. Using a multilevel Poisson regression, we quantified ICU mortality-relative risk, adjusted for patient turnover, severity, and staffing levels. The risk of death was increased by 3.5 (95% CI, 1.3-9.1) when the patient-to-nurse ratio was greater than 2.5, and it was increased by 2.0 (95% CI, 1.3-3.2) when the patient-to-physician ratio exceeded 14. The highest ratios occurred more frequently during the weekend for nurse staffing and during the night for physicians (p < 0.001). High patient turnover (adjusted relative risk, 5.6 [2.0-15.0]) and the volume of life-sustaining procedures performed by staff (adjusted relative risk, 5.9 [4.3-7.9]) were also associated with increased mortality. This study proposes evidence-based thresholds for patient-to-caregiver ratios, above which patient safety may be endangered in the ICU. Real-time monitoring of staffing levels and workload is feasible for adjusting caregivers' resources to patients' needs.

Outcomes in severe middle cerebral artery ischemic stroke.

Severe middle cerebral artery stroke (MCA) is associated with a high rate of morbidity and mortality. We assessed the hypothesis that patient-specific variables may be associated with outcomes. We also sought to describe under-recognized patient-centered outcomes. A consecutive, multi-institution, retrospective cohort of adult patients (≤70 years) was established from 2009 to 2011. We included patients with NIHSS score ≥15 and infarct volume ≥60 mL measured within 48 h of symptom onset. Malignant edema was defined as the development of midline brain shift of ≥5 mm in the first 5 days. Exclusion criterion was enrollment in any experimental trial. A univariate and multivariate logistic regression analysis was performed to model and predict the factors related to outcomes. 46 patients (29 female, 17 male; mean age 57.3 ± 1.5 years) met study criteria. The mortality rate was 28% (n = 13). In a multivariate analysis, only concurrent anterior cerebral artery (ACA) involvement was associated with mortality (OR 9.78, 95% CI 1.15, 82.8, p = 0.04). In the malignant edema subgroup (n = 23, 58%), 4 died (17%), 7 underwent decompressive craniectomy (30%), 7 underwent tracheostomy (30%), and 15 underwent gastrostomy (65%). Adverse outcomes after severe stroke are common. Concurrent ACA involvement predicts mortality in severe MCA stroke. It is useful to understand the incidence of life-sustaining procedures, such as tracheostomy and gastrostomy, as well as factors that contribute to their necessity.

Refusal of life-sustaining treatment

Figure: Q: My patient has refused a life-sustaining procedure. What should I do?A: One of the greatest ethical dilemmas a nurse can encounter is when a patient refuses life-sustaining treatment—any procedure, medication, intervention, or use of medical technology that can postpone death. As healthcare providers, we're instilled with the primary objective to save lives. However, when treatment options are aimed at prolonging the patient's life, and no acceptable curative treatment option is available, patients may opt to cease medical treatment. Even when curative options are available, patients may not be willing to undergo the physical trauma, time involved, or associated emotional distress. As patient advocates, we're torn between the need to save the patient's life and ensuring that his or her psychosocial needs are met and decisions honored. Common examples of life-sustaining treatment include dialysis, mechanical ventilation, CPR, tube feeding, parenteral nutrition, I.V. fluids, antibiotics, chemotherapy, blood transfusions, extensive burn debridement, painful surgical interventions, and organ transplantation. Patients who've been deemed competent to make healthcare decisions can refuse to seek or accept a specific treatment, or all medical treatment, from healthcare practitioners. The term competent means the patient understands that refusing to accept treatment will result in eventual death. Some patients may elect to refuse specific medical treatments, such as blood transfusions, because of religious beliefs, but will accept synthetic blood plasma expanders that aren't made of donor blood. When a patient refuses initial life-sustaining treatment, respectfully explore the underlying reason for the refusal. This allows the healthcare team to identify alternative options that may be equally medically effective and also acceptable to the patient. In the end, the patient has the right to accept or refuse life-sustaining medical treatment. After a competent patient chooses to forego a life-sustaining treatment or procedure, the healthcare team is faced with only one option: We must support the wishes of the patient that will ultimately result in his or her death. Forcing treatment on a patient without his or her informed consent is illegal. Ensure that the risks and benefits of all treatment options are discussed with the patient so that he or she can make an informed decision that reflects his or her values and beliefs. In acute care settings, the decision to remove or withhold life-sustaining treatment can be very traumatic for families. It's imperative that the healthcare team conveys information to the patient and family as soon as a prognosis is known. This allows the patient and family to develop realistic expectations. After the decision has been made to refuse life-sustaining treatment, ensure the patient and family have access to ancillary services that can make their transition easier. Providing care for patients who refuse life-sustaining treatment can cause you to experience many different emotions. If you feel uncomfortable withholding artificial food, fluids, or medications, consult with your management team to see if a temporary alternative assignment can be arranged. Often, just discussing your concerns may help you understand the patient's decision. Medical technology can potentially allow the prolonging of a patient's life. However, these treatments carry risks and may also cause the patient physical, spiritual, or emotional pain. Many patients state that they would prefer their remaining life to be filled with family, friends, and enjoyable activities. Be consciously aware not to impose your values or beliefs onto your patient who refuses life-sustaining treatment. Allow the patient to make the end-of-life care choices that reflect his or her values and beliefs so that quality of life can be optimized. As nurses, our goal is not only to promote our patients' health, but also enhance the remaining time that our critically and terminally ill patients have with their family and loved ones. BONUS BLOG Want to know more about this topic? Check out our blog at www.NursingMadeIncrediblyEasy.com.

