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End-of-Life preferences appear to remain
stable as health declines
Newswise — Most individuals’ preferences
regarding life-sustaining treatment do not
appear to change over a three-year period,
regardless of declines in physical and
mental health, according to a report in the
October 27 issue of Archives of Internal
Medicine, one of the JAMA/Archives journals.
Individuals who say they want aggressive
care and those without advance directives
are most likely to change their end-of-life
wishes over time.
“Efforts to improve the experience of
patients and families at the end of life
must incorporate patient perspectives,” the
authors write as background information in
the article.
“Advance directives are one strategy through
which patient preferences can be elicited
and recorded, to be invoked at a time when
the patient may not be able to make
decisions directing care.”
However,
they note, preferences for life-sustaining
treatment given in one state of health may
not reflect the choices patients would make
if their health status changed.
Marsha N. Wittink, M.D., M.B.E., of the
University of Pennsylvania School of
Medicine, Philadelphia, and colleagues
assessed end-of-life preferences in 818
physicians (average age 69) who graduated
from medical school at Johns Hopkins
University between 1948 and 1964.
Participants completed questionnaires about
their health status and their end-of-life
preferences in 1999 and again in 2002.
They were asked to consider what treatments
they would want in the event of brain death
that left them unable to speak or recognize
people.
They reported how likely they were to desire
each of 10 interventions, including
cardiopulmonary resuscitation, major
surgery, a feeding tube and dialysis.
The physicians were divided into three
clusters based on their preferences: those
who would want most of the interventions
were classified as preferring aggressive
care (12 percent in 1999 and 14 percent in
2002), those who would want intravenous
fluids and antibiotics as the primary
interventions as preferring intermediate
care (26 percent in 1999 and 26 percent in
2002) and those who would decline most
interventions as desiring least aggressive
care (62 percent in 1999 and 60 percent in
2002).
“In general, procedures that were declined
in 1999 were likely also to be declined in
2002,” the authors write.
“Nevertheless, a substantial proportion of
persons who desired an intervention in 1999
declined the treatment in 2002.”
A total of 41 percent of those who said they
desired aggressive care in 1999 remained in
that category in 2002.
In addition, physicians who did not have a
living will or durable power of attorney
were twice as likely to transition to the
most aggressive category as those without
advance directives.
Age and declines in mental and physical
health were not associated with transitions
to either more or less aggressive care.
“We believe that the results of this study
suggest that although physician-respondents
were relatively stable in their preferences,
persons without advance directives and who
desired the most aggressive treatment at
baseline exhibited the most changeable
preferences,” the authors write.
“Persons who express a desire for aggressive
treatment and those who have not
communicated their wishes with a more formal
written document (advance directives) may
require frequent clinical re-evaluation to
assess whether wishes have changed.”
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