Intended for healthcare professionals


Older Americans hold on to life dearly

BMJ 2000; 320 doi: (Published 29 April 2000) Cite this as: BMJ 2000;320:1206
  1. Randall McShine, fellow of geriatrics.,
  2. Gerson T Lesser, assistant professor of geriatrics. (glesser{at},
  3. Antonios Likourezos, research associate
  1. Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, and Jewish Home and Hospital, 120 West 106th Street, New York, NY 10025, USA

    EDITOR—The study of Salkeld et al in Australia of the choices of older patients in hypothetical illness scenarios is particularly pertinent to those of us dealing with patients in nursing homes.1 We are struck by the contrasting attitudes and expectations of the elderly patients with whom we are in daily contact. In our experience, most older Americans hold on to life very dearly and usually opt for even noxious treatments, such as chemotherapy, to gain a few months or years of life that is reduced in quality. These attitudes are consistent with observations in patients of 80 years or more who were in hospital, many of them in poor health.2 When they were asked to choose between their current state of health or a shorter life in excellent health, over two thirds were unwilling to exchange even 10% of life expectancy for the benefit of excellent health.2

    Basic expectations also seem to differ between elderly Australians and Americans. While many would attest to having had a fair or good long life, we rarely hear any suggestion that one has lived overlong or “on borrowed time at the expense of younger people.” Patient choices are amenable to influence and alteration.3 The choices of the subjects in the study of Salkeld et al conformed to attitudes and opinions of the investigators, who note in several places that all subjects had already “exceeded average life expectancy.” Certainly people are unwilling to lose independence of function or decision, but we cannot readily accept (even for Australians) that 80% would rather be dead than suffer a hip fracture and subsequent admission to a nursing home. (Is there any incidence of suicide or request for death when such events are actually faced?)

    This prompts further consideration that advance preferences or directives may not conform with those when crisis is at hand. In abstract discussion (or in living wills) tube feeding, having to breathe on a respirator, and even intravenous treatments are often abjured, but such prohibitions are rarely carried forward when the acute illness is faced. The attitudes of those already in nursing homes with hip fractures might be compared with those of the subects in the study by Salkeld al. Our rehabilitation department deals with over 80 patients recovering from hip fracture annually; many remain for long term care. While some of those receiving long term care are depressed, most soon accommodate, adjust, and have a reasonable quality of life.


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