Posts Tagged ‘Prehospital Medical Care Directive’

Two Reports Raise Concerns for Medical Care of Elderly


Two different stories about medical care for the elderly in recent weeks caught our attention atElder Law Issues. Although they appear to be unrelated, they both address the growing problems of securing adequate care for older Americans.

Falls in the Home

An all-too-common story among the elderly begins with a fall at home and ends with placement in a nursing home. Logic would suggest that this scenario plays out more often among those who live alone; a recent study confirms that this is true.

According to research conducted at the University of California at San Francisco and reported in a recent issue of The New England Journal of Medicine, each year approximately 300,000 elderly live-alones will be found by neighbors, family or professionals after having fallen in their home. What happens after they have been found is not usually positive.

About one-quarter of those elderly will be found dead in their homes. Another ten percent or so will die shortly after in the hospital.

Of those who survive the fall, slightly more than half will end up in long-term custodial care or skilled nursing care. In other words, only about a third of all elderly live-alones who fall and are unable to get up on their own remain in their homes after the incident.

This is true even though the subjects of the study were not necessarily poor. In fact, most were middle-class and lived in residential neighborhoods. Seventy percent even had supplemental medical insurance (Medigap) policies.

What can be done to reduce the danger for these at-risk elderly? In an editorial accompanying theJournal article, Deputy Editor Edward W. Campion observed that “the best solution to the dangers of isolation is the most obvious one: being part of a community that will respond … well-designed communities that work and that people want to join and can afford.”

Geriatrician Shortage

In a separate report, the Alliance for Aging Research warned that the shortage of doctors qualified in geriatric medicine is bound to worsen in the next few years. Currently, according to the Alliance, there are only about one-third as many geriatrics specialists as are needed, and the outlook is not good for improvement of the shortage.

Currently 6,784 doctors nationwide are certified in geriatrics. That figure represents less than one percent of all doctors.

Only 14 of the nation’s 126 medical schools make geriatric training mandatory. The number of geriatrics programs is small and has failed to grow with the population of potential elderly patients.

Q&A: From Our Readers

Question: What should a hospital or nursing facility do after a patient has signed a “Do Not Resuscitate” form but before the physician has entered a formal DNR order?

Answer: You are probably thinking of the Prehospital Medical Care Directive, often described as “the Orange form” for its required bright orange color. The Directive instructs emergency room doctors and emergency medical technicians not to resuscitate the patient, and is effective immediately after it has been properly completed.

In most institutions a “DNR” order requires the attending physician’s signature. Should the patient’s wishes be honored before the doctor has signed? Absolutely. Patients have the right to refuse treatment even without the doctor’s permission. In nursing home cases the more important question is usually whether to transport to the hospital in the even of a cardio-pulmonary attack. If transported, the Orange form should accompany the patient, and CPR should be withheld.

Population Trends Among The Elderly In America


The “Aging of America” is a familiar theme. Almost everyone knows that our population is growing collectively older, and that seniors are the fastest growing segment of our society.

Aging Americans are not monolithic, however. A number of demographic trends appear among the increasing numbers of the elderly.

The dimensions of the change in society are astonishing. Although only one in twenty-five Americans was over the age of 65 at the turn of the last century, one in eight are at least that old today. Shortly after the next turn of the century, “Baby Boomers” will begin to join the ranks of the elderly, and one in five Americans will be elderly by the time the last Boomers turn 65 in the year 2030.

Older Americans will be increasingly diverse in coming decades. Although about 10% of seniors are members of at least one minority group today, that percentage will double in 50 years. Hispanics, for example, will increase from 4% of the elderly population to 16%. But the biggest increases in the elderly population will continue to be among the oldest Americans.

Since 1960, the country’s population has increased by about 45%. The number of over-65 Americans doubled in the same period. But the over-85 crowd has almost quadrupled in the same period. And those trends will continue; by 2050, the number of over-85 Americans will increase by over 500%, and the ratio of over-85s to over-65s (currently about 9%) will triple.

Women live longer than men and so make up a majority of the elderly. In the first five years after age 65, women outnumber men 6 to 5; among 85-year-olds the ratio is 5 to 2. And women are more likely than men to require assistance with activities of daily living, and to live in nursing homes.

The “old old” are more likely to need help. About 1% of those aged 65 to 74 live in nursing homes today; among those over age 85, that figure increases to 25%. Half of the “old old” need help with activities of daily living, while only 9% of those 65 to 74 require assistance.

As the population ages, demands for nursing care and nursing home placements should be expected to increase, both in absolute terms and as a proportion of all health care needs and spending.

Q & A

Q: The attending physician for one of our nursing home patients has recommended both “Do Not Resuscitate” (DNR) and “Do Not Hospitalize” (DNH) orders. The patient’s court-appointed guardian agrees. Our corporate policy seems to require that someone secure Court approval before the orders can be entered. Can this be the law?

A: No. Under Arizona law, a guardian has the power to make medical decisions for her ward, including the power to sign necessary consents and authorizations. In fact, it is clear (thanks to theRasmussen v. Fleming case) that a guardian can even authorize removal of feeding tubes in appropriate cases.

Arizona statutes do not specifically address DNR or DNH orders. There is provision, however, for a “Prehospital Medical Care Directive,” better known as the “orange form.” By executing an “orange form” a competent patient can express her wishes not to be resuscitated by emergency medical personnel, including paramedics. While this is not the same as a DNH order, it does address the same issues as a DNR. Both kinds of orders are “entered” by physicians, though consent of the patient, agent or guardian is required.

Guardians are specifically authorized to execute the “orange form” on behalf of wards. It is clear that a guardian has the power to make medical decisions generally, and the decision to approve a DNR or DNH order specifically.

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