Advance Directives, Medical Conditions, and Preferences for End-of-Life Care Among Physicians: 12-year Follow-Up of the Johns Hopkins Precursors Study

Abstract

Context: Stability of preferences for life-sustaining treatment may vary depending on personal characteristics.

Objective: We estimated the stability of preferences for end-of-life treatment over 12 years and whether advance directives and medical conditions were associated with change in preferences for end-of-life treatment.

Design: Mailed survey of older physicians.

Methods: Longitudinal cohort study of medical students in the graduating classes from 1948 to 1964 at Johns Hopkins University. Eight hundred ninety eight physicians who completed the life-sustaining treatment questionnaire anytime in 1999, 2002, 2005, and 2011 (mean age 68.2 years at baseline). Preferences for life-sustaining treatment were assessed using a checklist questionnaire in response to a standard "brain injury" scenario and considered as a package using the latent class transition model.

Results: End-of-life preferences grouped into three classes: most aggressive (wanting most interventions; 14% of physicians), least aggressive (declining most interventions; 61%), and an intermediate class (declining most interventions except intravenous fluids and antibiotics; 25%). Physicians without an advance directive were more likely to desire more treatment and were less likely to transition out the most aggressive class. Transition probabilities from class to class did not vary over time. Persons with cancer expressed preference for the least aggressive treatment, whereas persons with cardiovascular disease and depression had preferences for more aggressive treatment.

Conclusion: Transitions in end-of-life preferences and the factors influencing change and stability suggest that periodic reassessment for planning end-of-life care is needed.

Keywords: End-of-life preferences; advance directives; latent transition analysis.

Figure 1.

Probability of desiring specific interventions given class of desire for aggressiveness of care. Data are from The Johns Hopkins Precursors Study (1999–2011).

Figure 2.

Initial preferences of aggressiveness of care according to whether the participant had an advance directive.* Data are from The Johns Hopkins Precursors Study (1999–2011). * p < 0.001 (G² = 170.84 with df = 2)

Figure 3.

Initial preferences of aggressiveness of care according to whether the participant has cardiovascular disease (CVD), diabetes, cancer, or depression (black bars) or not (white bars).* Data are from The Johns Hopkins Precursors Study (1999–2011). * p >0.05 for all comparisons