End-of-life treatment preferences may change as health declines

A study of older adults with advanced chronic illnesses indicates that as a patient's health declines, that individual may be more likely to accept treatments that would result in mild to severe functional disability, according to an article in the April 24 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Previous studies have suggested a patient's current health status may affect how they view treatments that might result in a diminished health state, according to background information in the article. For instance, patients with diminished states of health rate these health states more highly than does the general public. In addition, cancer patients are more willing to undergo intensive treatment with a small chance of benefit than are members of the general public or physicians.

Terri R. Fried, M.D., VA Connecticut Healthcare System and Yale University School of Medicine, New Haven, Conn., and colleagues conducted in-home interviews of 226 older adults with advanced chronic illnesses. Thirty-five percent had cancer, 36 percent had chronic obstructive pulmonary disease (COPD) and 29 percent had congestive heart failure. The patients were interviewed at least once every four months for a period of up to two years. At each interview, researchers assessed the participants' health condition and asked the participants whether they would accept treatment for their condition if the treatment resulted in one of four health states: mild physical disability, severe physical disability, cognitive (memory) impairment or pain. Mild physical disability was defined as being unable to leave the house for work, to visit family or for other reasons, and severe physical disability meant the individual would need assistance with everyday tasks. Rating a treatment as acceptable meant that the patients would agree to undergo that treatment, and rating a treatment as unacceptable meant that they would rather die than proceed with treatment.

Over the course of the study, patients became significantly more likely to rate mild and severe physical disability as acceptable outcomes of treatment. While 6 percent of patients changed their ratings of mild and severe physical disability from acceptable to unacceptable, 19 percent for mild and 20 percent for severe physical disability changed their answer from unacceptable to acceptable. Patients who had declines in their functional abilities over time also became more likely to rate physical disability as acceptable. At all interviews, cognitive impairment was unacceptable to 75 percent of participants, and the likelihood of rating cognitive impairment as acceptable decreased over time. Pain was unacceptable to 37 percent of patients throughout the study; patients who already had moderate to severe pain were more likely to rate pain as acceptable.

The findings suggest that it is difficult for some patients to predict how they will feel about particular treatments in the future. This poses a challenge to advance care planning, in which patients record instructions and preferences for their end-of-life care before they have reached that stage, the authors write. "The problems with predicting future hypothetical states of health have led some to conclude that instructional advance directives are a misguided means of care planning," they continue. "However, the methods we used to demonstrate the problem of predicting future health states provide a partial solution to the problem. Many patients were still able to think about and express their preferences regarding these states after experiencing a change in their health status. This finding implies that if advance care planning is conducted as a process over time, in which patients are asked to reflect on their preferences after experiencing a change in their health, they will have an opportunity to reflect on how their preferences may be changing."