Physical functioning, depression, and preferences for treatment at the end of life: the Johns Hopkins Precursors Study

National End-of-Life-Treatment Preferences are Stable Over Time: National Health and Aging Trends Study

CONTEXT

Advance Care Planning is a process of understanding and sharing preferences regarding future medical care.

OBJECTIVE

To explore individual and national stability of end-of-life treatment preferences among a sample of older adults.

METHODS

National Health and Aging Trends Study is a nationally representative sample of older adults. In 2012, a random sample, and in 2018, the entire sample were queried on end-of-life treatment preferences defined as acceptance or rejection of life prolonging treatment (LPT) if they had a serious illness and were at the end of their life and in severe pain or had severe disability. Using a cohort design, we explored individual trends in preferences for LPT among those with responses in both waves (pain scenario: N = 606, disability scenario: N = 628) and, using a serial cross-sectional design, national trends in LPT among the entire sample (1702 older adults in wave 2 and 4342 in wave 8).

RESULTS

In the cohort study, individual preferences were stable over time (overall percent agreement = 86% for disability and 76% for pain scenarios), particularly for older adults who would reject LPT in wave 2 (overall agreement 92% for disability and 86% for pain). In the serial cross-sectional study, national trends in preferences for receipt of LPT were stable over time in the pain (27.4% vs. 27.0%, P = 0.80) and disability (15.8% vs. 15.7%, P = 0.99) scenarios.

CONCLUSIONS

We found that national trends in preferences for end-of-life treatment did not substantially change over time and may be stable within individual older adults.

Preferences of Cognitively Impaired Patients and Patients Living with Dementia: A Systematic Review of Quantitative Patient Preference Studies

BACKGROUND

Treatment decisions based on guidelines rather than patients' preferences determine adherence to and compliance with treatment, which, in turn, could improve health-related outcomes.

OBJECTIVES

To summarize the stated treatment and care preferences of people with dementia (PwD).

METHODS

A systematic review was conducted to assess the stated preferences of PwD. The inclusion criterion was the use of quantitative methods to elicit stated preferences, enabling a ranking of preferences.

RESULTS

Eleven studies revealed preferences for diagnostics, treatment decisions, patient-related outcomes, care services, end-of-life care, leisure activities, and digital life story work. PwDs prefer accurate, pain-free, and comfortable diagnostic procedures without radioactive markers as well as being accompanied by a caregiver. PwD's quality of life (QoL), self-efficacy, and depression were equally most important for PwD and caregivers. However, PwD memory was only important for caregivers but not for PwD, and caregiver QoL was moderately important for PwD but least important for caregivers. Additionally, comfort and family involvement were most important for patients' end-of-life care, whereas caregivers most preferred good communication and pain management. Also, preferences depend on the living situation: Patients living not alone prefer a regular care provider most, whereas those living alone only want to live nearby the caregiver. Preferences for leisure activities did not differ between past and present ratings, indicating that PwD prefer activities that have always been carried out.

CONCLUSION

Only a few studies have applied quantitative methods to elicit the preferences of PwD. More research is needed to capture the stated preferences for the treatment, care, and support of PwD to improve health-related outcomes and the allocation of healthcare resources.

Understanding End-of-Life Preferences: Predicting Life-Prolonging Treatment Preferences Among Community-Dwelling Older Americans

OBJECTIVES

To determine how demographic, socioeconomic, health, and psychosocial factors predict preferences to accept life-prolonging treatments (LPTs) at the end of life (EOL).

METHODS

This is a retrospective cohort study of a nationally representative sample of community-dwelling older Americans (N = 1648). Acceptance of LPT was defined as wanting to receive all LPTs in the hypothetical event of severe disability or severe chronic pain at the EOL. Participants with a durable power of attorney, living will, or who discussed EOL with family were determined to have expressed their EOL preferences. The primary analysis used survey-weighted logistic regression to measure the association between older adult characteristics and acceptance of LPT. Secondarily, the associations between LPT preferences and health outcomes were measured using regression models.

RESULTS

Approximately 31% of older adults would accept LPT. Nonwhite race/ethnicity (odds ratio [OR] 0.54; 95% CI 0.41, 0.70; white vs. nonwhite), self-realization (OR 1.34; 95% CI 1.01, 1.79), attendance of religious services (OR 1.44; 95% CI 1.07, 1.94), and expression of preferences (OR 0.54; 95% CI 0.40, 0.72) were associated with acceptance of LPT. LPT preferences were not independently associated with mortality or disability.

CONCLUSIONS

Approximately one-third of older Americans would accept LPT in the setting of severe disability or severe chronic pain at the EOL. Adults who discussed their EOL preferences were more likely to reject LPT. Conversely, minorities were more likely to accept LPT. Sociodemographics, physical capacity, and health status were poor predictors of acceptance of LPT. A better understanding of the complexities of LPT preferences is important to ensuring patient-centered care.

Extent and Determinants of Terminally Ill Cancer Patients' Concordance Between Preferred and Received Life-Sustaining Treatment States: An Advance Care Planning Randomized Trial in Taiwan

CONTEXT

Promoting patient value-concordant end-of-life care is a priority in health care systems but has rarely been examined in randomized clinical trials.

OBJECTIVES

To examine the effectiveness of an advance care planning intervention in facilitating concordance between cancer patients' preferred and received life-sustaining treatment (LST) states and to explore modifiable factors facilitating or impeding such concordance.

METHODS

Terminal cancer patients (N = 460) were randomly assigned 1:1 to the experimental and control arms of a randomized clinical trial, with 430 deceased participants comprising the final sample. States of preferred LSTs (cardiopulmonary resuscitation, intensive care unit care, chest compression, intubation with mechanical ventilation, intravenous nutrition, and nasogastric tube feeding) and LSTs received in the last month were examined by hidden Markov modeling. Concordance and its modifiable predictors were evaluated by kappa and multivariate logistic regression, respectively.

