Recent judicial decisions underscore the intricacy in making health care decisions on behalf of incompetent patients. The use of advance directives has been advocated as one way to avoid ethical dilemmas in treatment decisions. Residents in long term care facilities are at particularly high risk of acute illness, requiring life sustaining treatment, while also being particularly at high risk for being excluded from treatment decisions. The objectives of this study are to: 1) ascertain whether there are institutional and/or individual factors that are associated with treatment preferences; 2) determine whether there are institutional and/or individual factors that are associated with a higher likelihood of a resident having previously discussed treatment preferences with others and/or having prepared written advance directives; and 3) determine whether residents of nursing homes with varying degrees of cognitive impairment are able to meaningfully express preferences regarding the use of life sustaining treatments. This survey will include a randomly selected sample of 400 residents from 40 nursing homes in the Philadelphia Consolidated Metropolitan Statistical Area. Residents will undergo standardized assessment of cognitive function and self-perceived health status. Preferences regarding cardiopulmonary resuscitation and tube feeding will be assessed under a variety of scenarios. Half of the questionnaires will include questions regarding CPR preferences with and without detailed information about CPR in order to determine if preferences regarding CPR are influenced by the description of CPR. Residents will be asked whether they have ever discussed these treatments with others or whether they have prepared written advance directives. The charge nurse will provide a standardized assessment of functional status and a prediction of the resident's treatment preferences. The director of nursing at each of the 40 facilities will provide institutional information (such as religious and/or academic affiliation) and describe current institutional policies regarding discussion and/or promotion of the use of advance directives. Data analysis will consist of (1) descriptive statistics on residents' cognitive function, self-perceived health status, decision making capacity, treatment preferences, prior discussion of treatment preferences, and use of written advance directives; and (2) logistic regression models to identify associations between potential predictors (such as institutional policy, cognitive function, and perceived health status) and the outcome variables (treatment preferences, prior discussion of treatment preferences, and use of written advance directives). In addition, models will be developed to identify predictors of nurses' correctly identifying residents' preferences. The results of this study will be essential for the development of educational programs for nursing homes, residents, and their families. This study will provide important information with which we will use to enhance nursing home residents' autonomy and dignity in these crucial issues.
