Health care decisions among elderly long-term care residents and their potential proxies.

Seventy residents of the residential care section of a long-term care facility were asked to make health decisions after being presented four clinical vignettes. Two vignettes involved high-risk procedures (aortic valve replacement and carotid endarterectomy) and two were low risk (flu vaccination and psychotropic medication). Comparisons were made between decisions made by the elderly participants and predictions of those decisions by potential proxies, including the participant's closest relative and a nurse, a social worker, and a physician in the facility. There was a low rate of agreement between decisions made by the elderly participant and the decisions the potential proxies thought they would make. The highest agreement was found between the participants' actual decision and the decision predicted by their relatives. The lowest agreement occurred between what the physician thought the participant would choose for the two high-risk vignettes and what the participant actually chose. The quality of the elderly participant's decisions was also rated on a four-point scale by the potential proxy, as well as by a researcher. Highest ratings of the quality of the elderly person's decision-making ability were assigned by the relative. A significant negative correlation was obtained between the elderly person's age and the decision-making rating assigned by the physician, and significant positive correlations were obtained between mental status and decision-making ratings by the other raters. These data have important implications for designing and implementing strategies to maximize the ability of elderly people in long-term care settings to participate in decisions about their health care.

Informing the elderly. A comparison of four methods.

Providing elderly persons with understandable information with which they can make informed health care decisions is a difficult, yet critical, task. Four methods of enhancing understanding of the Resident's Bill of Rights were evaluated in residents of the board and care section of a long-term care facility. The methods included the use of large print and simplified language, a storybook, and a videotape. There was no significant improvement for performance on the comprehension test after any of the methods of presentation of the Bill of Rights. A number of subjects were found to be very deficient in short term memory or in verbal knowledge. When these subjects were eliminated from the analyses, significant improvement was demonstrated with the simplified version of the Bill of Rights yielding the most improvement. These findings indicate that many elderly people can benefit from an informed consent procedure that provides information clearly and simply. Furthermore, with relatively simple cognitive screening procedures, it should be possible to identify those unable to process the information necessary to participate in common health care decisions.

Decisions about enteral tube feeding among the elderly.

OBJECTIVE: To determine choices about enteral tube feeding and factors associated with deciding to accept or forego this intervention in a group of ambulatory non-demented older individuals. DESIGN: Descriptive survey. SETTING AND PARTICIPANTS: Thirty four volunteers from a senior adult day center and 34 volunteers from the residential care section of a multilevel long-term care institution, mean age 77.8. INTERVENTION: Structured interview using a hypothetical clinical vignette in simplified language, story-book format depicting an irreversibly and severely impaired state of health. MEASUREMENT: Choice of whether to accept or forego enteral tube feeding based on the clinical vignette. RESULTS: Thirty four (50%) decided to accept and 34 (50%) chose to forego enteral tube feeding in the situation presented in the vignette. No demographic, cognitive, or affective factors were associated with the decision. Presentation of the vignette and associated questions were not anxiety-provoking or upsetting to the vast majority of participants. CONCLUSION: A hypothetical clinical vignette depicting a state of severely impaired health resulted in 34 (50%) of 68 ambulatory non-demented older individuals deciding to accept enteral tube feeding. No factors we examined were strongly associated with the decision. The vignette and discussion were not anxiety-provoking when presented in the format used in this study. Advance-directive discussions about enteral tube feeding and other health care decisions, using understandable hypothetical clinical vignettes that describe risks and benefits that might influence decisions, should be encouraged in the practice of geriatric medicine.

How informed can consent be? New light on comprehension among elderly people making decisions about enteral tube feeding.

Elderly people in long-term care facilities do not understand much about various medical procedures, including enteral feeding. After presentation of empirically precise information about enteral tube feeding, residents in both long-term care and community-dwelling groups showed significant improvement in their understanding. The community-dwelling group showed even greater improvement. For both, comprehension was negatively related to age and depression scores, but positively related to IQ, reading comprehension, social support, and mental status. The MMSE proved the best predictor of comprehension. Implications of the results are discussed.

Effective decision-making/problem-solving training with mothers who have mental retardation.

Nine mothers with mental retardation received group training in decision-making using vignettes describing child-raising situations. A multiple baseline procedure was used to assess the effectiveness of training in how to identify and apply decision-making steps to trained and untrained vignettes. Significant changes in step identification and use were observed and maintained for a month for both types of vignettes. Although training included nothing to improve the appropriateness of decisions, there was significant improvement for the high-risk situations used in training. Results suggest that parents with mental retardation are able to learn and apply basic steps of decision-making.

