The purpose of this paper is to examine the relationships between cognition, life satisfaction, demography, and attitudes regarding life support among the elderly. The goal is to provide information that would be useful in developing programs and policies for the elderly in a variety of settings. A study using sixty-six male and female subjects was used for much of this research. In this study the subjects were asked to respond to the following instruments: The Life Satisfaction Index, the Mini-Mental State Examination, the Values History questionnaire, and a demographic questionnaire.
One finding of this study was the majority of the subjects preferred quality of life over quantity of life and did not wish to receive artificial respiration or nutrition, although half wished to receive cardiopulmonary resuscitation (CPR).
People age in different ways. Some reach old age with prestige, affluence, and comfort; others face age wrought with hardship and difficult circumstances. The more unfortunate face poor health, declining mental function, inadequate financial resources, and loss of loved ones.
Many issues regarding the aged have come into public focus. One concern that has gained prominence is whether or not a person should be kept alive when faced with imminent death or total incapacitation. (Crane, 1975) Many people express the wish that heroic or extraordinary efforts not be used if the life to be maintained would be of very low quality. Desires related to this issue may be expressed in the advanced directives or living wills. Advanced directives have been available but are not widely used, and there are problems regarding their use and interpretation.
(Doukas and McCullough, 1991)
There is considerable variation among the elderly so it can be expected that there will not be uniformity regarding issues such as the desirability for life support. It will be useful to identify factors, such as degree of life satisfaction and mental competence, which may affect opinions about life support. The purpose of this paper is to clarify factors that relate to a person’s feelings and opinions regarding life support issues. The intent has been to look at the factors of mental competence and life satisfaction as they affect opinions regarding life support. Demographic factors were also considered. It is hoped that this knowledge will enhance the ability to deal effectively with the elderly and improve the understanding of the related issues. DISCUSSIONOne issue is the effect cognitive status may have on the wishes of the elderly regarding life support in the face of imminent death or extreme disability. One ethical question which may be raised is whether to follow the instructions of an incompetent individual in the same way as those of an individual in good mental condition. The court, however, has determined that the rights of the competent and incompetent person are the same regarding the right to decline life-prolonging treatment. (Annas, 1978) Another issue is the relationship between a person’s opinions regarding life support and that person’s general satisfaction with life. Is a person with a high level of life satisfaction more or less likely to choose artificial life support in the case of a life-threatening illness? The right of competent patients to forego life-sustaining treatment has been upheld in the courts and is generally accepted by medical ethicists. (ibid) This relates to the principle of autonomy and self-determination. The person’s ability to make the decisions related to life support depends on his or her ability to understand the relevant information, reflect on it by his or her values, and communicate with caregivers. (ibid) Making decisions regarding life support is one of the most difficult decisions in medicine but health care providers are concerned about providing inappropriate care to patients near the end of life and about inadequate participation by patients in end-of-life decision-making. One reason for withholding resuscitation is that the quality of life expected after resuscitation would be unacceptable or that the patient’s current quality of life is unacceptable either to him or him or to the family if the patient is incompetent. (Sprung, 1990)
Questions raised by ethicists are: do quality-of-life considerations undermine and override the sanctity-of-life ethic and do quality-of-life and quantity-of-life represent opposing values. (ibid) We may even be moving toward the acceptance of active euthanasia. Patients who are severely depressed or in pain might wish for death, but be thankful for life once the pain or depression is eliminated. (ibid) Many hospitals have established ethics committees to provide advice to physicians, patients, and families when difficult decisions arise regarding life support. These committees guide in difficult situations. It is generally agreed that it is desirable to know a patient’s wishes regarding cardiopulmonary resuscitation and other life support measures; action, however, is frequently not by this philosophy (Schonwetter, Teasdale, et al, 1991) It has been shown that prediction of a person’s wishes regarding resuscitation preferences may not be accurate. The physician or family member often has an erroneous concept about the person’s wishes. Furthermore, it has been found that following a person’s advanced directive may not reflect that person’s preferences. With an advanced directive, the individual indicates his or her desires regarding decisions relative to life-sustaining treatment if such decisions become necessary. The person completes the directive when mentally competent and before incapacitation. Although the use of living wills has been widely endorsed, their actual use is relatively rare(Gilfax and Raffin, 1984) even when education about the subject is provided. Where legal, a living will is binding on health care providers, but it remains a document of uncertain legal reliability. (ibid) Ambiguity is inherent in the document which causes problems in interpretation. (ibid) Another solution to decisions regarding terminal care is the designation of proxy decision-makers through durable “power of attorney” laws which allow the assignment of a legally enforceable surrogate decision-maker for the incompetent patient. A document similar to an advanced directive is the Values History which provides more detailed information than a living will and is proposed as an ethically justified supplement to the living will. (ibid)
