Volume 70 Number 2 March 2003	back to contents

¹Mount Sinai School of Medicine, ²The Jewish Home and Hospital, and ³Henry L. Schwartz Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, NY.

This research was supported in part by an American Federation for Aging Research/John A. Hartford Foundation Fellowship, and was conducted at the Jewish Home and Hospital, New York, NY. The results were presented in part at the 12th Annual Meeting of the American Public Health Association in New York, NY, on November 19, 1996 and the Annual Meeting of the American Geriatrics Society in Atlanta, Georgia, on May 10, 1997. The manuscript has been updated as of July 17, 2002.

Address all correspondence to Dr. Paris, Division of Geriatrics, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219.

ABSTRACT

BACKGROUND: The use of advance directives is based on the consensus that physicians should respect preferences expressed by competent patients about future treatments. Patient preferences are, however, subject to change and may be influenced by a number of factors. The purpose of our study was to evaluate the durability over time of decisions made regarding terminal care of mentally intact nursing home patients and the influence of such factors as intervening illness, loss of significant others, and cognitive, emotional and functional decline.

METHODS: We undertook a longitudinal prospective cohort study in which 65 mentally competent nursing home patients were interviewed at three intervals (at baseline and after one and two years). For each patient, demographic, medical and socioeconomic data were collected and assessment of mood, function, cognition and preference for life-sustaining therapies (including cardiopulmonary resuscitation and parenteral and enteral nutrition) was obtained.

RESULTS: Preferences regarding cardiopulmonary resuscitation and parenteral and enteral nutrition changed over both the 12- and 24-month study periods. Only degree of change in cognitive status proved to be predictive of changes in decision. Gender, presence or absence of depression, change in level of functional abilities and intercurrent illness or stressor did not influence change regarding life-sustaining therapy.

CONCLUSIONS: In light of our findings, we suggest that periodic re-evaluation of these advance directives be performed and that ongoing discussions be initiated with their patients by health care professionals.

KEYWORDS

Advance directives, life-sustaining treatment, stability of decisions.

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