ISSUES IN THE “NOT SO GOLDEN YEARS”
Educational Objectives
| The goal of this program is to improve the management of ethical dilemmas in end-of-life care and medication problems
in elderly patients. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Describe legal statutes that govern treatment decisions.
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| 2. Counsel patients and family members about advance directive decisions.
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| 3. Incorporate values history and effective communication into advance planning.
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| 4. Select appropriate medications to reduce risk for adverse drug effects in elderly patients.
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| 5. Provide measures to improve adherence to appropriate medication use.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.
Acknowledgments
Dr. Pound spoke in San Francisco, CA, at Annual Review in Family Medicine: Controversies and Challenges in Primary
Care, presented April 6-8, 2008, by the University of California, San Francisco, School of Medicine. Dr. Simpson
was recorded in Kiawah Island, SC, at An Intensive Review of Family Medicine, presented June 18-23, 2007, by
the Medical University of South Carolina. The Audio-Digest Foundation thanks the speakers and the sponsors for
their cooperation in the production of this program.
| ADVANCE DIRECTIVES: ETHICAL ISSUES— Daniel Pound, MD, Professor of Family and Community Medicine,
University of California, San Francisco, School of Medicine
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| Case presentation: background—woman, 80 yr of age, with severe Alzheimer’s dementia; dependent on family
members for activities of daily living; chest mass seen on chest x-ray during visit to emergency department (ED);
surgeon advised surgery to prevent hemoptysis or metastasis, while acknowledging dementia would increase risk
for postoperative complications; after surgery, woman developed pneumonia and bronchopleural fistula, underwent
tracheostomy, needed ventilator, and had persistent fevers, acute renal failure, myocardial infarction, methicillin-resistant
Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE); patient difficult to
arouse; appeared to struggle against ventilator; swollen “from head to foot”; woman spent 3 mo in intensive care
unit (ICU); family wanted “full code,” but no dialysis; nurses felt woman appeared to be suffering; family
conflict—woman’s 6 children “not all in agreement”; daughter who had written power of attorney hoped mother
would survive; this caused isolation from siblings, due to disagreements; daughter did not tell friends or coworkers
mother in hospital, and felt guilty about deciding to have mother undergo surgery; daughter failed to perceive
mother’s suffering and could not engage in meaningful discussion; ethical dilemma—due to conflict in perceptions,
values, and expectations between family and medical team; considerations—increasing antibiotics; starting
dialysis; focusing on pain treatment and agitation; discontinuing antibiotics; documenting hypotension and cardiac
arrest
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| Efficacy of cardiopulmonary resuscitation (CPR): in 1960, paper stated CPR resulted in “overall permanent
survival rate of 70%”; 1 in 3 people in hospitals survive immediate event of CPR (two-thirds die within days to
weeks of admission to ICU; one-third of those who survive hospital discharge more likely to have disability or to
be placed in long-term care facility); 1 in 6 survive hospital discharge after undergoing CPR (statistic unchanged
for 40 yr; however, lower survival rates published after 1960); patients with sepsis, multiorgan failure, or renal failure
have <10% chance for survival to hospital discharge; in patients with drug reaction, drug overdose, or acute
coronary syndrome, chance for survival ≤40%; metastatic cancer—case studies published before 1990 showed 0%
survival; large study in 2006 looking at 40-yr period found hospital survival rate after CPR, 5.6% (7.8% in last 15
yr); functional status and critical illness more important predictors of survival
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| Medical futility: definitions—physiologically impossible to succeed; “unlikely” (0%-13%; zero survival in 100
cases); outcome not desirable; unlikely to produce benefit; not cost-effective; relationship between effectiveness,
benefit, and burden of treatment in question; futility cannot be determined objectively; determining process to work
around futility issues best approach; overtones of futility—pertains to particular goal (eg, short-term survival); offering
CPR as hope to families when patient not expected to survive may be viewed as cruel; perceptions of
families—physicians paternalistic (ie, make decisions for patients, want to overrule patient and family’s decisions);
physicians use futility as trump card to win argument; “if you say it’s futile, you don’t think my loved one is worthy
of care anymore”
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| Unilateral orders based on medical futility: can invoke futility (or similar arguments) about orders that may
seem meaningless (eg, do not resuscitate [DNR]); many physicians unaware of state laws and hospital policies; in
1993, legal statutes for individual states proposed (10 states adopted laws based on Uniform Health Care Decisions
Act); Texas and California—enacted extensive legal statutes on medical futility; writing unilateral order requires
that patient or proxy be informed and involved (requires concurrence of 2 physicians, and patient should be offered
transfer to another facility); in Texas, care must be continued for 10 days (if patient not transferred to another hospital,
then physicians can stop some life support treatments); in California, supportive care must be continued until
it appears transfer cannot be accomplished; Texas maintains Internet registry of people willing to help patients trying
to find facility that would accept them; transferring of patients uncommon; Texas requires ethics or medical
committee to review case; 2006 revision of University of California, San Francisco, Medical Center policy states
CPR not indicated if reasonable promise for recovery not present, burdens grossly disproportionate to expected
benefit, or if CPR would only artificially postpone patient’s death; to write unilateral DNR order, patient or surrogate
