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Purpose: This study examined change in the decision-making autonomy of a single nursing facility resident., Design and Methods: This case analysis was part of a larger 3-year ethnographic investigation of decision-making events in four nursing facilities. In this case analysis, the resident, her daughter, and three staff members closely associated with the resident's care were each interviewed five times over a 15-month period., Results: Analysis of interview transcripts revealed four themes in decision making. Temporal change was evident in a complex scenario regarding room changes. Spatial context reflected the need for predictability and adaptability in decisions using space. Interdependence of decisions and decision makers was most evident with medical treatment and health care decisions. Awareness, being informed, and knowing what was going on was the final theme., Implications: Despite having the best interests of the resident in mind, the process of decision making in nursing facilities may contribute to a pattern of gradual withdrawal of decisional autonomy from residents regardless of their ability to make decisions.

l. Family members remain fully involved in nursing home decision-making after their relative has been admitted to a facility. 2. Family involvement in nursing home decision-making serves to individualize care and provide a continuing link to the resident's personal history and preferences. 3. Family members assume an array of decision-making roles in nursing homes, including: caregiving, pampering, comforting, engaging, educating, monitoring, mediating, colluding and controlling.

Older people are increasingly the focus of biomedical and behavioral research not only because the elderly constitute the fastest growing segment of our population but because there is a societal concern to improve the elderly's quality of life. The profound need to advance that research carries with it an equally profound obligation to protect the rights and welfare of elderly research subjects, and thus raises difficult ethical and legal issues. Against a background of foundational principles for the protection of human subjects, we discuss whether older subjects should be treated as a special class, the ethical and legal issues over informed consent, capacities for consent, and special problems related to cognitive impairment. We discuss surrogate/proxy consent procedures in research, recruitment of elderly subjects, conflicts of interest, special problems regarding institutional research, and risk/benefit analyses. We offer recommendations and practical guidelines for conducting current and future research involving elderly participants.

The necessity of surrogate decision making arises for geriatric patients who can no longer make decisions for themselves. Almost every clinical situation involves some assessment of a patient's decisional capacity. Because decisional capacity is decision specific and entails the ability to manipulate information, it is best to conduct functional evaluations and use psychiatric measurements for dementia cautiously in determining decisional capacity. Traditionally, the medical community has relied on family members to be surrogate decision makers when a patient is assessed as decisionally incapacitated. That practice still has moral warrant, even amid advocacy for the use of advance directives, because most people have not completed such planning instruments. The family as a primary social unit is likely the most concerned for the welfare and wishes of the patient. These theoretical grounds are supplemented by emerging empirical evidence that elderly patients themselves almost always prefer that family members serve in the role of surrogate decision makers. Dealing with family surrogates obliges the geriatrician to ensure that failures in communication do not arise and that conflicts of interest are avoided in protecting the best interests of the patient. Although recent legal climate has shown a preference for a substituted judgment standard in surrogate decision making, medical concern for the best interests of the patient, together with empirical evidence that the elderly are most interested in decisions that arise out of trusted interdependencies, suggests that rules and laws are no substitute for the good faith human actions of trusted surrogates.

Although nursing home relocation has been extensively studied, very little research has investigated the more commonly occurring phenomenon of room changes within nursing homes. Room changes were monitored in four nursing homes over a one-year period. Participant observation; repeated interviews with residents, family members and nursing home staff; and event analyses were used in developing detailed case studies of the room change decision-making process. A model of the room change process and factors influencing this process is offered, involving five distinctive phases--precursors, initiation, decision, action, and outcomes.

Advancement of Alzheimer disease (AD) research will not only depend on increased participation of patients with AD as subjects, but researchers will likely face increasingly difficult ethical issues. Presented are the results of a survey of researchers at the 15 federally funded Alzheimer Disease Research Centers concerning the ethical issues for subjects with AD participating in research. Experiences from 99 projects are assessed. Major findings include a significant lack of uniformity on the assessment of competency of subjects to consent to research, proxy informed consent overwhelmingly provided informally by family members, no wide use of durable powers of attorney and guardians, perception by the investigators that most projects present only minimal risks to the subjects, and Institutional Review Boards not being viewed by the investigators as preventing or inhibiting the advancement of AD research. It is recommended that research is needed to develop greater clarity in assessment of capacity of subjects to provide informed consent, that ethical and legal empowerment of family members to provide proxy consent be sustained, and that the issue of risk/benefit ratios for AD participants in research be reevaluated in the light of potentially greater risks to subjects.

