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A new study supported by the Agency for Healthcare Research and Quality (HS09833) sheds some light on how decisions are made on whether or not to initiate different types of treatment when the patient's health status changes. Jiska Cohen-Mansfield, Ph.D., and Steven Lipson, M.D., M.P.H., of the Research Institute on Aging of the Hebrew Home of Greater Washington, asked six male physicians and three female nurse practitioners to complete several questionnaires that described the medical decisionmaking process for 70 residents of a large nonprofit nursing home. These residents had suffered from breathing difficulty, an infection, a fall, or other event that changed their medical status. The researchers also interviewed the clinicians within several days of the event to obtain their personal opinion about these cases and the related decision process.
Based on questionnaire results, hospitalization was the treatment most frequently considered and chosen. Family members were involved in 39 percent and nurses in 34 percent of decisions. The resident's quality of life, relative effectiveness of the treatment options, and the family's wishes were the most important considerations in making a decision. Cost of alternate treatments and the resident's wishes, which were frequently unavailable, were least important.
For nearly half of the residents studied, the physician on call participated in the decision rather than their personal physician. Physicians lacked familiarity with the wishes of 70 percent of the residents concerning care but felt familiar or very familiar with family wishes in 51 percent of cases.
Treatment decisions also reflected the physicians' practice styles, which varied. For instance, there were significant differences across physicians in the ratings of importance of the following six factors to the decisionmaking process: resident's quality of life, family's wishes, treatment practices for this condition, prolongation of resident's life, potential liability issues, and cost of alternative treatments.
See "Medical staff's decision-making process in the nursing home," by Drs. Cohen-Mansfield and Lipson, in the Journal of Gerontology: Medical Sciences 58A(3), pp. 271-278, 2003.
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