Tube feeding preferences among nursing home residents.

OBJECTIVE: To determine the preferences of nursing home residents regarding the use of tube feedings and to characterize the clinical, functional, and psychosocial factors that are associated with preferences. DESIGN: In-person survey. SETTING: Forty-nine randomly selected nursing homes. PATIENTS/PARTICIPANTS: Three hundred seventy-nine randomly selected, decisionally capable, nursing home residents. MAIN RESULTS: Thirty-three percent of participants would prefer tube feedings if no longer able to eat because of permanent brain damage. Factors positively associated with preferences for tube feedings include male gender. African-American race, never having discussed treatment preferences with family members or health care providers, never having signed an advance directive, and believing that tube feeding preferences will be respected by the nursing home staff. Twenty-five percent of the participants changed from preferring tube feedings to not preferring tube feedings on learning that physical restraints are sometimes applied during the tube feeding process. CONCLUSIONS: Demographic and social factors are associated with preferences for tube feedings. The provision of information about the potential use of physical restraint altered a proportion of nursing home residents' treatment preferences.

Impact of advance directive videotape on patient comprehension and treatment preferences.

OBJECTIVE: To examine the effects of an advance directive videotape on patient comprehension of advance directive concepts and preferences for resuscitation. DESIGN: Pilot study, randomized cohort trial. SETTING: Extended Care and Rehabilitation Center, Veterans Affairs Medical Center, Durham, NC. PARTICIPANTS: Thirty-six residents of the center; mean age, 69 years. INTERVENTIONS: Sixteen subjects observed an advance directive videotape, and 20 subjects observed a health-relative videotape. All subjects received written material and counseling on advance directives. MEASUREMENT: Structured interviews were conducted at three time points relative to the educational program (pretest, posttest, delayed posttest), measuring comprehension of two advance directive concepts (living will and cardiopulmonary resuscitation) and resuscitation preferences based on hypothetical clinical vignettes. Mean comprehension and mean resuscitation preference scores were derived for each time point. RESULTS: The mean comprehension score improved an average of 1.6 points for all subjects from pretest to delayed posttest (P < .001); however, score changes were not significantly different between the two video groups (P = .39). Mean resuscitation preference scores were stable over time, and there were no significant score differences between the two video groups. CONCLUSION: The advance directive videotape did not significantly affect resuscitation preferences or comprehension of selected advance directive concepts.

Nursing home residents' preferences for life-sustaining treatments.

OBJECTIVES: To determine life-sustaining treatment preferences among nursing home residents, whether information regarding cardiopulmonary resuscitation (CPR) affected these preferences, and with whom treatment preferences had been discussed, and to identify factors associated with CPR preferences. DESIGN: In-person survey. SETTING: Forty-nine randomly selected nursing homes. SUBJECTS: Four hundred twenty-one randomly selected nursing home residents capable of making decisions. MAIN OUTCOME MEASURES: Preferences regarding CPR, hospitalization, and enteral tube feedings, and individual factors associated with CPR preferences. RESULTS: Of 1458 randomly selected nursing home residents assessed for the ability to participate in the study, 552 residents (38%) were eligible to participate and 421 agreed to be interviewed. Sixty percent of participants able to participate in the decision reported that they would elect CPR, 89% would choose hospitalization if seriously ill, and 33% would elect enteral tube feedings if no longer able to eat because of permanent brain damage. Individual factors associated with preferences for CPR included the following: African-American ethnicity, high self-reported physical mobility, belief that most important medical care decisions should be made by the doctor, moderate-to-severe impairment in daily decision-making skills, and not having a spouse. Fourteen percent changed their preference from preferring CPR to not preferring CPR after receiving additional information about CPR procedures. Twelve percent reported having discussed preferences with health care providers, and 31% discussed preferences with family members. CONCLUSIONS: More than half of nursing home residents capable of making decisions preferred the use of CPR. Few had discussed their preferences with health care providers. Individual preferences should be assessed when considering the use of life-sustaining treatments.

Prolonged thrombocytopenia associated with procainamide in an elderly patient.

OBJECTIVE: To report a case of thrombocytopenia associated with the use of extended-release procainamide hydrochloride in a geriatric patient. CASE SUMMARY: A 77-year-old man was admitted to the hospital for four-vessel coronary artery bypass surgery. He subsequently developed new onset atrial fibrillation and was started on extended-release procainamide on hospital day 7. The patient's platelet count on admission was 229 x 10(9)/L. The platelet count began to decrease on hospital day 22 and was 79 x 10(9)/L by day 30 and 13 x 10(9)/L by hospital day 37. The patient exhibited gross hematuria and lower extremity petechiae. There were no signs of splenic sequestration and other hematologic indices were normal. Procainamide was discontinued on hospital day 32. There was full recovery of the platelet count to baseline 33 days after procainamide was discontinued. DISCUSSION: Other possible medical and drug-related causes of thrombocytopenia are reviewed and ruled out. Previous reports of procainamide-associated thrombocytopenia describe an immune-mediated peripheral destruction of platelets with platelet recovery within three to eight days after drug discontinuation. However, the prolonged recovery period and the presence of antiplatelet antibodies suggest an immune-mediated process in the bone marrow of this patient. CONCLUSIONS: Clinicians should be aware of the possible adverse hematologic effects of procainamide in the elderly.