Oct. 27, 2008 Most individuals' preferences regarding life-sustaining treatment do not appear to change over a three-year period, regardless of declines in physical and mental health, according to a new report. Individuals who say they want aggressive care and those without advance directives are most likely to change their end-of-life wishes over time.
"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: those who would want most of the interventions were classified as preferring aggressive care (12 percent in 1999 and 14 percent in 2002), 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 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."
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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- Marsha N. Wittink; Knashawn H. Morales; Lucy A. Meoni; Daniel E. Ford; Nae-yuh Wang; Michael J. Klag; Joseph J. Gallo. Stability of Preferences for End-of-Life Treatment After 3 Years of Follow-up: The Johns Hopkins Precursors Study. Arch Intern Med., 2008;168(19):2125-2130 [link]
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