Decisions to treat or not to treat pneumonia in demented psychogeriatric nursing home patients: development of a guideline

Non-treatment decisions concerning demented patients are complex: in addition to issues concerning the health of patients, ethical and legal issues are involved. This paper describes a method for the development of a guideline that clarifies the steps to be taken in the decision making process whether to forgo curative treatment of pneumonia in psychogeriatric nursing home patients. The method of development consisted of seven steps. Step 1 was a literature study from which ethical, juridical and medical factors concerning the patient's health and prognosis were identified. In step 2, a questionnaire was sent to 26 nursing home physicians to determine the relative importance of these factors in clinical practice. In a meeting of nine experienced physicians (step 3), the factors identified in step 2 were confirmed by most of these professionals. To prevent the final guideline being too directive, a concept guideline that included ethical and legal aspects was designed in the form of a 'checklist of considerations' (step 4). Experts in the fields of nursing home medicine, ethics and law reviewed and commented on the concept guideline (step 5). The accordingly adapted 'checklist of considerations' was tested in a pilot study (step 6), after which all experts endorsed the checklist (step 7). The resulting 'checklist of considerations' structures the decision making process according to three primary domains: medical aspects, patient's autonomy, and patient's best interest (see annex at end of paper). (Journal of Medical Ethics 2000;26:114-120) Keywords: Decision making; medical futility; patient advocacy; pneumonia; practice guidelines; nursing homes
Introduction Physicians involved in the care of elderly patients with a limited life expectancy are often confronted with the dilemma of whether treatment should be given or should be considered [...]