RESULTS

We identified three LST-preference states (uniformly preferring LSTs, rejecting LSTs except intravenous nutrition support, and mixed LST preferences) and three received LST states (uniformly receiving LSTs, received intravenous nutrition only, and selectively receiving LSTs). Concordance was not significantly higher in the experimental than the control arm (kappa [95% CI]: 0.126 [0.032, 0.221] vs. 0.050 [-0.028, 0.128]; arm difference: odds ratio [95% CI]: 1.008 [0.675, 1.5001]). Preferred-received LST-state concordance was facilitated by accurate prognostic awareness, better quality of life, and more depressive symptoms, whereas concordance was impeded by more anxiety symptoms.

CONCLUSIONS

Our advance care planning intervention did not facilitate concordance between terminally ill cancer patients' preferred and received LST states, but patient value-concordant end-of-life care may be facilitated by interventions to cultivate accurate prognostic awareness, improve quality of life, support depressive patients, and clarify anxious patients' overexpectations of LST efficacy.

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

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.

Physician Preferences for Aggressive Treatment at the End of Life and Area-Level Health Care Spending: The Johns Hopkins Precursors Study

Objective: To determine whether physician preferences for end-of-life care were associated with variation in health care spending. Method: We studied 737 physicians who completed the life-sustaining treatment questionnaire in 1999 and were linked to end-of-life care data for the years 1999 to 2009 from Medicare-eligible beneficiaries from the Dartmouth Atlas of Health Care (in hospital-related regions [HRRs]). Using latent class analysis to group physician preferences for end-of-life treatment into most, intermediate, and least aggressive categories, we examined how physician preferences were associated with health care spending over a 7-year period. Results: When all HRRs in the nation were arrayed in quartiles by spending, the prevalence of study physicians who preferred aggressive end-of-life care was greater in the highest spending HRRs. The mean area-level intensive care unit charges per patient were estimated to be US$1,595 higher in the last 6 months of life and US$657 higher during the hospitalization in which death occurred for physicians who preferred the most aggressive treatment at the end of life, when compared with average spending. Conclusions: Physician preference for aggressive end-of-life care was correlated with area-level spending in the last 6 months of life. Policy measures intended to minimize geographic variation in health care spending should incorporate physician preferences and style.

Decision Making Among Older Adults at the End of Life: A Theoretical Perspective

Understanding changes in decision making among older adults across time is important for health care providers. We examined how older adults with a limited prognosis used their perception of prognosis and health in their decision-making processes and related these findings to prospect theory. The theme of decision making in the context of ambiguity emerged, reflecting how participants used both prognosis and health to value choices, a behavior not fully captured by prospect theory. We propose an extension of the theory that can be used to better visualize decision making at this unique time of life among older adults.

Symptom Burden and End-of-Life Treatment Preferences in the Very Old

CONTEXT

End-of-life (EOL) treatment preferences among the very old (age 85+) may differ from preferences in younger aged populations because of high levels of symptom burden and disability and high risk of mortality. It is unclear if symptom burden or level of disability is more important for such preferences.

OBJECTIVES

To investigate whether distress from daily symptom burden was an independent correlate of EOL treatment preferences over two years of follow-up in people with median age 86 (participants) and 88 (reported by proxies) at baseline.

METHODS

The End of Life in Very Old Age is an ancillary study to the Health, Aging and Body Composition study. At baseline in Year 15 of Health, Aging and Body Composition, 1038 participants and 189 proxies reported levels of symptom distress every quarter, as well as 0-8 EOL treatment preferences elicited once each year.

RESULTS

At baseline, the mean (SD) count of EOL treatment preferences was 4.2 (2.1) in participants, and 2.9 (2.3) in proxies. EOL treatment preference was not associated with symptom distress. By contrast, black race, male gender, and reported ease walking a quarter mile were independently associated with more aggressive EOL treatment preferences.

CONCLUSION

Preferences for more aggressive EOL treatment were not related to daily symptom distress but were significantly more likely to be endorsed among those with better mobility, suggesting that disability is an independent predictor of EOL treatment preferences in the very old.

The Natural History of Changes in Preferences for Life-Sustaining Treatments and Implications for Inpatient Mortality in Younger and Older Hospitalized Adults

OBJECTIVES

To compare changes in preferences for life-sustaining treatments (LSTs) and subsequent mortality of younger and older inpatients.

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Northern California (KPNC).

PARTICIPANTS

Individuals hospitalized at 21 KPNC hospitals between 2008 and 2012 (N = 227,525).

MEASUREMENTS

Participants were divided according to age (<65, 65-84, ≥85). The effect of age on adding new and reversing prior LST limitations was evaluated. Survival to inpatient discharge was compared according to age group after adding new LST limitations.

RESULTS

At admission, 18,254 (54.2%) of those aged 85 and older, 18,349 (20.8%) of those aged 65 to 84, and 3,258 (3.1%) of those younger than 65 had requested that the use of LST be limited. Of the 187,664 participants who initially did not request limitations on the use of LST, 15,932 (8.5%) had new LST limitations added; of the 39,861 admitted with LST limitations, 3,017 (7.6%) had these reversed. New limitations were more likely to be seen in older participants (aged 65-84, odds ratio (OR) = 2.27, 95% confidence interval (CI) = 2.16-2.39; aged ≥85, OR = 6.43, 95% CI = 6.05-6.84), and reversals of prior limitations were less likely to be seen in older individuals (aged 65-84, OR = 0.73, 95% CI = 0.65-0.83; aged ≥85, OR = 0.46, 95% CI = 0.41-0.53) than in those younger than 65. Survival rates to inpatient discharge were 71.7% of subjects aged 85 and older who added new limitations, 57.2% of those aged 65 to 84, and 43.4% of those younger than 65 (P < .001).

CONCLUSION

Changes in preferences for LSTs were common in hospitalized individuals. Age was an important determinant of likelihood of adding new or reversing prior LST limitations. Of subjects who added LST limitations, those who were older were more likely than those who were younger to survive to hospital discharge.

Advance directives: empowering patients at the end of life

Advance directives were conceived as a prospective means of empowering patients to direct their own end-of-life care. Unfortunately, these directives have been inadequately incorporated into healthcare decisions due to less-than-optimal execution and implementation. The authors explore challenges to implementing advance directives and propose potential solutions.

