Changes in preferences for life-sustaining treatment among older persons with advanced illness

Abstract

Background: There are conflicting assumptions regarding how patients' preferences for life-sustaining treatment change over the course of serious illness.

Objective: To examine changes in treatment preferences over time.

Design: Longitudinal cohort study with 2-year follow-up.

Participants: Two hundred twenty-six community-dwelling persons age > or =60 years with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease.

Measurements: Participants were asked, if faced with an illness exacerbation that would be fatal if untreated, whether they would: a) undergo high-burden treatment at a given likelihood of death and b) undergo low-burden treatment at a given likelihood of severe disability, versus a return to current health.

Results: There was little change in the overall proportions of participants who would undergo therapy at a given likelihood of death or disability from first to final interview. Diversity within the population regarding the highest likelihood of death or disability at which the individual would undergo therapy remained substantial over time. Despite a small magnitude of change, the odds of participants' willingness to undergo high-burden therapy at a given likelihood of death and to undergo low-burden therapy at a given likelihood of severe cognitive disability decreased significantly over time. Greater functional disability, poorer quality of life, and lower self-rated life expectancy were associated with decreased willingness to undergo therapy.

Conclusions: Diversity among older persons with advanced illness regarding treatment preferences persists over time. Although the magnitude of change is small, there is a decreased willingness to undergo highly burdensome therapy or to risk severe disability in order to avoid death over time and with declining health status.

Figure 1

Proportion of participants who were willing to undergo either low- or high-burden therapy at a given likelihood of adverse outcome versus a return to current health. The diamonds represent participants’ responses at the initial interview, and the squares represent participants’ responses at the final interview.