Moral reasoning, self-transcendence, and end-of-life decisions in a group of community-dwelling elders

Abstract

A societal consensus has developed around the principle that decisions about life sustaining treatment should be guided by patient preferences. This view is supported by the American Nurses' Association, which promotes the patient's right to self determination in end-of-life decisions and the nurse's involvement in facilitating decision-making for patients making such choices. This idea is further evidenced by the Patient Self-Determination Act of 1991, where hospitals are required to ascertain whether or not the patient has an advance directive and to counsel patients about their rights to formulate an advance directive. Little is known about how people make decisions concerning their life in the midst of current biotechnical advances that extend life. This study attempted to gain insight into moral reasoning and other contextual, developmental factors that may account for elders' perspectives related to end-of-life care. Elders' perceptions about the end of life and the reasoning processes used to formulate preferences for treatment at the end of life were investigated. The advance directive decision, as one practice issue, was studied as an indicator of preferences for end-of-life treatment. Also, contextual factors (age, education, gender, self-reported health status, prior experience with an advance directive decision) and self-transcendence, regarded as an indicator of a developmental transition in older adults, were examined as correlates of moral reasoning about end-of-life choices as well as desires for end-of-life treatment. Findings revealed that older adults (N = 126) use an integrated and complex approach to reasoning in the context of end-of-life decisions. Self transcendence, an indicator of this unique characteristic of adult cognition, was significantly related to the level of integrated moral reasoning and may explain why reasoning about end-of-life treatment options takes on a more complex and integrated approach. In addition to elders' unique patterns of thinking, the context of their experiences impact preferences for end-of-life treatment. Level of education, prior experience with a life-threatening illness, and the decision to complete a living will are important indicators of the desired aggressiveness of end-of-life treatment. Thus, moral development in the context of end-of-life decisions may be explained in part through an understanding of a contextual-dialectic process.