Quality of life changes and intensive care preferences in terminal cancer patients

Objective:

There is scarce research on the short-term fluctuations in end-of-life (EoL) care planning for seriously ill patients. The aim of our study was to investigate the stability of preferences regarding treatment in an intensive care unit (ICU) and identify the factors associated with changes in preferences in terms of quality of life (QoL).

Method:

A prospective examination on preference changes for ICU care in 141 terminal cancer patients was conducted. Patients were categorized according to their change in preference during the final two months of their lives into four categories: (1) the keep–accept group, (2) the keep–reject group, (3) the change to accept group, and (4) the change to reject group. Using multiple logistic analyses, we explored the association between patient demographics, health-related QoL, and changes in ICU preference.

Results:

The overall stability of ICU preferences near the end of life was 66.7% (κ = 0.33, p < 0.001). Married patients were more likely to change their preference regarding ICU care [adjusted odds ratio (aOR) toward accept 12.35, p = 0.021; aOR toward reject 10.56, p = 0.020] than unmarried patients. Patients with stable physical function tended to accept ICU care (aOR = 5.05, p = 0.023), whereas those with poor performance (aOR = 5.32, p = 0.018), worsened QoL (aOR = 8.34, p = 0.007), or non-aggravated fatigue (aOR = 8.36, p = 0.006) were more likely to not accept ICU care.

Significance of results:

The attitudes of terminally ill cancer patients regarding ICU care at the end of life were not stable over time, and changes in their QoL were associated with a tendency to change their preferences about ICU care. Attention should thus be paid to patients' QoL changes to improve medical decision making with regard to EoL care.

Factors Related to the Differential Preference for Cardiopulmonary Resuscitation Between Patients With Terminal Cancer and That of Their Respective Family Caregivers

There is little information regarding concordance between preferences for end-of-life care of terminally ill patients with cancer and those of their family caregivers. A cross-sectional exploration of cardiopulmonary resuscitation (CPR) preference in 361 dyads was conducted. Patients or family caregivers who were willing to approve CPR were compared with dyads who did not support CPR. The patient's quality of life was more associated with family caregiver's willingness than patient's willingness. A patient was more likely to prefer CPR than their caregiver in dyads of females and emotionally stable patients. A family caregiver showed stronger support for CPR if the patient had controlled pain or stable health and the family caregiver had not been counseled for CPR. Communications should be focused on these individuals to improve the planning of end-of-life care.

Do unto others: doctors' personal end-of-life resuscitation preferences and their attitudes toward advance directives

OBJECTIVE

High-intensity interventions are provided to seriously-ill patients in the last months of life by medical sub-specialists. This study was undertaken to determine if doctors' age, ethnicity, medical sub-specialty and personal resuscitation and organ donation preferences influenced their attitudes toward Advance Directives (AD) and to compare a cohort of 2013 doctors to a 1989 (one year before the Patient Self Determination Act in 1990) cohort to determine any changes in attitudes towards AD in the past 23 years.

DESIGN

Doctors in two academic medical centers participated in an AD simulation and attitudes survey in 2013 and their responses were compared to a cohort of doctors in 1989.

OUTCOMES

Resuscitation and organ donation preferences (2013 cohort) and attitudes toward AD (1989 and 2013 cohorts).

RESULTS

In 2013, 1081 (94.2%) doctors of the 1147 approached participated. Compared to 1989, 2013 cohort did not feel that widespread acceptance of AD would result in less aggressive treatment even of patients who do not have an AD (p<0.001, AUC = 0.77); had greater confidence in their treatment decisions if guided by an AD (p<.001, AUC = 0.58) and were less worried about legal consequences of limiting treatment when following an AD (p<.001, AUC  = 0.57). The gender (p = 0.00172), ethnicity (χ2 14.68, DF = 3,p = .0021) and sub-specialty (χ2 28.92, p = .004, DF = 12) influenced their attitudes towards AD. 88.3% doctors chose do-not-resuscitate status and wanted to become organ donors. Those less supportive of AD were more likely to opt for "full code" even if terminally ill and were less supportive of organ donation.

CONCLUSIONS

Doctors' attitudes towards AD has not changed significantly in the past 23 years. Doctors' gender, ethnicity and sub-specialty influence their attitudes towards AD. Our study raises questions about why doctors continue to provide high-intensity care for terminally ill patients but personally forego such care for themselves at the end of life.

Effect of physician perspective on allocation of Medicare resources for patients with advanced cancer

OBJECTIVES

To assess how physician perspective (perspective of patient vs perspective of physician) affects Medicare resource allocation for patients with advanced cancer and compare physician allocations with actual cancer patient and caregiver allocations.

STUDY DESIGN

Cross-sectional assessment.

SETTING

National assessment.

SUBJECTS

Otolaryngologists.

METHODS

Physicians used a validated tool to create a Medicare plan for patients with advanced cancer. Participants took the perspective of an advanced cancer patient and made resource allocations between 15 benefit categories (assessment 2, November/December 2012). Results were compared with data from a prior assessment made from a physician's perspective (assessment 1, February/March 2012) and with data from a separate study with patients with cancer and caregivers.

RESULTS

In total, 767 physicians completed assessment 1 and 237 completed assessment 2. Results were compared with 146 cancer patient and 114 caregiver assessments. Assessment 1 physician responses differed significantly from patients/caregivers in 14 categories (P < .05), while assessment 2 differed in 11. When comparing physician data, assessment 2 allocations differed significantly from assessment 1 in 7 categories. When these 7 categories were compared with patient/caregiver data, assessment 2 allocations in emotional care, drug coverage, and nursing facility categories were not significantly different. Assessment 1 allocations in cosmetic care, dental, home care, and primary care categories were more similar to patient/caregiver preferences, although all but home care were still significantly different.

CONCLUSIONS

Otolaryngology-head and neck surgery physician perspectives on end-of-life care differ significantly from cancer patient/caregiver perspectives, even when physicians take a patient's perspective when allocating resources. This demonstrates the challenges inherent in end-of-life discussions.