The Role of the Speech-Language Pathologist in the Schools for the Treatment of Voice Disorders: Working within the Framework of the Individuals with Disabilities Education Improvement Act

The role of the speech-language pathologist (SLP) has developed considerably over the past 20 years given the medical and technological advances in life-sustaining procedures. Children born with congenital, surgical, or "medically fragile" conditions become mainstreamed into regular school-based settings, thus extending the traditional role of the treating SLP and multidisciplinary team. Understanding the impact of associated voice disorders on educational performance requires dissemination of additional and important information, as eligibility decisions for students in school-based settings must be made within the framework of the federal legislation and regulations governing the provision of services for students with disabilities. This article discusses how to identify children with voice disorders under the Individuals with Disabilities Education Improvement Act (IDEA), the role of the SLP in various triaging scenarios, and how models of voice therapy can be integrated in a school-based setting.

Abstract 32: Variation in Discharge Practices and Use of Life-Sustaining Procedures: Potential Pitfalls for Adjusted Mortality Quality Measures

Introduction: The Center for Medicare and Medicaid Services (CMS) is developing a risk-standardized stroke mortality measure intended for public comparison of hospital-level quality of care. We sought to determine the impact of discharge practices and use of life sustaining procedures on risk-standardized mortality. We could then address questions such as, how much does mortality differ between hospitals that routinely discharge patients to hospice and those that don’t? Methods: We estimated risk standardized stroke inpatient mortality for all hospitals in the Nationwide Inpatient Sample (NIS) from 2008-9, using hierarchical logistic regression following a similar approach used for existing CMS mortality measures. Hospital-level adjusted stoke mortality was then categorized as below average, average or above average using standardized Hospital Compare methodology. We then developed individual and hospital level variables to characterize hospital-level practices of interest: discharge to long term acute care (LTAC), discharge to hospice and a life-sustaining procedure index which combined the rates of gastrostomy, tracheostomy, hemicraniectomy and ventriculostomy. These variables were added to the base model in a second hierarchical logistic regression model. This model was used to compare differences in risk-standardized mortality from hospitals grouped in the highest and lowest practice quintiles and to estimate the effects of the hospital practices on grades. Results: A total of 186,689 stroke patients were identified. Median age was 72 (IQR 60-82) and 52% were female. Seventy six percent of strokes were ischemic, 19% were ICH and 5% were SAH. Of the 1,366 hospitals in the sample 1,210 received average, 73 below average and 83 above average grades for stroke mortality using the base model. Hospitals that more commonly discharged patients to hospice or LTAC or used more life-sustaining procedures had lower mortality. Mean risk standardized mortality was higher in the lowest quintile of hospice utilizing hospitals compared to the highest (11.4% vs. 10.0%, p &lt; 0.01) and in the lowest quintile of LTAC utilizing hospitals compared to the highest (11.4% vs. 10.3%, p = 0.02). Similarly, mean risk standardized mortality was higher in the lowest quintile of hospital use of life-sustaining procedures compared to the highest (11.3% vs. 10.7%, p &lt; 0.01). Accounting for changes in hospital-level practices resulted in significant hospital grade reassignment. Of the 73 initial below average grades, 19 (26%)were reclassified to average and of the 83 initial above average grades, 35 (42%) were reclassified to average. Overall, 6% were reclassified. Conclusions: Variation in discharge practices and use of life-sustaining procedures alters hospital mortality rankings and distorts perceptions of comparative hospital quality. ns of comparative hospital quality.

