Advance directives assume that patients are able to decide what interventions they would wish in the event of catastrophic illness. This study examines the preferences of nurses and physicians, who have extensive exposure to sick patients, for care at the end of life.
Nursing and medical staff of a community teaching hospital were asked to complete the medical directive, detailing which of 12 interventions they would wish for themselves in each of four scenarios. Two additional scenarios were added to ascertain preferences for care in the event of severe illness in a previously healthy 85-year-old subject and in a chronically ill 75-year-old subject.
Refusal rate among the 127 nurses and 115 physicians who completed the questionnaire, averaged over the four scenarios, was 78%. Nurses and physicians refused 31% of proposed therapies in the case of acute illness in a previously healthy 85-year-old subject and 57% of interventions in the case of major illness in a 75-year-old subject with multiple debilitating chronic illnesses. Nurses reported significantly higher refusal rates than physicians for the scenarios involving possible reversible coma, the healthy 85-year-old subject, and the chronically ill 75-year-old subject. Factors predicting refusal patterns were age and being a nurse.
We conclude that physicians and nurses, who have extensive exposure to hospitals and sick patients, are unlikely to wish aggressive treatment if they become terminally ill, demented, or are in a persistent vegetative state. Many would also decline aggressive care on the basis of age alone, especially in the presence of functional impairment. These findings call into question the utility of detailed advance directives and suggest a need to focus on the goals of treatment for all elderly patients.