Factors that affect decisions to receive (or not receive) life-sustaining treatment in advance care planning

This study identifies factors that affect decisions people make regarding whether they want to receive life-sustaining treatment. It is an interpretive-descriptive study based on qualitative data from three focus groups (N = 23), representing a diverse population in central Pennsylvania. Study sites included a suburban senior center serving a primarily White, middle-class population; an urban senior center serving a frail, underserved, African American population; and a breast cancer support group. The most important factors affecting whether participants wished to receive life-sustaining medical treatment were prognosis, expected quality of life, burden to others, burden to oneself in terms of the medical condition and treatment, and effect on mental functioning and independence. Our findings contribute to the knowledge of the complex factors that influence how people make decisions about advance care planning and life-sustaining treatments. This understanding is critical if nurses are to translate the patient's goals, values, and preferences into an actionable medical plan.

Physician allocation of Medicare resources for patients with advanced cancer

BACKGROUND

Little is known about what patients and physicians value in end-of-life care, or how these groups would craft a health plan for those with advanced cancer.

OBJECTIVE

The study objective was to assess how otolaryngology, head and neck surgery (OHNS) physicians would structure a Medicare benefit plan for patients with advanced cancer, and to compare this with cancer patient and cancer patient caregiver preferences.

DESIGN

OHNS physicians used an online version of a validated tool for assessing preferences for health plans in the setting of limited resources. These data were compared to cancer patient and caregiver preferences.

SETTING AND PARTICIPANTS

OHNS physicians nationwide were assessed with comparison to similar data obtained in a separate study of cancer patients and their caregivers treated at Duke University Medical Center.

RESULTS

Otolaryngology physicians (n=767) completed the online assessment and this was compared with data from 146 patients and 114 caregivers. OHNS physician allocations differed significantly in 14 of the 15 benefit categories when compared with patients and caregivers. Physicians elected more coverage in the Advice, Emotional Care, Palliative Care, and Treatment for Cancer benefit categories. Patients and their caregivers elected more coverage in the Cash, Complementary Care, Cosmetic Care, Dental and Vision, Drug Coverage, Home Improvement, House Calls, Nursing Facility, Other Medical Care, and Primary Care benefit categories.

CONCLUSIONS

Otolaryngology physicians have significantly different values in end-of-life care than cancer patients and their caregivers. This information is important for efficient allocation of scarce Medicare resources and for effective end-of-life discussions, both of which are key for developing appropriate health policy.

Elders' preferences for life-prolonging treatment and their proxies' substituted judgment: influence of the elders' current health

OBJECTIVE

People in poor health tend to view life-prolonging treatments (e.g., tube feeding) as more acceptable than do healthier people. Do proxies' substituted judgments reveal a similar tendency, showing greater acceptance when the elder is in worse health?

METHOD

In a cross-sectional telephone-based survey of 202 elderly individuals and their proxies, preferences for 4 life-prolonging treatments in 7 health prospects were examined in relation to the elder's current health status, operationalized as number of deficits in activities of daily living.

RESULTS

Stronger preferences for life-prolonging treatments in worse-health prospects were expressed by both elders and proxies when the elders' current health was relatively poor. The interaction effect was at least as pronounced for proxies' substituted judgment as for elders' own preferences.

DISCUSSION

Findings provide important insight into proxy decision making and have particular implications for proxy decision making on behalf of elders with dementia or other causes of decisional incapacity.

‘Ambivalence’ at the end of life

Health-care professionals in end-of-life care are frequently confronted with patients who seem to be ‘ambivalent’ about treatment decisions, especially if they express a wish to die. This article investigates this phenomenon by analysing two case stories based on narrative interviews with two patients and their caregivers. First, we argue that a respectful approach to patients requires acknowledging that coexistence of opposing wishes can be part of authentic, multi-layered experiences and moral understandings at the end of life. Second, caregivers need to understand when contradictory statements point to tensions in a patient’s moral experience that require support. Third, caregivers should be careful not to negatively label or even pathologize seemingly contradictory patient statements.

Attitudes regarding the use of ventilator support given a supposed terminal condition among community-dwelling Mexican American and non-Hispanic white older adults: a pilot study

Purpose. To determine the factors that are associated with Mexican Americans' preference for ventilator support, given a supposed terminal diagnosis. Methods. 100 Mexican Americans, aged 60–89, were recruited and screened for MMSE scores above 18. Eligible subjects answered a questionnaire in their preferred language (English/Spanish) concerning ventilator use during terminal illness. Mediator variables examined included demographics, generation, religiosity, occupation, self-reported depression, self-reported health, and activities of daily living. Results. Being first or second generation American (OR = 0.18, CI = 0.05–0.66) with no IADL disability (OR = 0.11, CI = 0.02–0.59) and having depressive symptoms (OR = 1.43, CI = 1.08–1.89) were associated with preference for ventilator support. Implications. First and second generation older Mexican Americans and those functionally independent are more likely to prefer end-of-life ventilation support. Although depressive symptoms were inversely associated with ventilator use at the end of life, scores may more accurately reflect psychological stress associated with enduring the scenario. Further studies are needed to determine these factors' generalizability to the larger Mexican American community.

The need for safeguards in advance care planning

The recent uproar about Medicare "death panels" draws attention to public and professional concerns that advance care planning might restrict access to desired life-sustaining care. The primary goal of advance care planning is to promote the autonomy of a decisionally incapacitated patient when choices about life-sustaining treatments are encountered, but the safety of this procedure has not received deserved scrutiny. Patients often do not understand their decisions or they may change their mind without changing their advance care directives. Likewise, concordance between patients' wishes and the understanding of the physicians and surrogate decision makers who need to represent these wishes is disappointingly poor. A few recent reports show encouraging outcomes from advance care planning, but most studies indicate that the procedure is ineffective in protecting patients from unwanted treatments and may even undermine autonomy by leading to choices that do not reflect patient values, goals, and preferences. Safeguards for advance care planning should be put in place, such as encouraging physicians to err on the side of preserving life when advance care directives are unclear, requiring a trained advisor to review non-emergent patient choices to limit life-sustaining treatment, training of clinicians in conducting such conversations, and structured discussion formats that first address values and goals rather than particular life-sustaining procedures. Key targets for research include: how to improve completion rates for person wanting advance care directives, especially among minorities; more effective and standardized approaches to advance care planning discussions, including how best to present prognostic information to patients; methods for training clinicians and others to assist patients in this process; and systems for assuring that directives are available and up-to-date.