This study tested the efficacy of educational interventions to increase the use of advance directives among the elderly. Three types of educational materials, various community-dwelling populations of older people (n = 293), and offers of free legal assistance were examined. Interventions increased use slightly, not dramatically, especially with the group receiving a moderate level of materials plus an invitation to a meeting. Knowledge and use were also associated with race and education levels. The most common reason given for nonuse was deferring to others and putting it off.

Because patients with Alzheimer's disease are on a path of declining capacity to give consent, advancement of research with Alzheimer's disease subjects presents challenging and perplexing ethical and legal dilemmas. Although generic regulations for the protection of human subjects apply, special considerations for cognitively impaired dementia subjects have depended on local Institutional Review Boards and relevant state laws and regulations, producing a lack of uniformity regarding encouragement of research and protection of subjects. Discussed are the dilemmas encountered in advancing research with Alzheimer's disease subjects, including (1) issues about informed consent, (2) determination of decision-making capacity (competency), (3) problems in dealing with subjects of mild and fluctuating impairment, and (4) proxy and advance consent measures for severely impaired subjects. Proposed is an agenda of ethical research needs for advancing biomedical research on Alzheimer's disease. Needed are empirical studies concerning recruitment of Alzheimer's disease subjects, the actual processes of informed consent, and the difficulties encountered by researchers, collaborative development of tests for both diagnosing Alzheimer's disease and assessing subjects' capacities to provide informed consent, and exploration of innovative uses of advance and proxy consents for participation in Alzheimer's disease research.

Nurses are increasingly caring for older persons who have become decisionally incapacitated due to acute or chronic illnesses. A nurse may be called on to share in the decision-making process for the elderly patient or to assist in bringing about a surrogate decision involving the patient's relatives and the medical team.

Findings of a statewide survey indicate that only 9% of Kentucky adults are completing Living Wills and an equal percent are designating Health Care Surrogates. Designed to protect patient's rights of self-determination in treatment decisions and protect physicians and other health care professionals from liability in complying with patient wishes, only 37% of the state's residents know about Kentucky's Living Will and 24% known about the Designation of Health Care Surrogate. In view of the results, it is recommended that educational efforts be undertaken, changes in legislation occur to ease advance medical directive access and use, and that, following customary medical practice, legislation be enacted to provide authorization of family members to serve as substitute health care decision makers for incapacitated patients.

Are gerontologists creating a new myth about families by emphasizing individual autonomy as independence without family interdependence, by advocating advance directives instead of supporting a rebuttable presumption of family surrogates, and following the lead of the U.S. Supreme Court in the Cruzan case (Cruzan v. Director, 1990), by ignoring intergenerational interdependencies in surrogate decision making? This paper argues that another antifamily trend is developing despite empirical evidence showing that elderly persons themselves prefer family members to represent them in surrogate decision making. Research and public policy suggestions are offered for protecting the elderly's preferences.

Medical professionals are increasingly faced with ethical dilemmas of caring for older patients who are decisionally incapacitated. Most often they rely on family to serve as surrogate decision makers. Does that practice agree with the preferences of the elderly themselves? Examined are the exploratory and qualitative findings of a sample of men and women, age 65 to 91 (N = 71). Comparisons are made between those elderly who have families and those who do not have families regarding the use of and interest in advance directives and proxy appointments. The findings suggest that elderly persons with families prefer to rely on relatives to conduct substitute decision making informally, unencumbered by legally executed living wills or proxy documents. Those without families view friends and doctors as their surrogate resource and endorse the use of legal proxy appointments. Implications for the use of advance directives and further public policy are discussed.

