Treatment Preferences for End-of-Life Care Changes With Time and Declining Health

New Haven, Conn. — Over time, older people change their preferences for end-of-life care and are more willing to accept treatment resulting in physical disability than treatment resulting in cognitive disability, researchers at Yale School of Medicine report in the current Archives of Internal Medicine.

Advance care planning, the process by which patients indicate the medical care they would want to receive if they could no longer make decisions for themselves, asks patients to indicate whether they would want various life-sustaining treatments.

“This process asks patients to predict what their future preferences would be, and therefore assumes that preferences will not change over time,” said first author Terri Fried, M.D., associate professor of internal medicine, geriatrics at Yale School of Medicine. “This study demonstrated that patients’ preferences changed over time and with changes in their health state, raising questions about patients’ abilities to predict their future preferences.”

Trained research assistants conducted in-home interviews with 226 persons age 60 and older and seriously ill with cancer, congestive heart failure or chronic obstructive pulmonary disease. Interviews were conducted at least every four months for up to two years and more frequently with changes in the patient’s health status. Patients facing a worsening of illness were asked to rate whether treatment for their illness would be acceptable if it resulted in a series of health states. A rating of “unacceptable” meant they would prefer to die than to receive treatment.

Over time, patients became more likely to rate as acceptable treatment resulting in mild or severe physical disability. Patients who experienced a decline in their ability to perform complex activities of daily living were more likely to rate treatment resulting in mild or severe disability as acceptable. These patients became less likely over time to rate as acceptable treatment that would result in severe cognitive disability.

Other authors on the study were Amy L. Byers, William T. Gallo, Peter H. Van Ness, Virginia R. Towle, John R. O’Leary and Joel A. Dubin.

Citation: Archives of Internal Medicine, 166: 890-895 April 24, 2006

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