The palliative care model for emergency department patients with advanced illness

BACKGROUND

Large gaps in the delivery of palliative care services exist in the outpatient setting, where there is a failure to address goals of care and to plan for and treat predictable crises. While not originally considered an ideal environment to deliver palliative care services, the emergency department presents a key decision point at which providers set the course for a patient's subsequent trajectory and goals of care. Many patients with serious and life-threatening illness present to emergency departments because symptoms, such as pain or nausea and vomiting, cannot be controlled at home, in an assisted living facility, or in a provider's office. Even for patients in whom goals of care are clear, families often need support for their loved one's physical as well as mental distress. The emergency department is often the only place that can provide needed interventions (e.g., intravenous fluids or pain medications) as well as immediate access to advanced diagnostic tests (e.g. computed tomography or magnetic resonance imaging).

DISCUSSION

Palliative care services provide relief of burdensome symptoms, attention to spiritual and social concerns, goal setting, and patient-provider communication that are often not addressed in the acute care setting. While emergency providers could provide some of these services, there is a knowledge gap regarding palliative care in the emergency department setting. Emergency department-based palliative care programs are currently consultations for symptoms and/or goals of care, and have been initiated both by both the palliative care team and palliative care champions in the emergency department. Some programs have focused on the provision of hospice services through partnerships with hospice providers, which can potentially help emergency department providers with disposition.

CONCLUSION

Although some data on pilot programs are available, optimal models of delivery of emergency department-based palliative care have not been rigorously studied. Research is needed to determine how these services are best organized, what affect they will have on patients and caregivers, and whether they can decrease symptom burden and health care utilization.

Artificial nutrition and hydration at the end of life

Considerable controversy surrounds the issue of care at the end of life (EOL) for older adults. Technological advances and the legal, ethical, clinical, religious, cultural, personal, and fiscal considerations in the provision of artificial hydration and nutrition support to older adults near death are presented in this comprehensive review.

The association of depression and preferences for life-sustaining treatments in veterans with chronic obstructive pulmonary disease

CONTEXT

Depressive symptoms are common among patients with chronic obstructive pulmonary disease (COPD) and may modify patients' preferences for life-sustaining therapy. Examining the relationship between patient preferences for life-sustaining treatments and depressive symptoms is important for clinicians engaging in end-of-life care discussions.

OBJECTIVES

To assess whether a history of depression or active depressive symptoms is associated with preferences for life-sustaining therapies among veterans with COPD.

METHODS

This was a cross-sectional study of 376 veterans who participated in a randomized trial to improve the occurrence and quality of end-of-life communication between providers and patients. Depressive symptoms were assessed by self-reported history and the Mental Health Index-5 survey. Preferences for mechanical ventilation (MV) and cardiopulmonary resuscitation (CPR) were assessed using standardized instruments. Multivariate logistic regression was conducted to adjust for potential confounding factors.

RESULTS

Participants were older men with severe COPD. A substantial proportion of participants noted that they would want MV (64.2%) or CPR (77.8%). Depressive history and active symptoms were not associated with preferences for MV and CPR either before or after adjusting for confounding variables.

CONCLUSION

Depressive history and active symptoms among veterans with severe COPD were not associated with their decisions for life-sustaining treatments. Clinicians caring for patients with COPD should understand the importance of assessing and treating patients with depressive symptoms, yet recognize that depressive symptoms may not be predictive of a patient declining life-sustaining treatments.

Elders' environs and their end-of-life preferences

HYPOTHESIS

Elders' predilections regarding end-of-life interventions vary with their living environs.

METHODS

Patients in 3 settings--assisted living/outpatient, skilled nursing facility (SNF), and acute hospitalization--were asked to complete a brief questionnaire.

RESULTS

A total of 269 patients who averaged 80.0 ± (SD) 8.1 years, 44% male, 70% white were studied. Eighty-five patients were outpatient elderly, 101 were hospitalized for acute illnesses, and 83 were interviewed in SNFs. Outpatients (44/85; 52%) and acutely ill inpatients (40/101; 40%) were more likely than patients residing in SNFs (19/81; 23%) to choose comfort care only (P = .047) for acute pneumonia requiring endotracheal intubation (ETI). Overall, 32% changed their choice for ETI, opting for comfort care only if acute pneumonia was followed by disposition to an SNF. However, ambulatory and acutely ill elderly patients were 3 times as likely as SNF patients to change from aggressive to comfort care if the most likely outcome was disposition to an SNF (P < .001). In multivariate regression models, age (>80), gender, number of lost ADLs (>2), and self-described quality of life were not associated with choosing comfort care instead of ETI, whereas place of residence (SNF versus home) was independently associated with choosing ETI (odds ratio = 3.5; 95%CI = 1.9-6.4). Similarly, those already living in an SNF were more likely to opt for remaining there for advancing dementia (odds ratio = 7.7; 95%CI = 3.8-15.8). However, choices for ETI did not coincide with choosing an SNF for advancing dementia.

CONCLUSIONS

Elders residing in nursing homes were more likely than ambulatory patients to request invasive end-of-life care, a difference that was more pronounced when outcome required disposition to an SNF. These preferences were not dependent on patients' self-described disability or quality of life. This study suggests that qualitative outcomes matter to patients and their choices are associated with their place of residence.

Redefining the "planning" in advance care planning: preparing for end-of-life decision making

The traditional objective of advance care planning has been to have patients make treatment decisions in advance so that clinicians can attempt to provide care consistent with their goals. The authors contend that the objective for advance care planning ought to be the preparation of patients and surrogates to participate with clinicians in making the best possible in-the-moment medical decisions. They provide practical steps for clinicians to help patients and surrogate decision makers achieve this objective in the outpatient setting. Preparation for in-the-moment decision making shifts the focus from having patients make premature decisions based on incomplete information to preparing them and their surrogates for the types of decisions and conflicts they may encounter when they do have to make in-the-moment decisions. Advance directives, although important, are just one piece of information to be used at the time of decision making.

