Background Many older adults with severe dementia receive potentially life-extending treatments even when caregivers do not wish to prolong their life inappropriately. Objective Explore factors that influence caregiver preferences for potentially life-extending treatments for older adults with severe dementia, and reasons for discordance between overall end-of-life care goal and treatment preferences. Design Semi-structured in-depth interviews asking caregivers their overall end-of-life care goal for older adults and preferences for intravenous (IV) antibiotics, tube feeding and cardiopulmonary resuscitation (CPR). Participants A total of 26 caregivers of community-dwelling older adults with severe dementia in Singapore. Approach Reflexive thematic analysis. Results Most caregivers’ (77%) overall end-of-life care goal was ‘no life extension’. Yet, 80% preferred IV antibiotics for a life-threatening infection, 60% preferred tube feeding and 45% preferred CPR. Caregivers preferred these treatments because they (1) perceived letting go by withholding treatments as unethical, (2) felt they had no choice as they deferred to the health care provider, (3) wanted to alleviate suffering rather than extend life and (4) desired trying minimally invasive treatments that had the potential to be withdrawn. Themes explaining discordance were (1) feared regret about making the ‘wrong’ decision, (2) considered treatments to address immediate needs even when long-term goal did not match providing that treatment and (3) anticipated disagreement with other family members on overall goal of care. Conclusion To reduce discordance between caregivers’ overall end-of-life care goal and preferences for life-extending treatments, clinicians can use a shared decision-making approach involving discussions of both their overall end-of-life care goal and treatment preferences.

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BACKGROUND: Evidence suggests that tube feeding persons with severe dementia (PWSDs) does not improve survival or quality of life, yet many continue to be tube fed. Reasons why caregivers choose to do so are not entirely understood. OBJECTIVE: To understand what shapes caregiver preference toward nasogastric (NG) tube feeding for communitydwelling PWSDs. DESIGN: A qualitative study that employed semistructured interviews. SETTING AND SUBJECTS: Primary informal caregivers of community-dwelling persons diagnosed with dementia Functional Assessment Staging Test (FAST) stage 7 in Singapore. METHODS: Caregivers participated in qualitative in-depth interviews during which their preferences toward NG tube feeding of PWSDs were explored. We used principles of reflexive thematic analysis to compare caregivers who expressed a preference for NG tube feeding with those who did not prefer it. RESULTS: We interviewed 27 caregivers of PWSDs. Most caregivers, 67% (n = 18), expressed a preference for tube feeding. We conceptualized four main themes describing what shapes caregiver preference toward NG tube feeding: (1) willingness to use tube feeding to prolong life at the expense of suffering, (2) deference to healthcare provider's (HCP's) recommendation, (3) caregiver knowledge of alternatives to tube feeding, and (4) caregivers' internal and external conflicts. CONCLUSION: Results from this study highlight the need for new inclusive approaches to shared decision-making between HCPs and caregivers regarding tube feeding for community-dwelling PWSDs.

Family caregivers of older adults with severe dementia are decisive in use of potentially life-extending interventions for their care recipients. We conducted in-depth interviews with 26 caregivers of community-dwelling older adults with severe dementia in Singapore to assess their preferences for intravenous (IV) antibiotics for a life threatening infection, tube feeding, and cardiopulmonary resuscitation (CPR), and reasons thereof. Most caregivers’ (77%) end-of-life care goal was ‘no life extension’. Yet, 80%, 60% and 45% preferred IV antibiotics, tube feeding and CPR, respectively, as they: 1) perceived letting go by withholding interventions as unethical, 2) felt they had no choice, deferring to health care providers (HCPs), 3) wanted to alleviate suffering, and 4) desired trying minimally invasive (and potentially withdrawable) interventions. There was discordance between caregivers’ end-of-life care goal and preferences for life-extending interventions. HCPs can suggest intervention options that concur with caregivers’ end-of-life care goal, and use a shared decision-making approach. Part of a symposium sponsored by the Aging Among Asians Interest Group.