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Most nursing home residents prefer life-sustaining
treatments, but do not discuss this topic with caregivers
The majority of nursing home residents who are capable of making
decisions prefer life-sustaining treatments in the event of
sudden cardiac arrest or other life-threatening event. However,
the types of treatments they prefer vary considerably, according
to a random survey of 421 residents of 49 nursing homes that was
led by Linda A. O'Brien, R.N., M.A., and Jeane Ann Grisso, M.D.,
M.Sc., of the University of Pennsylvania School of Medicine.
In a study supported in part by the Agency for Health Care Policy
and Research (HS06815), the researchers found that only 12
percent of residents had discussed preferences with health care
providers, although 31 percent had discussed their preferences
with family members. Overall, 60 percent of nursing home
residents preferred the use of cardiopulmonary resuscitation
(CPR) in the event of sudden cardiac arrest, and 89 percent would
choose hospitalization if seriously ill. Of those preferring
hospitalization, 73 percent wanted to be hospitalized in the
event of permanent brain damage, and 33 percent elected enteral
tube feedings if they were unable to eat because of permanent
Residents who preferred CPR were more likely to be black,
physically mobile, believe that most important medical care
decisions should be made by the doctor, have moderate to severe
impairment in daily decisionmaking skills, and not have a spouse.
Patients who believed their doctors should make important medical
care decisions were nearly five times as likely as others to
choose hospitalization for serious illness. Black residents were
four times as likely to elect tube feedings as other residents.
The researchers speculate that black patients may feel
disenfranchised from the health care system and, therefore,
prefer to err on the side of overtreatment rather than
Details are in "Nursing-home residents' preferences for
life-sustaining treatments," by Linda A. O'Brien, R.N., M.A., Dr.
Grisso, Greg Maislin, M.S., M.A., and others, in the December 13,
1995, Journal of the American Medical Association 274(22),
Many poor families do not take advantage of free health care
Making health services free is not enough to ensure that poor
families will use them, according to a study supported by the
Agency for Health Care Policy and Research (HS06507). It shows
that only one-third of eligible poor children in North Carolina
received health checkups and immunizations offered by Medicaid's
Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
program. Many low-income parents, particularly single parents,
were often coping with difficult life situations that often took
priority over these checkups. Also, they had difficulty getting
time off work or care for other children in order to make
appointments at clinics, where appointment times and staff are
limited due to budget constraints.
Families might be more likely to use these preventive health
services if State agencies informed them about the program's
tangible benefits, such as eyeglasses, medicine, and immunization
reports required for school or day care. Also, expanding clinic
hours, increasing availability of providers and locations,
improving the EPSDT transportation system, and improving outreach
materials used to inform parents about the program might motivate
individuals to use the program, suggests Maija Selby-Harrington,
Dr.P.H., R.N., of the University of North Carolina at Greensboro,
the study's lead investigator.
Parents in this study often had difficulty locating providers who
participated in the EPSDT program, and many had problems getting
appointments within a reasonable time. Some parents encountered
long waiting-room delays (43 minutes on average) and perceived a
lack of respect on the part of staff, which led the parents to
question the quality of care they received. Even program-provided
minibus transport and mileage reimbursement were not sufficient
to overcome transportation barriers for some families.
In the study, low-income parents in six rural North Carolina
counties whose children were overdue for an EPSDT visit were
provided with information about the program (either mailed
pamphlet and letter, phone call and mailed pamphlet, or home
visit with pamphlet). Public health nurses then interviewed the
parents about their reasons for use or nonuse of the EPSDT
program. Of the 110 parents who did not use these services, 55
percent cited family and personal issues that competed with the
need for preventive health care; 25 percent cited competing
health concerns. Perceived or actual barriers in the health care
system discouraged 24 percent of parents who tried but were
unable to use the system. About 32 percent of parents indicated
that the specific type of outreach method had failed either to
reach them or convey the needed information.
See "Barriers to the use of preventive health care services for
children," by Roberta Riportella-Muller, Ph.D., Dr.
Selby-Harrington, Lenora A. Richardson, D.S.N., R.N., and others,
in the January/February 1996 Public Health Reports 111,
Some older Mexican Americans may not ask family members
for the help they need to avoid a nursing home stay
A recent study, supported in part by the Agency for Health Care
Policy and Research (HS07397), suggests that older Mexican
Americans may not make use of family support when they become
ill, despite the fact that many Mexican Americans reside in
multigenerational households. This may be because relationships
between elderly Mexican Americans and their families tend to be
reciprocal, including exchanges of goods and services, financial
assistance, moral/emotional support, and advice-giving.
Participants in this study may have been reluctant to ask for
help because they were concerned it would undermine their ability
to maintain these ongoing reciprocal exchanges, suggest
researchers at the AHCPR-supported Mexican-American Medical
Effectiveness Research Center in San Antonio, TX.
Almost 30 percent of older Mexican Americans of lower and middle
socioeconomic status (SES) in this study perceived that they
would have no available caregiver should they become ill and need
long-term help. Individuals with chronic illnesses—who are
at greatest risk of nursing home admission in the absence of a
caregiver—were the least likely to believe a caregiver would
be available to them. The researchers used home or phone
interviews to examine differences in perceived availability of
long-term caregivers among 649 lower, middle, and upper SES
Mexican Americans and non-Hispanic white persons 58-74 years of
age in San Antonio, TX.
For Mexican Americans across all three SES groups, women, widows,
and those with chronic illnesses were more likely to believe
there would be no one to care for them. Almost twice as many
low-SES versus upper-SES Mexican Americans perceived that they
would have no available caregiver (30 vs. 17 percent). Nearly all
of the participants had at least one living first-degree relative
other than a spouse, and many had three or more first-degree
relatives other than a spouse.
See "SES and ethnic differences in perceived caregiver
availability among young-old Mexican Americans and non-Hispanic
whites," by Melissa A. Talamantes, M.S., John Cornell, Ph.D.,
David V. Espino, M.D., and others, in The Gerontologist 36(1),
pp. 88-99, 1996.
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