From Our 2008 Archives

Seniors Tend to Stick With End-of-Life Care Preferences

By Alan Mozes
HealthDay Reporter

MONDAY, Oct. 27 (HealthDay News) - Regardless of declines in either mental or physical health, most senior citizens do not change their outlook on how they want their end-of-life care to be when the time comes, new research suggests.

The study notes, however, that despite observing an overall stability in patient perspective, certain patients do seem to change their mind over time.

"We found that the people who wanted the least [aggressive treatment] were the most likely to continue wanting the least, whereas the people wanting the most were the most likely to change over to wanting less over time," noted study author Dr. Marsha N. Wittink from the department of family medicine and community health at the University of Pennsylvania School of Medicine in Philadelphia.

Wittink and her team published the observations in the Oct. 27 issue of the Archives of Internal Medicine.

Their findings are based on a comparative analysis of two end-of-life treatment preference questionnaires completed by 818 physicians, all of whom graduated from Johns Hopkins University between 1948 and 1964.

At an average age of 69 when the study was launched, all the participants completed an initial survey in 1999, followed by a second survey in 2002.

At both times, the patients were asked to indicate which types of interventions they would want should they experience brain death that rendered them unable to either speak or recognize those around them. Possible interventions included surgery, insertion of a feeding tube, dialysis, and/or cardiopulmonary resuscitation.

Serious changes in the participants' physical and/or mental health over the course of the intervening three years were also monitored.

The research team found that the overall percentage of study participants who fell into each level of treatment preference --"aggressive," "intermediate" or "least aggressive"-- remained pretty constant over the three years, as patients who turned down particular treatments in 1999 continued to be likely to do so in 2002.

Specifically, while 12%, 26% and 62% respectively preferred aggressive, intermediate or least aggressive treatment in 1999, overall preferences had shifted only slightly by 2002: to 14%, 26% and 60%, respectively.

Getting older or experiencing a decline in either mental or physical health did not appear to impact patient preferences, the researchers noted.

However, although the absolute numbers of those choosing one type of treatment approach or another remained more or less constant, individuals didn't necessarily stay in their original category, with some gravitating towards more or less aggressive intervention over time.

For example, among those who had indicated that they wanted "aggressive" treatment in 1999, just 41% maintained that preference in 2002.

On the other hand, those who lacked either a living will or a durable power of attorney when they first outlined their preferences in 1999 were twice as likely to want "aggressive" life-sustaining care (as opposed to "least aggressive" care) when they were re-interviewed in 2002.

"This dynamic is important to understand, because even though most people are stable in their preferences -- which is not surprising -- some people are not," said Wittink. "So that means that both doctors and patients need to be thinking and communicating about patient feelings as preferences change."

Dr. Steven Pantilat, director of the palliative program at the University of California, San Francisco, suggested that the findings make intuitive sense.

"Previous research has actually suggested that people do change their minds, and that it's hard to predict whether an individual will end up wanting more or less aggressive treatment down the road," he said. "But even though this finding is a little different than what the prior literature has indicated, I have to say that it's more in line with what I've personally observed. Which reflects the fact that generally people's values and goals don't change that much over time."

"I also think that moving from wanting more treatment to wanting less is typical of many patients," he said. "Because as seriously ill people experience the increasing burden of treatment coupled with what they realistically can expect to get from it, there is often a shift in focus towards gaining comfort and a better quality of life, and away from aggressive life-prolonging intervention."

"Whatever the case, what's important is that patients are upfront at an early stage about their preferences, so they get the care they want," he stressed. "Because preferences about end-of-life are not whims. And if you don't express yourself you may very well get the kind of care you don't want."

SOURCES: Marsha N. Wittink, M.D., M.B.E., department of family medicine and community health, University of Pennsylvania School of Medicine, Philadelphia; Steven Pantilat, M.D., professor, medicine, and director, palliative program, University of California, San Francisco; Oct. 27, 2008, Archives of Internal Medicine

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