Patient values in healthcare decision making among diverse older adults

Abstract

Objective: To provide high-quality healthcare, it is essential to understand values that guide the healthcare decisions of older adults. We investigated the types of values that culturally diverse older adults incorporate in medical decision making.

Methods: Focus groups were held with older adults who varied in cognitive status (mildly impaired versus those with normal cognition) and ethnicity (Hispanic and non-Hispanic). Investigators used a qualitative descriptive approach to analyze transcripts and identify themes.

Results: Forty-nine individuals (49% with cognitive impairment; 51% Hispanic) participated. Participants expressed a wide range of values relating to individual factors, familial/cultural beliefs and expectations, balancing risks and benefits, receiving decisional support, and considering values other than their own. Participants emphasized that values are individual-specific, influenced by aging, and change throughout life course. Participants described barriers and facilitators that interfere with or promote value solicitation and incorporation during medical encounters.

Conclusion: Study findings highlight that in older adults with various health experiences, cognitive and physical health status, and sociocultural backgrounds, medical decisions are influenced by a variety of values.

Practical implications: Clinicians should take time to elicit, understand, and reassess the different types of values of older adults.

Keywords: Decision-making; Elders/elderly; Ethnic groups; Health priorities.

Figure 1:. Example of how values change over time throughout late life

While individual experiences and values varied, participants in this study suggested values change over time. For the exemplar individual presented in Figure 1, the overall focus shifted from disease prevention to an overarching focus on quality of life (i.e., global values). Based on interviews, when an individual is in earlier disease stages, they prioritize medication changes that balance side effects and treatment efficacy. Later in life, an individual may prioritize avoiding medication side effects when evaluating therapeutic options (i.e., decisional values). Similarly, many participants described valuing independence in medical decision making but desiring more family and clinician involvement in decision making encounters over time (i.e. external values).

Figure 2:. Intersection of values across different individuals

Person A’s global value is taking a prevention-oriented approach in all decisions. When faced with their doctor’s recommendation to undergo a routine screening procedure, Person A evaluates relevant risks, but values quality of life in the long run (i.e., decisional value) resulting from potentially identifying cancer early, while also balancing competing demands as a caregiver (i.e., external value). Person B’s global value is prioritizing quality of life. When deciding to proceed with a screening procedure, they weigh the short-term deficit of quality of life associated with procedure (e.g. colonoscopy preparation), but value the high predictive value of the procedure (i.e., decisional value). They value their family’s opinion, so they seek advice before making a decision (e.g., external value). Person C is anxious-avoidant for all non-emergency procedures (e.g., global value/characteristic). When their doctor recommends a screening exam, Person C further hesitates because they anticipate difficulties requesting time off from work (i.e., decisional value). Although both global and decisional values reflect hesitancy to undergo the diagnostic exam, Person C ultimately decides to proceed after realizing they’ve met their deductible (i.e., situational value).