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Withholding Medical Treatment From the Severely Demented PatientDecisional Processes and Cost Implications
Nelda Wray, MD, MPH;
Baruch Brody, PhD;
Timothy Bayer, MD;
Eugene Boisaubin, MD;
Fidel Davila, MD;
Rebecca Dresser, JD;
J. Kay Dunn, PhD;
H. T. Engelhardt, Jr, PhD, MD;
Harold Haley, MD;
J. Devance Hamilton, MD;
Stewart Niefield, MD;
Earl Shelp, PhD;
James Scheurich, MD
Arch Intern Med. 1988;148(9):1980-1984.
Abstract
• We performed an observational study to determine the prevalence of severe dementia in a general medicine unit, the categories of acute medical care provided to these patients, the process by which treatment decisions are made, and their cost implications. The prevalence of severe dementia was 4.4%. The patients from whom some form of acute medical care was withheld (26 [45.6%] of 57) were more severely ill at admission and had a mortality rate five times higher than those who received full care. Physicians cited family wishes in 75.9% of the decisions to limit care but in only 10.9% of the decisions to give full care. The only differences in charges incurred were due to differential mortality rates in individuals from whom care was withheld. We recommend that hospitals develop and implement protocols for decision making in the care of the severely demented to promote open discussions among providers and families and to increase family contributions to decision making. We believe that the extension of this consultative approach to decisions involving severely demented patients may have the virtue of combining more humane care with more cost-effective care.
(Arch Intern Med 1988;148:1980-1984)
Author Affiliations
From the Departments of Medicine (Drs Wray, Boisaubin, Davila, Niefield, and Scheurich), Psychiatry (Drs Bayer and Hamilton), and Surgery (Dr Haley) and the Center for Ethics (Drs Brody, Dresser, Engelhardt, and Shelp), Baylor College of Medicine, Houston. Dr Davila is currently at McNeal Hospital, Berwyn, Ill. Dr Niefield is now in private practice in Houston.
Footnotes
Accepted for publication April 20, 1988.
Presented in part at the meeting of the Association of American Medical Colleges, Washington, DC, Nov 9, 1987, and at the meeting of the Southern Region of the Society for General Internal Medicine, New Orleans, Feb 5, 1988.
Reprints not available.
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