Redefining the "planning" in advance care planning: preparing for end-of-life decision making

The traditional objective of advance care planning has been to have patients make treatment decisions in advance so that clinicians can attempt to provide care consistent with their goals. The authors contend that the objective for advance care planning ought to be the preparation of patients and surrogates to participate with clinicians in making the best possible in-the-moment medical decisions. They provide practical steps for clinicians to help patients and surrogate decision makers achieve this objective in the outpatient setting. Preparation for in-the-moment decision making shifts the focus from having patients make premature decisions based on incomplete information to preparing them and their surrogates for the types of decisions and conflicts they may encounter when they do have to make in-the-moment decisions. Advance directives, although important, are just one piece of information to be used at the time of decision making.

End of life decision-making for cancer patients

This article reviews research on end-of-life (EOL) decision-making in general and published guidelines on communicating with patients about EOL treatment options. The literature on EOL decision-making, most of which concerns advance care planning decisions, has identified several factors that influence treatment choices including race, religiosity, current health, and family conflict. This literature also documents widespread lack of understanding about dying and palliative care and fears of abandonment by health care providers. This article reviews guidelines for communicating with patients, stresses the role of prognostication in good decision-making, and provides numerous suggestions for initiating and structuring conversations with patients and families about EOL care.

Attitudes of patients with malignancies towards completion of advance directives

AIM

The purpose of advance directives (AD) is to preserve the patient's autonomy at the end of his/her life. In a cohort study, we investigated attitudes towards AD in hospitalized patients with malignant disease.

MATERIALS AND METHODS

All patients were informed about the basic features of AD in a standardized manner by a single independent physician. One hundred and eight (39 women, 69 men; mean age 56.6 +/- 14.9 years) of 140 invited patients completed the study.

MAIN RESULTS

Five percent of patients (5/108) already had an AD; 85% (92/108) did not wish to issue an AD. "Full confidence in physicians" (22%) and "not important for me at the moment" (15%) were the most frequently stated reasons for not issuing an AD. Only 10% (11/108) of patients decided to complete an AD. Their decision was not related to a specific diagnosis or a number of socio-demographic variables that were studied. Patients who decided in favor of an AD had significantly higher Hospital Anxiety and Depression Scale (HADS-D) score than those who decided against it (HADS-D, 8.3 +/- 5.0 vs.5.8 +/- 4.1, p = 0.035). The patients' HADS depression score was negatively associated with their Karnofsky index (r = -0.232, p = 0.017).

CONCLUSIONS

Our data reveal a scarce demand for AD in our population of hospitalized cancer patients. Patients who wanted to issue an AD had a high HADS-D, which is associated with a low performance status.

Video decision support tool for advance care planning in dementia: randomised controlled trial

OBJECTIVE

To evaluate the effect of a video decision support tool on the preferences for future medical care in older people if they develop advanced dementia, and the stability of those preferences after six weeks.

DESIGN

Randomised controlled trial conducted between 1 September 2007 and 30 May 2008. Setting Four primary care clinics (two geriatric and two adult medicine) affiliated with three academic medical centres in Boston.

PARTICIPANTS

Convenience sample of 200 older people (>or=65 years) living in the community with previously scheduled appointments at one of the clinics. Mean age was 75 and 58% were women.

INTERVENTION

Verbal narrative alone (n=106) or with a video decision support tool (n=94).

MAIN OUTCOME MEASURES

Preferred goal of care: life prolonging care (cardiopulmonary resuscitation, mechanical ventilation), limited care (admission to hospital, antibiotics, but not cardiopulmonary resuscitation), or comfort care (treatment only to relieve symptoms). Preferences after six weeks. The principal category for analysis was the difference in proportions of participants in each group who preferred comfort care.

RESULTS

Among participants receiving the verbal narrative alone, 68 (64%) chose comfort care, 20 (19%) chose limited care, 15 (14%) chose life prolonging care, and three (3%) were uncertain. In the video group, 81 (86%) chose comfort care, eight (9%) chose limited care, four (4%) chose life prolonging care, and one (1%) was uncertain (chi(2)=13.0, df=3, P=0.003). Among all participants the factors associated with a greater likelihood of opting for comfort care were being a college graduate or higher, good or better health status, greater health literacy, white race, and randomisation to the video arm. In multivariable analysis, participants in the video group were more likely to prefer comfort care than those in the verbal group (adjusted odds ratio 3.9, 95% confidence interval 1.8 to 8.6). Participants were re-interviewed after six weeks. Among the 94/106 (89%) participants re-interviewed in the verbal group, 27 (29%) changed their preferences (kappa=0.35). Among the 84/94 (89%) participants re-interviewed in the video group, five (6%) changed their preferences (kappa=0.79) (P<0.001 for difference).

CONCLUSION

Older people who view a video depiction of a patient with advanced dementia after hearing a verbal description of the condition are more likely to opt for comfort as their goal of care compared with those who solely listen to a verbal description. They also have more stable preferences over time.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00704886.

Stability of preferences for end-of-life treatment after 3 years of follow-up: the Johns Hopkins Precursors Study

BACKGROUND

Preferences for life-sustaining treatment elicited in one state of health may not reflect preferences in another state of health.

METHODS

We estimated the stability of preferences for end-of-life treatment across 3 years and whether declines in physical functioning and mental health were associated with changes in preferences for end-of-life treatment. In this longitudinal cohort study of medical students in the graduating classes of 1948 to 1964 at Johns Hopkins University, 818 physicians completed the life-sustaining treatment questionnaire in 1999 and 2002 (mean age at baseline, 69 years).

RESULTS

Although the prevalence of the 3 clusters of life-sustaining treatment preferences remained stable across the 3-year follow-up, certain physicians changed their preferences with time. The probability that physicians were in the same cluster at follow-up as at baseline was 0.41 for "most aggressive," 0.50 for "intermediate care," and 0.80 for "least aggressive." Physicians without advance directives were more likely to transition to the most aggressive cluster than to the least aggressive cluster during the 3-year follow-up (odds ratio, 1.96; 95% confidence interval, 1.11-3.45). Age at baseline and decline in physical and mental health were not associated with transitions between 1999 and 2002.

CONCLUSION

Periodic reassessment of preferences is most critical for patients who desire aggressive end-of-life care or who do not have advance directives.