While most health care is provided at the primary care level, little research has been done to document the ethical issues of such care. A stratified random sample of 702 physicians, nurses, physical therapist, and physician assistants within one southeastern state was surveyed to determine the frequency of ethical issues in primary care. The most frequently occurring issue concerned moral decisions about the amount of time to spend with each patient. A comparison of physician and nonphysician professional groups revealed significant differences in frequencies of the issues. Age had a slight impact on the responses, while gender, religion, and region of practice had none. The study showed that the most frequently occurring issues are pragmatic, not dramatic, and center on patient self-determination, adequacy of care and professional responsibility, and distribution of resources.

The issues of truth telling and confidentiality, although less dramatic than foregoing life-sustaining treatments, are among the most important for any professionally moral relationship between a dying patient and nurse. The ethical dilemmas for the nurse caught in the middle are described. The interdependence of truth telling and keeping confidences is discussed. Guidelines for open communication and empathic listening are suggested.

It has been suggested in the lay literature that static stretching and/or warm-up will prevent the occurrence of Delayed-Onset Muscle Soreness (DOMS). The primary purpose of this study was to determine the effects of static stretching and/or warm-up on the level of pain associated with DOMS. Sixty-two healthy male and female volunteers were randomly assigned to four groups: (a) subjects who statically stretched the quadriceps muscle group before a step, (b) subjects who only performed a stepping warm-up, (c) subjects who both stretched and performed a stepping warm-up prior to a step test, and (d) subjects who only performed a step test. The step test (Asmussen, 1956) required subjects to do concentric work with their right leg and eccentric work with their left leg to voluntary exhaustion. Subjects rated their muscle soreness on a ratio scale from zero to six at 24-hour intervals for 5 days following the step test. A 4x2x2 ANOVA with repeated measures on legs and Duncan's New Multiple Range post-hoc test found no difference in peak muscle soreness among the groups doing the step test or for gender (p greater than .05). There was the expected significant difference in peak muscle soreness between eccentrically and concentrically worked legs, with the eccentrically worked leg experiencing greater muscle soreness. We concluded that static stretching and/or warm-up does not prevent DOMS resulting from exhaustive exercise.

Practitioners and elderly patients share a common interest in advance planning for future health care decision-making in the event of decisional incapacity. It is argued that advance directives can: assist the elderly person in maximizing self-determination; and help physicians in caring for the elderly and their families by removing conflict potential. Furthermore, the author compares the legal and medical understandings of patient self-determination and the uses of best interest and substituted judgment standards. It is argued that medicine and law differ on the important issues only in degree of emphasis, not in principle. To clarify the issues, a systematic classification of the multiple levels of instruction directives and agent-proxy decision-making models is developed. Finally, it is recommended that health care decision-making for the elderly can be enhanced by encouraging patients to create as much evidence as possible to affirm their preferences and values; and plan the delegation of decisions by appointing a proxy.

Although treating the elderly occasion the same kinds of ethical issues as treating other patients, specific problems do arise when making decisions for persons, once competent, who no longer can express their values. I examine the problem of decisional incapacity and offer a critique of the principles, such as substituted judgment, and the instruments, such as advance directives, living wills, other instructional directives, as well as surrogate decision-makers.

In this study techniques were employed to induce exercising subjects to focus attention on themselves or on an external event. A total of 20 adult subjects (10 men and 10 women) were familiarized with a treadmill exercise protocol and then on two subsequent occasions performed submaximal exercise followed by a run to exhaustion under attentional conditions of self-focus (watching themselves in a mirror while listening to their breathing) and external focus (watching and listening to a movie). The order of focus conditions was counterbalanced among subjects. Analysis of postexperimental responses from subjects indicated that the procedures used to induce each type of attentional focus were successful. However, physiological and psychological responses in the two focus conditions were not always uniform for men and women, particularly during light work when men tended to have higher heart rates and significantly lower Rated Perceived Exertion while women had lower heart rates and higher Rated Perceived Exertion under self-focused conditions than under externally focused conditions. Possible explanations for the incongruence of physiological and psychological responses of men and women to the two types of attentional focus are discussed.