Researchers studying end-of-life preferences found that those most likely to change their end-of-life wishes are individuals who say they want aggressive care and individuals who do not have advance directives (such as living wills). The study, published in the October 27 issue of Archives of Internal Medicine, also found that over a three-year period, most people do not change their preferences regarding life-sustaining treatment, whether or not they face declines in physical and mental health.
Marsha N. Wittink, M.D., M.B.E. (University of Pennsylvania School of Medicine, Philadelphia) and colleagues write that, “Efforts to improve the experience of patients and families at the end of life must incorporate patient perspectives.” They add that, “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.” If a patient changes preferences for life-sustaining treatment depending on his or her state of health, however, the task of determining the correct path for the patient becomes much more complicated.
To further study the dynamics involved in end-of-life preference, Wittink and colleagues surveyed 818 physicians who graduated from Johns Hopkins University medical school between 1948 and 1964. The participants, who averaged 69 years old, filled out questionnaires that collected data regarding their health status and their end-of-life preferences in 1999 and in 2002. Questions were as specific as asking the participants to choose treatments given hypothetical situations, such as brain death resulting in an inability to speak or recognize people. In addition, they indicated their receptiveness to ten interventions, including cardiopulmonary resuscitation (CPR), major surgery, a feeding tube, and dialysis.
The researchers were able to divide the physicians into three group based on the survey responses. Twelve percent in 1999 and 14% in 2002 preferred aggressive care or most of the interventions. Intermediate care – intravenous fluids and antibiotics as the primary interventions – was selected by 26% in 1999 and 26% in 2002. Further, about 62% in 1999 and 60% in 2002 desired the least aggressive care, decline most interventions.
“In general, procedures that were declined in 1999 were likely also to be declined in 2002,” write Wittink and colleagues. “Nevertheless, a substantial proportion of persons who desired an intervention in 1999 declined the treatment in 2002.” About 41% of those who were categorized as preferring aggressive care in 1999 felt the same way in 2002. If a physician did not have an advanced directive such as a living will or durable power of attorney, he or she was twice as likely to change to the most aggressive category in 2002. Finally, probabilities of transitioning between levels of care were not associated with age or declines in mental or physical health.
“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,” conclude the researchers. “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.”
Stability of Preferences for End-of-Life Treatment After 3 Years of Follow-up
Marsha N. Wittink, MD, MBE; Knashawn H. Morales, ScD; Lucy A. Meoni, ScM; Daniel E. Ford, MD, MPH; Nae-yuh Wang, PhD; Michael J. Klag, MD, MPH; Joseph J. Gallo, MD, MPH
Archives of Internal Medicine (2008); 168[19]: pp. 2125-2130.
Written by: Peter M Crosta