Titrating guidance: a model to guide physicians in assisting patients and family members who are facing complex decisions

Over the last century, developments in new medical treatments have led to an exponential increase in longevity, but, as a consequence, patients may be left with chronic illness associated with long-term severe functional and cognitive disability. Patients and their families are often forced to make a difficult and complex choice between death and long-term debility, neither of which is an acceptable outcome. Traditional models of medical decision making, however, do not fully address how clinicians should best assist with these decisions. Herein, we present a new paradigm that demonstrates how the role of the physician changes over time in response to the curved relationship between the predictability of a patient's outcome and the chance of returning to an acceptable quality of life. To translate this model into clinical practice, we propose a 5-step model for physicians with which they can (1) determine at which point the patient is on our model; (2) identify the cognitive factors and preferences for outcomes that affect the decision-making process of the patient and his or her family; (3) reflect on their own reaction to the decision at hand; (4) acknowledge how these factors can be addressed in conversation; and (5) guide the patient and his or her family in creating a plan of care. This model can help improve patient-physician communication and decision making so that complex and difficult decisions can be turned into ones that yield to medical expertise, good communication, and personal caring.

Using the experiences of bereaved caregivers to inform patient- and caregiver-centered advance care planning

BACKGROUND

Traditional approaches to advance care planning (ACP) have many limitations; new approaches are being developed with the goal of improving end-of-life care.

OBJECTIVE

To understand how the end-of-life care experiences of older patients and their caregivers can inform the development of new approaches to ACP.

DESIGN

Qualitative cross-sectional study.

PARTICIPANTS

Caregivers of community-dwelling persons age > or = 60 years who died with advanced cancer, chronic obstructive pulmonary disease, or heart failure during follow-up in a longitudinal study.

APPROACH

In-depth interviews were conducted 6 months after the patient's death with 64 caregivers. Interviews began with open-ended questions to encourage the caregiver to tell the story of the patient's experiences at the end of life. Additional questions asked about how decisions were made, patient-caregiver, patient-clinician, and caregiver-clinician communication.

MAIN RESULTS

Although the experiences recounted by caregivers were highly individual, several common themes emerged from the interviews. These included the following: 1) the lack of availability of treatment options for certain patients, prompting patients and caregivers to consider broader end-of-life issues, 2) changes in preferences at the very end of an illness, 3) variability in patient and caregiver desire for and readiness to hear information about the patient's illness, and 4) difficulties with patient-caregiver communication.

DISCUSSION

The experiences of older patients at the end of life and their caregivers support a form of ACP that includes a broader set of issues than treatment decision-making alone, recognizes the dynamic nature of preferences, and focuses on addressing barriers to patient-caregiver communication.

The effect of underlying health status on patient or surrogate preferences for end-of-life care: a pilot study

This study explored the role of health status, as measured by the Palliative Performance Score, in shaping patient preferences for end-of-life care. Scores were correlated with 3 potential goals of care: prolonging life, maintaining function, and maximizing comfort among patients seen in palliative care consultation. Eighty-six patients expressed treatment preferences: 16 (19%) preferred prolonging life, 23 (27%) preferred maintaining function, and 47 (54%) preferred maximizing comfort (P < .0001); their average scores +/- standard deviation were, respectively, 51.9 +/- 19.4, 56.5 +/- 16.7, and 45.3 +/- 14.1 (P = .0459). There was a significant relationship between patient preferences and Palliative Performance Score, with lower scores indicating preferences for comfort and higher scores indicating a preference for maintaining function and life expectancy. Further research is needed to test the sensitivity of health status, as measured by the Palliative Performance Score, in affecting patient preferences.

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

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.

Current health and preferences for life-prolonging treatments: an application of prospect theory to end-of-life decision making

As a substantial body of research attests, the acceptability of life-prolonging treatment (e.g., tube feeding) tends to be greater among people in worse health than among healthier ones. Because a decision for or against a life-prolonging treatment represents a choice between two prospects-life (usually in poor health) and death-we propose a decision model, Prospect Theory, as a theoretical account of this phenomenon. Prospect Theory postulates that pairs of distant prospects are less distinguishable than pairs of closer ones. Thus, to healthy individuals, the prospects of death and life in poor health would both be remote, and therefore, the distinction between them, small. To less healthy individuals, however, the difference between the same pairs of prospects would appear greater, and therefore, life-prolonging treatment may be more acceptable. In a cross-sectional study of 304 community-dwelling people, aged 60 years and over in the Philadelphia area, USA, preferences for 4 life-prolonging treatments in 9 health scenarios were examined in relation to participants' current health, operationalized as number of deficits in physical functioning. As predicted, less healthy people expressed stronger preferences for all life-prolonging treatments compared with healthier ones, with differences greatest in the worse-health scenarios. Preferences also varied by health scenario, with any treatment preferred in the better health scenarios. Treatment preferences did not differ by type of treatment, depressed mood or any demographic characteristic except race, with African-Americans expressing stronger treatment preferences. Implications for advance care planning are discussed.

The state of advance care planning: one decade after SUPPORT

The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) was a landmark study regarding end-of-life decision making and advance care planning. Phase I of the study looked at the state of end of life in various hospitals, and phase II implemented a nurse-facilitated intervention designed to improve advance care planning, patient-physician communication, and the dying process. The observational phase found poor quality of care at the end of life and the intervention failed to improve the targeted outcomes. The negative findings brought public attention to the need to improve care for the dying and spawned a wealth of additional research on decision-making at the end of life. In the decade since SUPPORT, researchers have defined the attributes of a "good death," addressed the role of advance directives in advance care planning, and studied the use of surrogate decision-making at the end of life. This rekindled the discussion on advance care planning and challenged health care providers to design more flexible approaches to end of life care.

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

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.

An evaluation of the Decisional Conflict Scale for measuring the quality of end-of-life decision making

OBJECTIVE

Researchers and clinicians acknowledge the complexity of planning for future medical treatment desired in the event of incapacitation. Unfortunately, many attempts to evaluate the quality of such difficult planning have been stymied by the lack of measures that can be shown to have validity. This study examines the psychometric characteristics of the Decisional Conflict Scale (DCS) when used as a measure of patients' evaluation of their end-of-life decision-making process.

