Depression in the elderly: effect on patient attitudes toward life-sustaining therapy

Abstract

Objective: To determine the effect of depression on preferences for life-sustaining therapy in older persons.

Design: A survey comparing depressed, older veterans and a similar, but non-depressed, control group.

Setting: A 490-bed Veterans Affairs teaching hospital.

Patients: Medical inpatients over 65 years of age were potential subjects. Patients who were in intensive care, cognitively impaired, unable to communicate, abusing alcohol or drugs, or unable to return for outpatient care were excluded. Ninety-five eligible subjects (29%) refused to participate. Depressed subjects scored >14 on the Geriatric Depression Scale (GDS) and were diagnosed as depressed by a psychiatrist who was blind to the GDS results. Complete data were collected on 50 depressed and 50 control subjects.

Main outcome measures: A self-administered questionnaire quantified patients' preferences regarding life-saving interventions in their current state of health and in four hypothetical scenarios of serious illness.

Results: Depressed subjects desired fewer interventions than control subjects in their current health and in hypothetical scenarios with a good prognosis (P < or = 0.05). There were no differences between groups in poor prognosis scenarios. However, depression did not explain more than 5% of the variance in decision-making in any situation. In good prognosis scenarios, subjects' assessment of quality of life was the most powerful predictor of desire for life-saving interventions, accounting for 9%-17% of the variance (P <0.01).

Conclusions: These results suggest that depression is associated with treatment refusal in situations with a good medical prognosis. Depression, however, is only a weak predictor of treatment refusal. Further research is needed to define which patients would accept medical treatment if effectively treated for depression.