must be informed and offered ethics consultation and transfer to another provider or hospital
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| Fears of family members: DNR often incorrectly interpreted as do not treat or do not try (eg, “don’t treat that patient,
they want to die anyway”); fear of abandonment
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| DNR and staff: interns who received ethics training shown to give greater attention to variety of medical concerns;
other educational and administrative programs unsuccessful; DNR order often marker of severity of patient’s illness,
rather than indicator of neglect by staff; for many interns, discussing DNR order with families emotional experience
and sometimes not pleasant memory; approaches to DNR—“allow natural death (AND)” coined by
Reverend Chuck Meyer in 2000; DNR can evoke negative feelings and sense of being threatened; speaker suggests
starting by discussing actions that will be taken before discussing things not chosen to be performed (“so they realize
I’m still involved and that I’m not abandoning them”); negative phrases may be harder for patients to understand
than positive phrases (eg, ask patient to identify wants [eg, “I want to be surrounded by my family” rather
than “I do not want intubation”])
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| AND vs DNR: AND—addresses death; when talking to patients, speaker uses language that addresses death, eg,
“when a person dies, doctors can try to bring you back to life, but it’s usually not successful” (rather than “what
should we do when your heart stops?”); study found 85% of nurses would endorse AND or DNR (nursing students
and control group less likely); groups with less medical background more likely to prefer AND over DNR
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| Four levels of care: Belgian study found DNR orders for frail elderly patients resulted in limited care; pick overall
level of care for patient; 1) terminal; lowest intervention; provide comfort in dying; involves hygiene and analgesia;
2) palliative; manage symptoms; adds mobility and oral nutrition; 3) usual; restore function; intravenous (IV)
or enteral treatment if indicated; 4) intensive; prolong life, even with invasive measures; involves resuscitation and
life support; first 3 levels considered DNR; many ways that patient might desire care considered DNR
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| Discussion with family: explain prognosis (eg, recurrence expected); determine what is most important to family
(eg, “I don’t want him to suffer”); ask about concerns (eg, patient’s dislike of hospital); choose intervention; many
family members prefer not to discuss hypothetical decisions and interventions; family discord, guilt, and distrust of
physicians may result in inability to make acute decisions
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| Common dilemma: patient receives different recommendations from different physicians; family members have
different ideas; patient becomes confused by discussions; burden of therapy on family (eg, taking patient who has
difficulty walking to radiation therapy every day)
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| Shortfalls of advance directives: physicians often unaware of advance directives or do not follow when making
decisions; families only slightly better than chance in predicting patient’s wants; standard documents unhelpful
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| New ideas: focus on communication training for medical students; incorporate values history in advance directives
(eg, ask “what were you thinking about when you talked about doing things that would make your life worth living?”);
importance of communication—advance directives not one-time event; help patients and families talk to each
other and to physicians; builds continuity and trust; values history—determine whether important for patient to be at
home or hospital when dying, what makes life worth living (eg, walking, going outside); address greatest hopes and
fears; ask, “what is important to you if you were dying?” “what does life mean to you if you couldn’t take care of
yourself, recognize your family, or talk and be understood by others?” “is it wrong to forgo treatment that could keep
you alive?”
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| Summary: state and local policies establish process for unilateral decisions, but do not provide clinical determinants
of futility; fear of restrictions in care may prevent early DNR orders; interaction with family about goals can
achieve consensus; ongoing discussion about prognosis and values can influence end-of-life treatment choices
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| Questions and answers: patient’s ability to adapt often leads to changes in advance directives (discussion important);
nursing homes—DNR forms often complicated or misunderstood; physician orders for life-sustaining treatment
(POLST; form designed in Wisconsin for nursing home patients) “best one to use”
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| MEDICATION PROBLEMS IN THE ELDERLY —William M. Simpson Jr, MD, Professor, Department of Family
Medicine, Medical University of South Carolina, Charleston
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| Introduction: goals include using best therapeutic regimens without side effects; people >65 yr of age (13% of
population) consume 2 to 3 times more prescription drugs and have on average 11 prescriptions per year
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| Prescription problems: study found 58 hospitalized patients took 193 prescription medications, but only 38 documented;
≤70% of patients take over-the-counter (OTC) medications (including herbal therapy) and do not tell physicians,
even when asked; prescriber problems—wrong diagnoses lead to wrong medications; treating symptoms
may result in incorrect medication use; drug interactions with other disease, food, or drug; overprescribing; patients
expect to receive prescription after visiting physician (legitimizes illness); elderly patients more likely to use medications
(especially OTC medications) for acute minor illnesses; 18% of hospital admissions for acute drug reactions
due to OTC drugs