The Need for Safeguards in Advance Care Planning

The recent uproar about Medicare "death panels" draws attention to public and professional concerns that advance care planning might restrict access to desired life-sustaining care. The primary goal of advance care planning is to promote the autonomy of a decisionally incapacitated patient when choices about life-sustaining treatments are encountered, but the safety of this procedure has not received deserved scrutiny. Patients often do not understand their decisions or they may change their mind without changing their advance care directives. Likewise, concordance between patients' wishes and the understanding of the physicians and surrogate decision makers who need to represent these wishes is disappointingly poor. A few recent reports show encouraging outcomes from advance care planning, but most studies indicate that the procedure is ineffective in protecting patients from unwanted treatments and may even undermine autonomy by leading to choices that do not reflect patient values, goals, and preferences. Safeguards for advance care planning should be put in place, such as encouraging physicians to err on the side of preserving life when advance care directives are unclear, requiring a trained advisor to review non-emergent patient choices to limit life-sustaining treatment, training of clinicians in conducting such conversations, and structured discussion formats that first address values and goals rather than particular life-sustaining procedures. Key targets for research include: how to improve completion rates for person wanting advance care directives, especially among minorities; more effective and standardized approaches to advance care planning discussions, including how best to present prognostic information to patients; methods for training clinicians and others to assist patients in this process; and systems for assuring that directives are available and up-to-date.

Acute Care and Long-term Mortality among Elderly Patients with Intracerebral Hemorrhage who Undergo Chronic Life-Sustaining Procedures

Little is known about patients with intracerebral hemorrhage (ICH) who undergo chronic life-sustaining procedures. We sought to explore variations in treatment, Medicare payments, and mortality among elderly patients with ICH who received a feeding tube, a tracheostomy, or neither chronic life-sustaining procedure. Medicare Provider Analysis and Review files from 2004 linked to Center for Medicaid and Medicare Services denominator files through January 2005 were analyzed. Patients over age 65 years with a primary diagnosis of ICH based on discharge code (ICD-9-CM 431) were divided into those who underwent tracheostomy, those who underwent feeding tube placement but not tracheostomy, and those who underwent neither procedure. Thirty-day and 1-year survival rates were estimated using Kaplan-Meier methods. Among the 32,210 patients studied, 6% underwent feeding tube placement, and 2.5% underwent tracheostomy. Compared with the patients who did not undergo a chronic life-sustaining procedure, those who underwent tracheostomy had a longer length of stay (median, 25 days vs 4 days; P < .01) and greater Medicare spending (median, $81,479 vs $6,008; P < .01) during their initial hospitalization. The 30-day and 1-year cumulative mortality risks were 47% and 59%, respectively, in patients who did not undergo a chronic life-sustaining procedure, 21% and 53% in patients who underwent feeding tube placement, and 19% and 65% in those who underwent tracheostomy (P < .01, log-rank test across the 3 groups). Our findings show high 1-year mortality among elderly patients with ICH, even in those who undergo chronic life-sustaining procedures. Medicare payments for patients who undergo tracheostomy are substantial. More information about functional outcomes is needed.

A Critique of the National POLST Paradigm through an Analysis of Colorado's New MOST Legislation.

Colorado recently legalized a new document for use in end-of-life care called a Medical Orders for Scope of Treatment (MOST) form. The legislation exempts from liability to homicide laws caregivers who execute MOST orders for the withdrawing or withholding of life-sustaining procedures. But it drops the requirement that patients be terminally ill before they are free to refuse those procedures. It permits anyone to refuse any medical treatment for any reason; and holds health-care institutions, practitioners, and surrogate decision makers free from liability when they carry out the orders. This essay criticizes the new law together with the view of autonomy implicit within it. The essay proposes six reasons grounded in the requisites of justice and the common good why the new law should be opposed. It recommends that Catholic hospitals refuse to accept MOST-type documents.

