TERMINAL CARE OF THE VERY OLD - CHANGES IN THE WAY WE DIE

Background: This study examines the use of advance directives, limitat ions of treatment, and medical interventions during the terminal hospi talization of the old-old. Study periods before and after the implemen tation of the Patient Self-Determination Act of 1990 were chosen to de termine if there has been a change in terminal care. Methods: Chart re view was performed for all patients 85 years and older who died in the hospital during 1988 and 1993. Patient characteristics, presence of a dvance directives, do-not-resuscitate orders, and other treatment limi tations were noted as were interventions listed in the Medical Directi ve. Results: Less than 12% of the 167 study patients had an advance di rective. Length of stay For these terminal admissions decreased from 1 8.5 to 9.6 days. Ninety-five percent of the patients were ''do not res uscitate'' by time of death, but orders were written sooner in 1993-75 % within 24 hours of admission. Patients with early do-not -resuscitat e orders had fewer high-intensity interventions. More patients had ''c omfort measures only'' during the study period. An overall decrease in high-intensity interventions and a specific decrease in the use of tr ansfusions, invasive tests, minor surgery, and cardiopulmonary resusci tation was seen. Conclusion: Patients 85 years and older are receiving fewer high-intensity interventions during their terminal hospitalizat ions. More attention is being paid to comfort and few are receiving ca rdiopulmonary resuscitation. There is little reference to formal advan ce directives in decision making for these patients.