Stability of preferences regarding life-sustaining treatment: a two-year prospective study of nursing home residents.

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.