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Refusal of Medical and Surgical Interventions by Older Persons with Advanced Chronic Disease

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Patients with advanced chronic disease are frequently offered medical and surgical interventions with potentially large trade-offs between benefits and burdens. Little is known about the frequency or outcomes of treatment refusal among these patients.


To assess the frequency of, reasons for, factors associated with, and outcomes of treatment refusal among older persons with advanced chronic disease.


Observational cohort study.


Two hundred twenty-six community-dwelling persons with advanced cancer, chronic obstructive pulmonary disease, or congestive heart failure, interviewed at least every 4 months for up to 2 years.


Participants were asked if they had refused any treatments recommended by their physicians, and why.


Thirty-six of 226 patients (16%) reported refusing 1 or more medical or surgical treatments recommended by their physician. The most frequently refused interventions were cardiac catheterization and surgery. The most common reason for refusal was fear of side effects (41%). Treatment refusal was more frequent among patients who wanted prognostic information (10% vs 2%, p = .02) or estimated their own longevity at 2 years or less (18% vs 5%, p = .02). There was an increased risk of mortality among refusers compared with non-refusers (HR 1.98, 95% CI 1.02–3.86).


Refusal of medical and surgical interventions other than medications is common among persons with advanced chronic disease, and is associated with a greater desire for, and understanding of, prognostic information.

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Supported by grant PCC-98-070-1 from VA HSR&D, R01 G19769 from the National Institute on Aging, P30 AG21342 from the Claude D. Pepper Older Americans Independence Center at Yale, and a Paul Beeson Physician Faculty Scholars Award. Dr. Rothman is a postdoctoral research fellow in geriatics and clinical epidemiology and is supported by a training grant from the National Institute on Aging (T32AG1934). Dr. Fried is supported by K02 AG20113 from the National Institute on Aging. The authors thank Carm Joncas, RN and Barbara Mendes, RN for their extraordinary interviewing skills. Portions of this work were presented previously at the 2005 Annual Meeting of the American Geriatrics Society.

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Correspondence to Marc D. Rothman MD.



Definition of Advanced Chronic Illness, by Diagnosis

Chronic Obstructive Pulmonary Disease:

  1. 1.

    Two of the following:

    1. a.

      PCO2 of 45 mmHg or greater or oxygen saturation of 90% or lower when breathing room air

    2. b.

      cor pulmonale

    3. c.

      respiratory failure episode (with intubation) in the prior year

    4. d.

      FEV1 (forced expiratory volume in 1 second) of lower than 0.5 L

    5. e.

      polycythemia (hematocrit >53%); or

  2. 2.

    Hospitalization within the past 6 months with breathlessness, respiratory failure, or mental status change as the main reason for hospital admission, and either:

    1. a.

      PO2 of 60 mmHg or lower and PCO2 of 50 mmHg or greater if patient is receiving room air; or

    2. b.

      PCO2 of 50 mmHg or greater if patient is receiving supplemental oxygen.

Congestive Heart Failure:

  1. 1.

    New York Heart Association class III or IV and use of 2 of the following 4 classes of medications: diuretics; inotropics; angiotensin-converting enzyme inhibitors; other vasodilators; or

  2. 2.

    Left ventricular ejection fraction of 20% or lower and use of 2 of the following 4 classes of medications: diuretics; inotropics; angiotensin-converting enzyme inhibitors; other vasodilators; or

  3. 3.

    Hospitalized and use of 2 of the following 4 classes of medications: diuretics; inotropics; angiotensin-converting enzyme inhibitors; other vasodilators.


  1. 1.

    All patients with brain cancer, liver cancer, inoperable non-small cell lung carcinoma lung cancer, pancreatic cancer, or gallbladder cancer; or

  2. 2.

    Patients with these cancers if they have had 1 hospitalization or more for their cancer: metastatic colon cancer or stage III or IV non-small cell lung cancer (involvement of mediastinum, hilum, peribronchial nodes, pleural space, or distant metastases); or

  3. 3.

    Patients with these cancers, if first-line therapy has failed and limited response expected to second-line therapy: breast cancer, colorectal cancer, head and neck cancer, stomach cancer, esophageal cancer, melanoma, leukemia, ovarian cancer, prostate cancer, renal cancer, sarcoma, lung cancer, myeloma, or lymphoma.

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Rothman, M.D., Van Ness, P.H., O’Leary, J.R. et al. Refusal of Medical and Surgical Interventions by Older Persons with Advanced Chronic Disease. J GEN INTERN MED 22, 982–987 (2007).

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