Predicting adequacy of parenting by people with mental retardation.

While there has been increased attention placed upon the inadequacy of parenting by persons with mental retardation, such attention does little to increase our understanding of the complexities of parenting. A refocusing of research and intervention efforts is needed to examine the concomitants of adequacy of parenting. What we know about both the inadequacy as well as the adequacy of parenting by persons with mental retardation and the limitations of the information upon which we base these statements is reviewed. New foci are suggested in understanding both adequacy and the inadequacy of parenting by persons with mental retardation.

Mothers with mental retardation who do or do not abuse or neglect their children.

Mothers with mental retardation with or without a history of child abuse and/or neglect were compared on a number of demographic variables. The reasons why children were or were not removed also were examined. The demographic comparisons showed that while those mothers with such a history generally had higher IQs, they were similar to the mothers without such a history. Twice as many of those with a history of abuse and/or neglect were married, lived independently, and had at least two children, one of which often had problems, in comparison to those without such a history. Examination of the reasons for child removal showed that removal occurred if the mother had a problem in addition to her retardation or if she was unwilling to attend and actively participate in a training program and/or did not have someone who could provide support. If a mother was willing and did attend training and had support, children were either not removed initially or were returned upon evidence that the mother was actively participating. In comparison to those mothers with a history of abuse and/or neglect, those without such a history functioned at a lower intellectual and functional level and were living with a relative who shared child-care responsibilities.

The home inventory of dangers and safety precautions-2: addressing critical needs for prescriptive assessment devices in child maltreatment and in healthcare.

OBJECTIVE: This paper describes the development and preliminary validation of a prescriptive home danger and safety precaution instrument containing 14 epidemiological categories to be used in the design and evaluation of family-tailored injury prevention and safety interventions. METHOD: The HIDSP-2 evolved from application and revision of the previous home danger and safety precaution recognition and observation instruments. As part of this process, the suitability of the HIDSP-2 for use in a broad-based trial was evaluated with 29 low income parents exhibiting individual learning needs. Inter-rater reliability and stability of scores were examined. Internal consistency was examined for total dangers and precautions and for those categories in which there were sufficient items to do so. RESULTS: Administrative time was reduced while continuing usefulness in the identification and remediation of dangers and implementation of precautions was demonstrated. Stability of observation was high. Alphas as a measure of internal consistency was satisfactory for total danger and precautions separately; however, those for most individual categories were low. There was significant reduction in the number of dangers identified initially and significant improvement in the safety precautions implemented. CONCLUSIONS: The HIDSP-2 can assist healthcare, education, disability, and child protective service workers in the development of home safety plans for remediating home dangers and implementing precautions. While we see this instrument as eminently suitable for use in broad-based interventions and in epidemiological studies, further research must continue to examine the psychometric characteristics of the individual danger and precaution categories.

Decision-making abilities of mothers with mental retardation.

The decision-making abilities of mothers with mental retardation and contrast mothers were examined. Both groups received two high- and two low-risk vignettes in full and partial formats. Although there were no significant differences between the two groups on the appropriateness of their decisions, as expected, the mothers with mental retardation scored lower both on the recall and elicited measures. Both groups scored lower on the partial formats than on the full formats, and on the high-risk vignettes than on the low-risk ones. These results suggest that familiarity with the parenting situation as well as the degree of risk inherent in that situation is of importance when one is examining decision making for either group. The results also suggest that although mothers with mental retardation can make in vitro decisions that are similar to those of nonhandicapped mothers of the same socioeconomic background, additional research must examine in vivo decision making for both groups.

Self-concepts of mothers who show mental retardation.

The Tennessee Self-concept Scale was orally administered to 27 mothers with mental retardation and self-administered to 95 mothers whose children attended daycare in the areas in which the former mothers lived. Analyses showed that the mothers with mental retardation scored significantly lower on all subscales. Where 72% of the comparison group scored above a recommended cut-off indicative of a positive self-concept, only 33% of the mothers with mental retardation did. Comparisons of the 27 mothers with mental retardation (18 with positive versus 9 with negative self-concepts) on personal, child, family, and other background variables suggested different relationships for the two groups. Cross-validation of the present work and studies of the actual childcare of these latter two groups of mothers are needed.