Health Care Costs in the Last Week of Life

Life-sustaining medical care of patients with advanced cancer at the end of life (EOL) is costly. Patient-physician discussions about EOL wishes are associated with lower rates of intensive interventions. Funded by the National Institute of Mental Health and the National Cancer Institute, Coping With Cancer is a longitudinal multi-institutional study of 627 patients with advanced cancer. Patients were interviewed at baseline and were followed up through death. Costs for intensive care unit and hospital stays, hospice care, and life-sustaining procedures (eg, mechanical ventilator use and resuscitation) received in the last week of life were aggregated. Generalized linear models were applied to test for cost differences in EOL care. Propensity score matching was used to reduce selection biases. Of 603 participants, 188 (31.2%) reported EOL discussions at baseline. After propensity score matching, the remaining 415 patients did not differ in sociodemographic characteristics, recruitment sites, illness acknowledgment, or treatment preferences. Further analyses, adjusted by quintiles of propensity scores and significant confounders, revealed that the mean (SE) aggregate costs of care (in 2008 US dollars) were $1876 ($177) for patients who reported EOL discussions compared with $2917 ($285) for patients who did not, a cost difference of $1041 (35.7% lower among patients who reported EOL discussions) (P =.002). Patients with higher costs had worse quality of death in their final week (Pearson production moment correlation partial r = -0.17, P =.006). Patients with advanced cancer who reported having EOL conversations with physicians had significantly lower health care costs in their final week of life. Higher costs were associated with worse quality of death.

Suicide and attempted suicide in the elderly. Should the physician give support to patient's wish to die?

Suicide is a major cause of death of older people. The most reason cited by older adults who consider suicide is loneliness. Feeling alone, worthless, helpless and hopeless are symptoms of depression which carries a high risk for suicide. The suicide risk in the elderly depends on the societies, communities and religious beliefs.On the other hand the patients who believe that their quality of life would be disturbed by the continued treatment, have the right to ask to stop the treatment. The further extention of this issue involves the wish to die and physician-assisted suicide. The physician-assisted suicide raises several ethical questions beside the conflicting roles of physicians in preseving life versus ending suffering. In the Hippocratic oath, physicians swear not to precribe a deadly drug or give advise to a patient that may cause death. Or, nowadays euthanasia and physician-assisted suicide have become sources of continuing controversy and are likely to be so far forseeable future.Once a physician swears to keep the patient alive, is it ethical when he / she administers a lethal dose of medication or another agent to a hopelessly ill or injured patient?The achivement of modern medicine in terms off technology and treatment, enable physicians to prolong life and to delay that even the presence of severly debilitating conditions. However, benefical medicine technology may be harmful when used as a life-sustaining measure, in terminally ill patients. Elderly people themselves often fear and believe a zealous aplication of that kind of life-sustaining procedures will just prolong their suffering.What the physician should do? To undertake the treatment and the life-support systems or follow the “do not resuscitate” order?

Treating Voice Disorders in the School-Based Setting

The role of the speech-language pathologist (SLP) has developed considerably over the last 10 years given the medical and technological advances in lifesustaining procedures. Over time, children born with congenital, surgical, or "medically fragile" conditions hav become mainstreamed into regular school-based settings, thus extending the traditional role of the SLP and multidisciplinary team. Understanding the impact of these voice disorders on the child's educational performance has been a struggle for many clinicians because the eligibility decisions for students in school-based settings must be made within the framework of federal legislation and regulations governing the provision of services for students with disabilities. This article discusses how to identify children with voice disorders under the Individuals With Disabilities Education Act (IDEA) definition, the role of the SLP in assigning priority in various voice management scenarios, and how models of therapy can be incorporated in the school-based setting.

In the interest of patients: an evidence-based assessment of the safety of vinyl infusion care devices.

Decisions in virtually every sector of modern healthcare are increasingly guided by the doctrine of evidence-based medicine. This includes the choice of materials and medical devices used in life-sustaining procedures such as infusion therapy. Environmental activists contend that devices made from plasticized vinyl, which are ubiquitous in healthcare settings, constitute a health risk to patients and should be deselected for these and other procedures. An evidence-based assessment refutes these allegations and makes clear that for most applications, vinyl remains superior to alternative materials in terms of safety and performance.

Older persons' opinions about life-sustaining procedures in the face of dementia.

