End-of-Life Issues

In January 2011, the National Center for Health Statistics released a report that found 45% of nursing home residents do not have advance directives (ADs) on record to ensure that their end-of-life wishes are documented (www.cdc.gov/nchs/data/databriefs/db54.pdf). Black residents and individuals younger than 65 years were less likely to have an AD than white residents and patients aged ≥85 years. Although no one really wants to think about end-of-life issues, patients and their families can benefit from having a concise AD on file. When patients do not have an AD, such as a living will or a do-not-resuscitate order, and are no longer able to communicate their wishes, physicians and families must make tough decisions on their behalf. For example, would a resident with advanced dementia who went into cardiac arrest want us to administer cardiopulmonary resuscitation (CPR) even if it would likely be futile? Does a patient with Alzheimer’s disease want a feeding tube placed, although it is unlikely to improve the quality or length of her life? Articles in this issue of Annals of Long-Term Care: Clinical Care and Aging (ALTC) examine these end-of-life concerns.

In a Perspectives article titled “Assault as Treatment: Mythology of CPR in End-of-Life Dementia Care,” Michael Gordon, MD, MSC, FRCP, tackles a complex issue and explains why it is not appropriate to administer CPR to every patient in cardiac arrest. Many people have come to view CPR as a routine intervention at the end of life, but Gordon notes it is sometimes more compassionate to withhold CPR, particularly for terminally ill patients who are unlikely to derive anything from CPR beyond the pain of cracked ribs as they take their last breaths. Gordon encourages healthcare providers to initiate blunt discussions with patients and their families about the true risks and consequences of CPR in an effort to spare patients unnecessary suffering at the end of life.

Another common dilemma in long-term care is whether to place feeding tubes in a patient approaching the end of life. Our AGS Viewpoint column (page 11) discusses a study published in the Journal of the American Geriatrics Society that showed 40% of individuals with late-stage dementia were bothered by their feeding tube and 33% required physical or pharmacological restraints to keep them from removing it. The column recommends that healthcare providers assist patients and their families develop ADs, ensuring preference regarding feeding tubes and other interventions are established well before the patient might require them. The American Geriatrics Society’s Foundation for Health in Aging has published an easy-to-understand guide to Ads, which is designed to be shared with patients and their families; it is available at www.healthinaging.org.

Inadequate nutritional intake is common among patients in long-term care and sometimes results from swallowing disorders, or dysphagia. Preventing complications from dysphagia often requires imposing severe dietary restrictions on patients or feeding them through tubes, actions that significantly compromise their quality of life. In “Does Amantadine Help Elderly Residents with Symptomless Dysphagia?” Murthy Gokula, CMD, MD, and colleagues explain dysphagia’s etiology and possible complications and discuss results of a small case study they conducted using amantadine. Of the 12 patients at their long-term care facility treated with amantadine, 11 experienced improvement in dysphagia symptoms and silent aspiration. The authors provide two case reports, including one of an 86-year-old stroke patient with several comorbidities who was placed in hospice care after several bouts of aspiration pneumonia and a failure to thrive. After 6 weeks of amantadine treatment, his dysphagia resolved. He gained weight, developed a renewed interest in life, and was discharged to home, where he died a year later from causes unrelated to dysphagia. His case provides an example of how some interventions might contribute to a meaningful extension of life for a patient considered terminally ill.

We’d like to know what you think about the articles in this month’s issue of ALTC. Are there any end-of-life issues thatyou struggle with at your facility? Send your feedback to Christina Loguidice, editorial director, at cloguidice@hmpcommunications.com. Responses may be published in an upcoming issue of the ALTC.

Thank you for reading!