title: Family decision-making for nursing home residents with dementia: rural-urban differences.
abstract: BACKGROUND
  Research has demonstrated substantial differences between end-of-life care in rural and urban settings. As the end of life approaches, rural elders are less likely to be hospitalized, to be placed in an intensive care unit, or to have a feeding tube, compared to their urban counterparts. These differences cannot be fully explained by rural-urban differences in access to medical services.
  
  
  OBJECTIVE
  To describe and understand rural-urban differences in attitudes toward death and in end-of-life decision making.
  
  
  METHODS
  Eight focus groups were convened in rural and urban Minnesota nursing homes. The 38 focus group participants were family members of nursing home residents with severe cognitive impairment.
  
  
  RESULTS
  Most rural focus group participants voiced unqualified acceptance of death and placed few conditions on death, beyond their hope that it would be quick and peaceful. Urban respondents presented a wider range of attitudes toward death, from unambiguous acceptance of immediate death to evident discomfort with welcoming death under any circumstances. These rural-urban differences had practical implications. Rural respondents were much less likely to endorse interventions that would impede death, compared to their urban counterparts.
  
  
  CONCLUSIONS
  Rural respondents tended to express confidence in natural forces; death was seen as neutral or beneficent. Resistance to the approach of death was more characteristic of urban respondents, some of whom insisted upon aggressive medical care in advanced dementia.
authors.affiliation: Division of Education and Research, SMDC Health System, Duluth, MN 55805, USA. cgessert@smdc.org
authors.forename: Charles E
authors.initials: CE
authors.lastname: Gessert
authors.forename: Barbara A
authors.initials: BA
authors.lastname: Elliott
authors.forename: Cynthia
authors.initials: C
authors.lastname: Peden-McAlpine
mesh_terms: D000368:Aged; D001293:Attitude to Death; D003657:Decision Making; D003704:Dementia / Q000451:nursing*; D005190:Family / Q000523:psychology*; D005260:Female; D017144:Focus Groups; D006801:Humans; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D009735:Nursing Homes; D012424:Rural Population; D014505:Urban Population