METHODS

This evaluation used the combined data from two independent samples in which 59 outpatients with a life-threatening illness and their surrogate decision makers were assigned to receive, a decision aid intervention, the patient-centered advance care planning (PcACP), or usual care only.

RESULTS

Internal consistency for the DCS in the end-of-life decision-making context was high. The DCS demonstrated convergent, construct, and discriminant validity based on the total scale scores.

CONCLUSION

The DCS appears to be a viable research instrument for measuring the quality of end-of-life decision making. However, the uncertainty subscale showed a weak discriminating ability and lack of association with the two other subscales, the modifiable factors contributing to uncertainty and the effectiveness of the decision making.

PRACTICE IMPLICATIONS

The findings of the study can be useful for measuring decisional conflict in individuals with serious illness facing end-of-life decision making.

Managed death in a PACE: pathways in present and advance directives

OBJECTIVES

To test the effect of an innovative method of documenting present and advance health care wishes on the rates of completion and the qualitative choices of health care wishes.

DESIGN

Interventional prospective cohort (pre- and post-).

SETTING

Program for All-inclusive Care of the Elderly (PACE) site in St. Louis, MO.

PARTICIPANTS

Enrolled PACE participants.

INTERVENTION

A documentation tool that captures both present and advance directives in a framework of "pathways," blending goals of care with typical procedure-oriented directives.

MEASUREMENTS

Data from medical records to calculate rates of health care wishes (HCW) completion, proportions of qualitative choices, and compliance with wishes at death.

RESULTS

Baseline prevalences of present directives (PD) and advance directives (AD) were 77% and 36%, respectively, while Do Not Resuscitate (DNR) wishes were documented in 48% of PD and 26% of AD. After implementation of the Pathways Tool, completion rates increased to 99% for both PD and AD. Documented DNR wishes decreased to 38% of PD and increased to 66% of AD. Qualitative choices for care (Longevity vs Function vs Palliation) changed toward a palliation pathway for AD (from 9% to 53%). The rate of dying at home increased from 24% to 65%. Compliance with end-of-life wishes increased from 72% to 96%. These are statistically significant.

CONCLUSION

Introduction of a novel pathways method of documenting HCW in a PACE site was associated with increased completion, preferences toward less invasive levels of care at life's end, and increased compliance with participants' wishes and deaths at home. Future research to validate the methodology employed in this intervention should be conducted in other long-term care settings.

Prospective study of health status preferences and changes in preferences over time in older adults

BACKGROUND

Instructional forms of advance care planning depend on the ability of patients to predict their future treatment preferences. However, preferences may change with changes in patients' health states.

METHODS

We conducted in-home interviews of 226 older community-dwelling persons with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease at least every 4 months for up to 2 years. Patients were asked to rate whether treatment for their illness would be acceptable if it resulted in 1 of 4 health states.

RESULTS

The likelihood of rating as acceptable a treatment resulting in mild (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.06-1.16) or severe (OR, 1.06; 95% CI, 1.03-1.09) functional disability increased with each month of participation. Patients who experienced a decline in their ability to perform instrumental activities of daily living were more likely to rate as acceptable treatment resulting in mild (OR, 1.23; 95% CI, 1.08-1.40) or severe (OR, 1.23; 95% CI, 1.11-1.37) disability. Although the overall likelihood of rating treatment resulting in a state of pain as acceptable did not change over time (OR, 0.98; 95% CI, 0.96-1.01), patients who had moderate to severe pain were more likely to rate this treatment as acceptable (OR, 2.55; 95% CI, 1.56-4.19) than were those who did not have moderate to severe pain.

CONCLUSIONS

For some patients, the acceptability of treatment resulting in certain diminished states of health increases with time, and increased acceptability is more likely among patients experiencing a decline in that same domain. These changes pose a challenge to advance care planning, which asks patients to predict their future treatment preferences.

Living wills and the Mental Capacity Act: a postal questionnaire survey of UK geriatricians

OBJECTIVE

To determine geriatricians' experience of and views on living wills, National Health Service Trusts' support of advance end-of-life health care planning and geriatricians' views on related legal changes in the Mental Capacity Act.

DESIGN

Anonymous postal questionnaire survey of all 1,426 British Geriatrics Society members in England, Wales and Northern Ireland.

RESULTS

A total of 842 (59%) questionnaires were returned. Of 811 geriatricians, 454 (56%) had cared for patients with living wills. Of the 280 who cared for patients when the living will had come into effect, 108 (39%) had changed treatment because of the living will and 84 (78%) of those felt that decisions had been easier to make. Living wills not already in effect made discussions with patients [171 of 178 (96%)] and families [135 of 178 (76%)] easier. Of 779 geriatricians, 713 (92%) saw advantages of older people using living wills; 467 of these also expressed concerns. Only 16 (2%) geriatricians who had concerns said that there were no advantages. A total of 214 (27%) were aware that their Trust had a form to help with discussions about cardiopulmonary resuscitation. Fewer [126 of 781 (16%)] were aware of a Trust policy on living wills. The proposal, in the Mental Capacity Bill, for advance refusals of treatment was supported by 59% (476 of 801), yet the proposal for a lasting power of attorney (LPA) covering health care was only supported by 47% (382 of 806).

CONCLUSION

Many geriatricians have positive experiences of caring for patients with living wills. Despite recognising potential problems, most geriatricians support the use of living wills by older people. However, most believe that their Trust does not have a policy to support advance health care planning. Geriatricians have reservations about LPAs covering health care.

When Written Advance Directives are not Enough

Advance directives have been promoted as being the best device for making decisions on behalf of patients who are unable to speak for themselves. It is believed that an advance directive would tell the health care professionals what to do. Conflicts would dissolve and the course would become clear. Such hopes and expectations probably exceed the capacity of these documents to provide context-based, real-time decisions. This article reviews the research on advance directives, including proxy and instructional documents, and discusses the strengths and limitations of each. Advance directives are often thought of as static, binding documents. Recommendations will be offered on how to use these documents as tools to facilitate patient-centered, dynamic decisions.