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| Adherence: compliance (ie, how well patient’s behavior conforms to medical advice); 50% of prescriptions in ED setting
not filled (nearly all prescriptions filled when patient in long-standing relationship with primary care practitioner);
nonadherence—improper administration or premature discontinuation; inappropriate use (eg, sharing medications
with family members, reusing old prescriptions); poor response due to poor adherence may lead to erroneous conclusions
about diagnosis or efficacy of therapy; with aging, increase in incidence of memory loss, number of diseases,
and number of medications (note, adherence decreases with greater number of medications); improving adherence—
health belief model (patients who believe in susceptibility of serious disease and efficacy of treatment more likely to
adhere); personalize diagnosis; simplify regimens; consider lifestyle; adequate labeling (eg, identify what medication is
for, large print); patient-friendly lids
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| Changes in pharmacokinetics: absorption—slight changes unless acid-dependent or patient has decreased mesenteric
blood flow (eg, abdominal angina); distribution—slight changes; due to decreased body weight and body
water, increased body fat mass, decreased lean body mass, and decreased plasma albumin; metabolism—oxidation
reduced in most patients; hydrolysis and reduction unchanged; conjugation unchanged unless patient has serious
liver disease; renal clearance—decline in glomerular filtration rate; serum creatinine based on muscle mass (does
not adequately measure renal function in elderly); environmental factors—less tobacco smoking and decreased caffeine
and alcohol intake reduce hepatic microsomal enzymes (may decrease metabolic rate of drugs)
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| Risk factors for adverse drug reactions: use of multiple drugs; women >50 yr of age (especially white
women); multiple medical problems; impaired renal function; cancer; positive history of adverse drug reactions;
15% of hospitalized elderly patients have adverse drug reaction during hospital stay; pharmacologic—toxic effect;
side effects; allergic effect; idiosyncratic effect
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| Potentially inappropriate medications for older adults (according to Beers list): propoxyphene; indomethacin;
oxybutynin; reserpine—low doses (<0.20 mg/day) acceptable; causes nasal congestion; no data about
increased rates of suicide with low doses; >0.25 mg/day not recommended
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| Drug use in nursing homes: evaluate residents’ signs and symptoms before prescribing medication; do not place
patients on medication without closing order; do not stop temporary medication for, eg, respiratory infection (appropriate
durations of medication use and medication orders important); consider nonpharmacologic interventions
(eg, assisting patient to restroom rather than placing him or her on medication for overactive bladder); monitor for
signs of adverse effects; clarify which conditions being treated; provide ending date for therapy; follow for adverse
events; be cautious with acetaminophen (>4.0 g/day) and other nonsteroidal anti-inflammatory drugs, antibiotics,
iron, and warfarin; use of psychotherapeutic medications requires documented diagnosis, reason for therapy, and
appropriate duration (when possible, periodically discontinue drug to check for need)
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| Key considerations: treating symptoms without diagnosis increases likelihood of difficulty with therapy (eg, use
of more medications, side effects); consider nonpharmacologic treatment when possible; consider whether symptoms
due to other medicines (consider changing or stopping therapy); minimize drug treatment whenever possible;
start medications low (and stay low as much as possible) and go slow; in Alzheimer’s disease, start medications
low and follow progression until patient on effective dose (may take longer to titrate); reevaluate patient at end of
drug course; transdermal systems (patches) or liquid forms of medications may be more useful to some patients;
when possible, decrease number of doses per day; utilize large print and non-childproof caps on medication bottles;
try to use lowest possible dose; avoid intermittent dosage schedules; giving written instructions at time of interaction
increases adherence by ≈30%; periodically (eg, every 3-6 mo) review patient’s medications; reminders to take
medications (eg, pill boxes) useful; inform patients to report adverse drug events; encourage patients to use one
pharmacy for all prescriptions (pharmacies with medication profiles of individual patients and drug-drug interaction
programs preferred); prescriber’s letter optimal reference for drug interactions and use
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Suggested Reading
Ardagh M: Futility has no utility in resuscitation medicine. Med Ethics 26:396, 2000; Aspinall S et al: Medication
errors in older adults: a review of recent publications. Am J Geriatr Pharmacother 5:75, 2007; Cantor MD et al: Do-
not-resuscitate orders and medical futility. Arch Intern Med 163:2689, 2003; Collins LG et al: The state of advance
care planning: one decade after SUPPORT. Am J Hosp Palliat Care 23:378, 2006; Kouwenhoven WB et al:
Closed-chest cardiac massage. JAMA 173:1064, 1960; Mansur N et al: Relationship of in-hospital medication modifications
of elderly patients to postdischarge medications, adherence, and mortality. Ann Pharmacother 42:783, 2008;
Peberdy MA et al: Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the
National Registry of Cardiopulmonary Resuscitation. Resuscitation 58:297, 2003; Pellegrino ED: Decisions to withdraw
life-sustaining treatment: a moral algorithm. JAMA 283:1065, 2000; Schlenk EA et al: Medication non-adherence
among older adults: a review of strategies and interventions for improvement. J Gerontol Nurs 30:33, 2004;
Shepler SA et al: Keep your older patients out of medication trouble. Nursing 36:44, 2006; Snowden A: Medication
management in older adults: a critique of concordance. Br J Nurs 17:114, 2008; Vanpee D et al: Scale of levels
of care versus DNR orders. J Med Ethics 30:351, 2004; Venneman SS et al: "Allow natural death" versus "do not resuscitate":
three words that can change a life. J Med Ethics 34:2, 2008.
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