This document provides a basis for making decisions regarding terminal care that is related to the values of the individual. The Patient Self-Determination Act went into effect in 1991 and requires institutions receiving government insurance payments to inform patients of their right to decide on life support measures and formulate advance directives, educate staff and patients on issues related to advance directives, and document a patient’s record if an advance directive has been executed. Although the law has limitations it acts to increase patient knowledge regarding living wills(Robinson, 1993) and it ensures that when a person becomes incompetent the person’s treatment preferences will be respected. This followed the well-publicized case of Nancy Cruzan who was left in a permanent vegetative state following a car accident. Her case was brought before the Supreme Court by her family. The court assumed that competent people have a constitutional right to refuse unwanted medical treatment, but that a state may insist that relatives prove by clear and convincing evidence that an incompetent patient had expressed wishes to forego treatment if left in a permanent vegetative state. (ibid) Another well-known case is that of Karen Ann Quinlan, another patient in a permanent vegetative state. The New Jersey Supreme Court authorized the removal of a ventilator based on her constitutional right to privacy. (ibid) Instruments are available to evaluate aspects of mental status. One of the shorter tests is the theMiniMentall State Examination (MMSE) of Folstein. Reliability and validity are acceptable. It has been noted, however, that it should not be used as the sole criterion for diagnosing dementia. It has been found that those with a higher educational level score higher on the MMSE. (Folstein, 1975)One of the various instruments to evaluate life satisfaction is the Life Satisfaction Index (LSI) of Neugarten. This instrument identifies five categories of life satisfaction: zest vs apathy, resolution and fortitude, congruence between desired and achieved goals, self-concept, and mood tone. The multidimensionality of life satisfaction has been emphasized. There are many aspects and a person might be satisfied in one respect, but unhappy in another. Most studies show that life satisfaction does not decline with increasing age, though this is not a universal finding. It has been reported that the married are happier than the unmarried or widowed. Many studies have reported health as an important predictor of life satisfaction.
Studies on the relationship between social participation and life satisfaction have been contradictory, but most studies have shown participation in activities enhances life satisfaction. (Neugarten, Havighurst, and Tobin, 1961) STUDY Sixty-six subjects 60 years of age or older of both sexes were used in this study. The sample was mainly a sample of convenience. The subjects were individuals known to the investigator and subjects who were not known before the study who were affiliated with the facilities mentioned below. The subjects were in relatively good health in that they did not have any major medical problems. This was ascertained primarily by the investigator during the interviews and by the answers provided by the subjects on the questionnaire administered. The subjects were from two locations, one a large city and the other a small city. Subjects included people living in the community, living in a nursing home, living in housing for the elderly, attending a senior citizens center, and attending a daycare center. The average age was 76.6. Five were African American, one was Hispanic, and the rest Caucasian. The subjects were informed regarding the nature of the study and entered the study only after providing informed consent. (Greer, 1995)
Four instruments were used to gather data. Values History form requests information regarding opinions about CPR, respirator use, artificial nutrition,n, and artificial hydration. It asks for opinions about quantity or duration of life versus quality of life. It asks for the person’s perception of the role of the doctor and other health caregivers. It is used to obtain data about the elderly’s use of written legal documents, such as living wills, and the existence of legal power of attorney or guardianship. It also asks for thoughts about independence and other values. The instrument used in this study is a revision of the original instrument. The MMSE is a short, easily administered tool developed to recognize cognitive impairment. Additional questions were added by the investigator in an attempt to improve sensitivity. Questions added were repeating digits, calculation, proverb explanation, and a judgment question. The MMSE has been used extensively in clinical settings as an index of cognitive function. The questions are grouped in iintosevenin categories: orientation to time, orientation to place, registration of three words, attention and calculation, recall of three words, language, and visual construction. Several instruments have been developed for measuring the life satisfaction of the elderly. One developed by Neugarten, Havighurst, and Tobin is the Life Satisfaction Index (LSI). The LSI used in this study presents a series of statements with which the subject is asked to indicate agreement or disagreement. This instrument has had wide use in gerontological research. Demographic and descriptive information about the subjects were obtained by a questionnaire. It included information about each subject’s background and current living situation, health, marital status, educational level, children, occupation, leisure activities, political party, parents’ background, alcohol, and tobacco use, church attendance, social interaction, and age. The instruments were administered orally by the investigator. Every attempt was made to keep the environment for obtaining responses to the instruments non-threatening.
