Inconsistency over time in the preferences of older persons with advanced illness for life-sustaining treatment

Abstract

Objectives: To determine whether preferences for future attempts at life-sustaining treatment change over time in a consistent and predictable manner.

Design: Observational cohort study.

Setting: Community.

Participants: One hundred eighty-nine community-dwelling persons ages 60 and older with advanced cancer, 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 undergo high-burden therapy for a chance to avoid death and risk an impaired health state to avoid death. Interviews occurred at least every 4 months for up to 2 years.

Results: When asked their willingness to undergo high-burden therapy for a chance to avoid death, 35% had an inconsistent preference trajectory (e.g., becoming more and then less willing over time or vice versa). The proportion with inconsistent trajectories increased to 48% and 49% when asked their willingness to risk physical or cognitive disability, respectively, to avoid death. Participants with variable health states over time were more likely to have inconsistent trajectories, although inconsistent trajectories were also common in those with stable health states.

Conclusion: A large proportion of older persons with advanced illness have inconsistent trajectories of willingness to undergo burdensome therapy or risk an impaired health state for a chance to avoid death. Variability in their health state over time explained this in part, although the frequency of inconsistent trajectories even in those with stable health states suggests that preferences are influenced by transient factors rather than representing stable core values.

Figure 1

Trajectories according to initial willingness to undergo life-sustaining therapy. Each bar represents the total number of participants according to their initial willingness to undergo life sustaining therapy. The subsections of each bar indicate the number of participants with consistent versus inconsistent trajectories. The numbers within each subsection indicate the proportion of participants who had that trajectory among all participants with a given initial willingness to undergo therapy.

Figure 1

Trajectories according to initial willingness to undergo life-sustaining therapy. Each bar represents the total number of participants according to their initial willingness to undergo life sustaining therapy. The subsections of each bar indicate the number of participants with consistent versus inconsistent trajectories. The numbers within each subsection indicate the proportion of participants who had that trajectory among all participants with a given initial willingness to undergo therapy.