The role of the CCRC as a potential mediator be-
tween terminally ill residents and the greater medical
culture is not well understood. It has been shown that
achieving one’s preference for place of death is more
likely when end-of-life issues, such as preparation of
an advance directive, are addressed (Institute of Medi-
cine, 1997; Teno, Lynn, et al., 1997; Tolle et al., 1999).
In the CCRC described herein, the same physician
provides health care on campus, exercises acute-care
admitting privileges on behalf of residents, and di-
rects their care during tertiary care hospitalizations.
Such provider continuity, including the effective trans-
fer of advance directives across different clinical set-
tings, may have contributed to the low prevalence of
deaths in acute care settings in this sample (Galanos
There is reason to hope that the culture surround-
ing death is changing and that caring professions will
embrace end-of-life care as important and possessing
its own body of knowledge and skills (Carron, Lynn, &
Keaney, 1999; Hammes & Rooney, 1998; Tolle et al.,
1999). Given adequate control of symptoms, many
older adults wish to die in low-intervention settings.
Honoring this preference may be easiest where health
systems and policy support specialization in geriatric
care and structural linkages across community, long-
term, and acute care settings.
References
Addington-Hall, J. M., MacDonald, L. D., Anderson, H. R., & Freeling, P.
(1991). Dying from cancer: The views of bereaved family and friends
about the experiences of terminally ill patients. Palliative Medicine, 5,
&
Sash, 1998). CCRCs may also provide particularly
207–214.
effective communication and support of informal care-
givers. Physical and emotional exhaustion of family
caregivers and patients associated with a prolonged
terminal phase is the most frequent reason for institu-
tional deaths among elders who prefer to die at home
American Health Decisions. (1997). The quest to die with dignity: An anal-
ysis of Americans’ values, opinions, and attitudes concerning end-of-
life care. Appleton, WI: Author.
Ashby, M., & Wakefield, M. (1993). Attitudes to some aspects of death and
dying, living wills and substituted health care decision-making in
South Australia: Public opinion survey for a parliamentary select com-
mittee. Palliative Medicine, 7, 273–282.
Benoliel, J. Q., & Degner, L. F. (1995). Institutional dying: A convergence
of cultural values, technology, and social organization. In: H. Wass &
R. A. Neimeyer (Eds.), Dying: Facing the facts, (3rd ed. pp. 117–141)
Washington, DC: Taylor & Francis.
Branch, L. G. (1987). Continuing care retirement communities: Self-insur-
ing for long-term care. The Gerontologist, 27, 4–8.
(
Groth-Junker & McCusker, 1983). For families in-
creasingly involved in decision making at the end of
a patient’s life, CCRCs provide settings for care that
are “known quantities”: chosen and financed in ad-
vance of need, clustered in a single setting, staffed by
clinicians known not only to the patient, but to the
family as well, and thus an acceptable alternative to
a high-tech environment.
Carron, A. T., Lynn, J., & Keaney, P. (1999). End-of-life care in medical
textbooks. Annals of Internal Medicine, 130, 82–86.
Chin, A. E., Hedberg, K., Higginson, G. K., & Fleming, D. W. (1999). Le-
galized physician-assisted suicide in Oregon—The first year’s exper-
ience. New England Journal of Medicine, 340, 577–583.
The findings from this study are highly preliminary
and lack generalizability. CCRC residents are more
likely to be White, well-educated, and financially se-
cure than their community-dwelling age peers (Sher-
wood et al., 1997), and the population of this CCRC
is typical in these respects. However, it is precisely in
such a population—one that is relatively healthy and
financially unconstrained—that unbiased preferences
are most likely to be elicited. This study was also lim-
ited to a single CCRC, and its contract, service lev-
els, and fee structure will differ from other CCRCs.
Whether enrollees in any of the patchwork of pro-
grams that constitute U.S. health care for elders (e.g.,
other CCRCs, Program of All-inclusive Care of the
Elderly projects [Eng, Pedulla, Eleazer, McCann, &
Fox, 1997], or social/health care maintenance orga-
nizations [Kane et al., 1997]) or enrollees in more
prevalent managed care or fee-for-service practices
report similar place-of-death preferences and similar
prevalent desires to discuss those preferences with
their care provider is a topic of great importance for
practice-based research. A recent study of home-
bound elders in a small community-based, physi-
cian-led house call program showed comparable
prevalence of planning (64%), prevalence of prefer-
ences for home death (5:1), and health status as a
predictor of planning (Leff, Kaffenbarger, & Rems-
burg, 2000). Finally, the cross-sectional design of this
survey does not permit estimates of success rates. We
cannot be sure that high rates of out-of-hospital
deaths among CCRC residents are associated with
the resident’s preferences for deaths in the commu-
nity.
Cohen, M. A., Tell, E. J., Batten, H. L., & Larson, M. J. (1988). Attitudes to-
wards joining continuing care retirement communities. The Gerontologist,
5, 637–643.
Coulehan, J. (1997). The man with stars inside. Annals of Internal Medi-
cine, 126, 799–802.
Danis, M., Mutran, E., Garrett, J. M., Stearns, S. C., Slifkin, R. T., Hanson,
L., Williams, J. F., & Churchill, L. R. (1996). A prospective study of the
impact of patient preferences on life-sustaining treatment and hospital
cost. Critical Care Medicine, 24, 1811–1817.
Dartmouth Medical School, Center for the Evaluative Clinical Sciences.
(
1998). The Dartmouth Atlas of Health Care 1998. Chicago: American
Hospital Publishing.
Donaldson, M. S., & Field, M. J. (1998). Measuring quality of care at the
end of life. Archives of Internal Medicine, 158, 121–128.
Eng, C., Pedulla, J., Eleazer, G. P., McCann, R., & Fox, N. (1997). Program
of All-inclusive Care for the Elderly (PACE): An innovative model of in-
tegrated geriatric care and financing. Journal of the American Geriatrics
Society, 45, 223–232.
Fischer, G. S., Tulsky, J. A., Rose, M. R., Siminoff, L. A., & Arnold, R. M.
(
1998). Patient knowledge and physician predictions of treatment pref-
erences after discussion of advance directives. Journal of General Internal
Medicine, 13, 447–454.
Fried, T. R., Pollack, D. M., Drickamer, M. A., & Tinetti, M. E. (1999). Who
dies at home? Determinants of site of death for community-based long-
term care patients. Journal of the American Geriatrics Society, 47, 25–29.
Galanos, A. N., & Sash, K. W. (1998). Impact of a continuing care retire-
ment community on place of death [Abstract]. The Gerontologist,
38(Special Issue 1), 354.
Groth-Junker, A., & McCusker, J. (1983). Where do elderly patients prefer
to die? Place of death and patient characteristics of 100 elderly patients
under the care of a home health care team. Journal of the American
Geriatrics Society, 1, 457–461.
Gupta, N., & Galanos, A. (1996). Why healthy elders move to a continuing
care retirement community. North Carolina Medical Journal, 57, 378–380.
Hakim, R. B., Teno, J. M., Harrell, F. E., Jr., Knaus, W. A., Wenger, N.,
Phillips, R. S., Layde, P., Califf, R., Connors, A. F., Jr., & Lynn, J. (1996).
Factors associated with do-not-resuscitate orders: patients’ preferences,
prognoses, and physicians’ judgments. Annals of Internal Medicine,
125, 284–293.
Hammes, B. J., & Rooney, B. L. (1998). Death and end-of-life planning in
one Midwestern community. Archives of Internal Medicine, 158, 383–
390.
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