Limiting treatment in nursing homes: knowledge and attitudes of nursing home medical directors.

OBJECTIVE

To determine nursing home medical directors' knowledge about cardiopulmonary resuscitation outcome and their support of treatment limitation requests and policies.

DESIGN

Mailed questionnaire, followed by telephone interview.

PARTICIPANTS

Forty-six medical directors of 70 community nursing homes in Harris County, Texas.

MEASUREMENTS

Medical directors were asked to estimate the CPR survival rate to discharge of all nursing home residents and that of two case scenarios. They were asked to indicate on a Likert scale their support for mandatory Do-Not-Resuscitate orders and for requests by nursing home patients to withhold other life support measures.

RESULTS

Responses were received from 33 directors. Overall CPR survival rate of older nursing home residents after cardiac arrest was thought to be 10.7%. The average CPR survival rate for healthy older people with witnessed arrests was believed to be 13.8%. The perceived rate for unwitnessed arrests in terminal patients was 4.6%, significantly lower than estimates for healthy older people (P = .003) and estimates of the overall survival rate (P = .02). Medical directors were split regarding mandatory Do-Not-Resuscitate orders for patients in vegetative states, with terminal illness, with an unwitnessed arrest, or in those older than 90 years of age. Mandatory use of Do-Not-Resuscitate orders for all nursing home residents was strongly opposed. Assuming a 2% survival rate did not significantly influence medical directors' opinions about mandatory DNR orders in these groups. Medical directors were more willing to support requests by stable nursing home residents to withhold resuscitation, mechanical ventilation, or hospitalization than requests to withhold antibiotics, intravenous fluids, or tube feedings (P < .005). The majority of medical directors were willing to withhold all such measures for terminal patients.

CONCLUSIONS

Health care professionals who are responsible for educating patients about the efficacy of cardiopulmonary resuscitation in nursing homes overestimate its benefit and may benefit from further education about its outcome. Although mandatory Do-Not-Resuscitate orders were favored for terminal or vegetative patients, medical directors are not supportive of such orders across the board. Medical directors are more willing to honor requests for treatment limitation by terminal patients than others.