To investigate the attitudes of cognitively normal older adults toward various life-sustaining procedures in the face of dementia. Participants were 84 cognitively normal men and women (70% response rate), 65 years and older, from a variety of urban and suburban settings, including private homes, assisted-living apartments, transitional care facilities, and nursing homes. In-person interviews were conducted with each participant to obtain information about demographic characteristics, life and health, and desire for various life-sustaining procedures for 4 hypothesized levels of dementia. Approximately three fourths of participants said they would not want cardiopulmonary resuscitation, use of a respirator, or parenteral or enteral tube nutrition with the milder forms of dementia, and 95% or more of participants would not want these procedures with severe dementia. In addition, only one third or fewer participants thought they would want to be hospitalized or given antibiotics if they were severely demented. Logistic regression analysis showed a relationship between participants' desire for life-sustaining procedures and having less education, greater independence, and a higher perceived quality of life. Most surveyed individuals did not desire life-sustaining treatments with any degree of dementia, and the proportion of individuals not desiring such treatments increased with the projected severity of dementia. These findings indicate a need for including dementia in advance directives planning.

Attitudes toward life-sustaining treatment of older persons in Hong Kong.

There have been few studies of the attitudes of older Asians toward life-sustaining therapy. This paper presents the knowledge of and attitudes toward cardiopulmonary resuscitation (CPR) and life support in a group of subjects in Hong Kong. Cross-sectional, descriptive study. Of the 543 subjects, 382 were old-age home residents and 161 were in-patients of geriatric wards. Sociodemographic data, functional ability (using the Barthel Index), self-perceived health scale, knowledge of life-sustaining procedures, and subjects' preferences for such treatments were studied. They were also asked to give the most important reason for wanting or declining CPR, and to indicate who they believe should be the decision-maker(s) regarding whether they should receive life-sustaining treatment. Approximately 80% of old-age home residents and 60% of hospitalized patients had no knowledge of life-sustaining therapy. The success rate of CPR was overestimated by older subjects, and most wished to be resuscitated. However, up to 20% changed their minds and declined CPR after they knew the true outcome of the procedure. Half of the subjects wanted life support. Univariate analysis found that advanced age and not having a spouse were associated significantly with CPR preference, whereas subjects' knowledge was associated with preference for life support. Multivariate analysis revealed that advanced age, not having a spouse, and female sex were independently associated with a tendency to decline CPR. A considerable proportion of older people wished to be involved in decision-making regarding life-sustaining treatment. Knowledge of life-sustaining procedures was poor among older people in Hong Kong compared with their counterparts in western countries. Although most older subjects wanted CPR, a number of them changed their minds after they knew the poor outcome. Therefore, older patients should be given more information about life-sustaining therapy and encouraged to take part in their treatment plans.

Washington State Initiative 119: the first public vote on legalizing physician-assisted death.

In the fall of 1991, voters in Washington state were asked to consider a public initiative that sought to legalize physician-assisted death: Initiative 119. Drafted by Washington Citizens for Death with Dignity, the initiative was intended to amend the existing state natural death act in several ways:1) expand the definition of “terminal condition” to include patients in irrevers ible coma or persistent vegetative state;2) specifically name “artificial nutrition and hydration” as life-sustaining medical procedures that could be refused or withdrawn;3) legally allow mentally competent patients with certifiably terminal conditions to request and receive “aid-in-dying” from their physician as a medical service.The first two proposed amendments were widely acknowledged as timely and appropriate; a coalition of medical, religious, and community organizations had been actively working on such additions for several years. It was the proposal to legalize “aid-in-dying,” however, that represented a radical shift in the conduct of physicians towards their patients and a dramatic shift in social policy.

Limiting Specific Interventions in Advance Directives

To the Editor. —Dr Brett's arguments against specifying unwanted interventions in health care directives 1 are exceptionally thoughtful and deserve serious attention. But, there are strong reasons for specification that also should be considered. Physicians do not always feel able to honor patient wishes that are expressed only generally. Physicians who respect patient preferences can still get stuck— on uncertainty about just what a patient wants, or on what the law allows, or on opposition from other clinicians or the family. Specifying preferences can help resolve such problems. Directives involve families, as well as physicians and patients. Physicians often seek family approval to withhold or withdraw life-sustaining procedures, even when patient wishes are known, and often will not honor patient choices if any family member objects. An im