Changes in Preferences for Life-Sustaining Treatment Among Older Persons with Advanced Illness
There are conflicting assumptions regarding how patients’ preferences for life-sustaining treatment change over the course of serious illness.
To examine changes in treatment preferences over time.
Longitudinal cohort study with 2-year follow-up.
Two hundred twenty-six community-dwelling persons age ≥60 years with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease.
Participants were asked, if faced with an illness exacerbation that would be fatal if untreated, whether they would: a) undergo high-burden treatment at a given likelihood of death and b) undergo low-burden treatment at a given likelihood of severe disability, versus a return to current health.
There was little change in the overall proportions of participants who would undergo therapy at a given likelihood of death or disability from first to final interview. Diversity within the population regarding the highest likelihood of death or disability at which the individual would undergo therapy remained substantial over time. Despite a small magnitude of change, the odds of participants’ willingness to undergo high-burden therapy at a given likelihood of death and to undergo low-burden therapy at a given likelihood of severe cognitive disability decreased significantly over time. Greater functional disability, poorer quality of life, and lower self-rated life expectancy were associated with decreased willingness to undergo therapy.
Diversity among older persons with advanced illness regarding treatment preferences persists over time. Although the magnitude of change is small, there is a decreased willingness to undergo highly burdensome therapy or to risk severe disability in order to avoid death over time and with declining health status.
KEY WORDSlife support care decision-making chronic disease
- 10.Rosenfeld KE, Wenger NS, Phillips RS, et al. Factors associated with change in resuscitation preference of seriously ill patients. The SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. Arch Intern Med. 1996;156:1558–64.PubMedCrossRefGoogle Scholar
- 15.The Connecticut Hospice Inc. Summary Guidelines for Initiation of Advanced Care. Branford, CT: John Thompson Institute; 1996.Google Scholar
- 35.McCulloch CE, Searle SR. Generalized, Linear, and Mixed Models. New York: John Wiley & Sons; 2001.Google Scholar
- 37.SAS Software System. Version 9.1. In. Cary, NC: SAS Institute; 2000.Google Scholar
- 38.Pearlman RA, Starks HE, Cain KC, Cole WG, Patrick DL, Uhlmann RF. Integrating preferences for life-sustaining treatments and health state ratings into meaningful advance care discussions. In: van der Heide A, Onwuteaka–Philipsen B, Emanuel EJ, van der Maas PJ, van der Wal G, eds. Clinical and Epidemiological Aspects of End-of-Life Decision-Making. Amsterdam: Royal Netherlands Academy of Arts and Sciences; 2001.Google Scholar
- 41.National Institutes of Health. State-of-the-Science Conference Statement: Improving End-of-Life Care. Bethesda, M.D.: U.S. Department of Health and Human Services; 2004.Google Scholar
- 43.Borum ML, Lynn J, Zhong Z. The effects of patient race on outcomes in seriously ill patients in SUPPORT: an overview of economic impact, medical intervention, and end-of-life decisions. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments. J Am Geriatr Soc. 2000;48:S194–8.PubMedGoogle Scholar
- 49.Little RJA, Rubin DB. Statistical Analysis with Missing Data. 2nd edition. Hoboken, NJ: John Wiley & Sons; 2002.Google Scholar