Senior Citizens Usually Stick by Their End-of-Life
Preferences as Health Declines
Those choosing most aggressive treatment are most
likely to change at end
Oct. 27, 2008 Among the toughest decision most of
us face is the advance determination of how we want the health care
system to manage our deaths. The legal document is called an advance
directive. A new study has found physicians who execute these advanced
directives do not usually change their minds at least within three
years - regardless of declines in physical and mental health. Those who
do change their minds about life-sustaining treatment are usually those
who say they want aggressive care and those who have no advance
directive.
All of the subjects in this study were physicians,
which may skew the results as they might apply to non-medical
professionals that are less familiar with treatments and end-of-life
conditions.
Over 60 percent of the physicians chose the least
aggressive care. And, in the follow-up, these were the least likely to
change preferences (80% of persons in the least aggressive category at
baseline were in the same category at follow-up).
Only 12 percent chose the most aggressive care at
baseline and they were the most likely to change preferences over time
(only 41% of the persons in the most aggressive category at baseline
were in the same category at follow-up).
In addition, they found that physicians without
advance directives were twice as likely as those with advance directives
to transition to the most aggressive category compared with a transition
to the least aggressive category during the 3-year follow-up.
"Efforts to improve the experience of patients and
families at the end of life must incorporate patient perspectives," the
authors write as background information in the article.
"Advance directives are one strategy through which
patient preferences can be elicited and recorded, to be invoked at a
time when the patient may not be able to make decisions directing care."
However, they note, preferences for life-sustaining
treatment given in one state of health may not reflect the choices
patients would make if their health status changed.
Marsha N. Wittink, M.D., M.B.E., of the University
of Pennsylvania School of Medicine, Philadelphia, and colleagues
assessed end-of-life preferences in 818 physicians (average age 69) who
graduated from medical school at Johns Hopkins University between 1948
and 1964.
Participants completed questionnaires about their
health status and their end-of-life preferences in 1999 and again in
2002.
They were asked to consider what treatments they
would want in the event of brain death that left them unable to speak or
recognize people. They reported how likely they were to desire each of
10 interventions, including cardiopulmonary resuscitation, major
surgery, a feeding tube and dialysis.
The physicians were divided into three clusters
based on their preferences:
1. those who would want most of the
interventions were classified as preferring aggressive care (12 percent
in 1999 and 14 percent in 2002),
2. those who would want intravenous fluids and
antibiotics as the primary interventions as preferring intermediate care
(26 percent in 1999 and 26 percent in 2002) and
3. those who would decline most interventions as
desiring least aggressive care (62 percent in 1999 and 60 percent in
2002).
"In general, procedures that were declined in 1999
were likely also to be declined in 2002," the authors write.
"Nevertheless, a substantial proportion of persons
who desired an intervention in 1999 declined the treatment in 2002."
A total of 41 percent of those who said they
desired aggressive care in 1999 remained in that category in 2002.
In addition, physicians who did not have a living
will or durable power of attorney were twice as likely to transition to
the most aggressive category as those without advance directives.
Age and declines in mental and physical health were
not associated with transitions to either more or less aggressive care.
"We believe that the results of this study suggest
that although physician-respondents were relatively stable in their
preferences, persons without advance directives and who desired the most
aggressive treatment at baseline exhibited the most changeable
preferences," the authors write.
"Persons who express a desire for aggressive
treatment and those who have not communicated their wishes with a more
formal written document (advance directives) may require frequent
clinical re-evaluation to assess whether wishes have changed."
The report on this study is in the October 27 issue
of Archives of Internal Medicine, one of the JAMA/Archives journals.
Editor's Note: Dr. Wittink was supported by
Mentored Patient-Oriented Research Career Development Award from the
National Institute of Mental Health. The Johns Hopkins Precursors Study
was supported by grants from the National Institutes of Health.
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