The data from the demographic questionnaire were summarized. Means and standard deviations were determined for the MMSE and the LSI. The questions on the Values History questionnaire phrased in Likert format were summarized by means and standard deviations and information from the other questions were subjects length subjects presented descriptively. Analysis of variance was used to analyze relations among responses on the Values History questionnaire and life satisfaction, mental status, and age. The majority of the subjects were fairly well-off, were in at least fair health, were widowed, and lived alone. The majority had children and grandchildren. Only three were employed. Twenty-seven percent reported drinking alcohol and 18% reported smoking. Forty percent attended church weekly. Thirty-seven percent belonged to clubs or organizations and 45% had hobbies. The majority spoke with family members weekly and even more spoke with friends frequently. Most of the subjects had less than a college degree, read newspapers and watched television, and were independent in self-care. The subjects were from two locations, one a large city and the other a small city. The average MMSE score was 25.1, of a possible 30, slightly lower than that reported by other investigators. A score below 24 would indicate mental impairment. Only 30% reported having a living will, 29% reported having legal power of attorney, and 33% reported having appointed someone to speak for them if they were to become incapacitated. Fifty-six percent disagreed or strongly disagreed with the statement “I want to live as long as possible regardless of the quality of life” and 86% agreed or strongly agreed with the statement “I want to preserve a good quality of life even if I may not live as long as possible.” This perhaps reflects an appreciation n for both lengths of life and quality of life. Fifty-one percent wanted to receive CPR if their chance of survival was small, but 58% did not want to be placed on a respirator and 73% did not want artificial nutrition.
These differences may indicate more familiarity with CPR and the more invasive nature of artificial respiration and nutrition. Seventy-six percent reported that independence was very important in their lives. Items on a values list chosen as most important were wanting to maintain the capacity to think clearly and not wanting to be a burden on the family. The average score on the LSI was 26.9 a possible total of 40. Those with higher mental status as determined by the expanded mental status test, but not the MMSE, are more satisfied with life and are younger. Regarding the question “I want to live as long as possible regardless of the quality of life” there was no significant difference in LSI scores among the levels of response to the question, but those answering agree obtained lower scores on the MMSE (Responses to the question “I want to preserve a good quality of life even if I may not live as long as possible” was not significantly related to the LSI score, mental status scores, or age. The responses to the statement “I want to receive CPR” were significantly related to LSI scores, with those strongly disagreeing having the highest LSI scores (subjects higher financial situation, with a higher educational level, in better health, who attended church frequently (-35), and who have gone on a recent holiday were more apt to disagree with the statement “I want to live as long as possible regardless of the quality of life”. In response to the statement “I want to preserve a good quality of life” those living alone or with a friend were more apt to agree with the statement than those living with a spouse or relative who was the more apt to agree than those living in a nursing home.
Those reading newspapers and those belonging to clubs were more apt to agree. In response to the statement “I want to receive cardiopulmonary resuscitation” those at a higher financial level, those with more comfortable living conditions, and those who attended church weekly disagreed more often. In response to the question “I want to be placed on a respirator” those speaking daily with family members were more apt to express not wanting the treatment than those speaking less frequently. Those having hobbies and attending church weekly were more apt to not want treatment by respirator than those not having hobbies or attending church infrequently. In response to the statement “I want to receive artificial nutrition and hydration” those attending church weekly, those speaking with family members daily or monthly, and those having hobbies disagreed more than those attending church infrequently, those speaking with family members infrequently, and those not having hobbies. (Greer, 1995)
The majority of the subjects in this study preferred quality of life over quantity of life and did not wish to receive artificial respiration or nutrition, although half wished to receive CPR. It could be that CPR was a better-known procedure, or that artificial respiration and nutrition appeared more invasive. A higher mental status was associated with higher life satisfaction. This could be because if a person senses that their cognitive status is slipping they will have less life satisfaction. There was some indication that preference for quality of life over quantity of life was positively related to mental status. Perhaps those with a higher mental status perceive a low quality of life to be unacceptable, whereas those of lower mental status is not as discerning. The desire to receive CPR was negatively related to life satisfaction although the desire to receive artificial respiration or nutrition was not related. Happier people appear to be more willing to forego CPR. Various demographic factors affected responses about the quality of life over quantity of life and life support issues. Those with a higher financial situation and who attended church weekly did not want CPR and preferred quality of life over quantity of life. Those with better educational backgrounds, in better health, and going on holiday preferred quality of life over quantity of life. Thus it appears that positive demographic factors are related to the appreciation of the quality of life. In summary, opinions of people regarding life support issues may be related to mental status, life satisfaction, and various demographic factors.