BMJ 2002;325:125 ( 20 July )

Papers

Planning for death but not serious future illness: qualitative study of housebound elderly patients

Joseph A Carrese, associate professor of medicine, a Jamie L Mullaney, assistant professor, b Ruth R Faden, Philip Franklin Wagley professor of biomedical ethics and director, c Thomas E Finucane, professor of medicine. d

a Phoebe R Berman Bioethics Institute, Johns Hopkins University, and Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224, USA, b Department of Sociology and Anthropology, Goucher College, MD 21204, USA, c Phoebe R Berman Bioethics Institute, Johns Hopkins University, 624 N Broadway, Hampton House 352, Baltimore, MD 21205, USA, d Phoebe R Berman Bioethics Institute, Johns Hopkins University, and Division of Geriatrics, Johns Hopkins Bayview Medical Center

Correspondence to: J A Carrese jcarrese{at}JHMI.edu

Objective: To understand how elderly patients think about and approach future illness and the end of life.
Design: Qualitative study conducted 1997-9.
Setting: Physician housecall programme affiliated to US university.
Participants: 20 chronically ill housebound patients aged over 75 years who could participate in an interview. Participants identified through purposive and random sampling.
Main outcome measures: In-depth semistructured interviews lasting one to two hours.
Results: Sixteen people said that they did not think about the future or did not in general plan for the future. Nineteen were particularly reluctant to think about, discuss, or plan for serious future illness. Instead they described a "one day at a time," "what is to be will be" approach to life, preferring to "cross that bridge" when they got to it. Participants considered end of life matters to be in the hands of God, though 13 participants had made wills and 19 had funeral plans. Although some had completed advance directives, these were not well understood and were intended for use only when death was near and certain.
Conclusions: The elderly people interviewed for this study were resistant to planning in advance for the hypothetical future, particularly for serious illness when death is possible but not certain.

What is already known on this topic
Advance care planning is widely endorsed as a means to improve quality of care for patients near the end of life

What this study adds
Elderly housebound patients described a world view that does not easily accommodate advance care planning: they live life a day at a time, preferring not to consider problems until they occur

These patients resisted planning for the hypothetical future

They most resisted planning for those situations when the most difficult decisions often arise, such as for serious illness when death is possible but not certain




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Elderly people do not plan for future illness
BMJ 2002 325: 0. [Full Text] [PDF]

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