Doctor’s Less Likely to Consider Patient’s Medical
Choice with Older Patients
Physicians having to make a decision for incapable
patient most likely to do what they think best - especially if they are
elderly
March 22, 2010 - When doctors have to make a
medical decision on behalf of a patient incapable of making the
decision, their most frequent choice is to do what they think is best
for the patient. Coming in second, however, is the more accepted
decision – doing what would be the patient’s choice. This option may be
in second place because the researchers found doctors less likely to
choose it for elderly patients.
"A growing number of hospitalized adults are
incapable of making their own health decisions," said Alexia Torke,
M.D., senior author of the study reported in the March 2010 issue of the
Journal of the American Geriatrics Society.
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"Doctors balance a lot of important considerations
when caring for a patient who cannot voice his or her own preferences.
These considerations include what the patient would have wanted and what
the physician and family think is best for the patient overall.
“While prior discussions or living wills may be
helpful especially in circumstances when the patient expressed strong
beliefs and is facing a difficult illness, these preferences are only
part of the equation."
Dr. Torke is an assistant professor of medicine at
the Indiana University School of Medicine, a Regenstrief Institute
investigator, and an IU Center for Aging Research scientist.
The study surveyed 281 internists, family practice
doctors, intensive care unit physicians and hospitalists, about half of
whom were in private practice. Slightly over half were male. Each was
asked questions about caring for their most recent patient who was
unable to make his or her own decisions and rated the importance of each
of the factors that influenced decisions on how to care for the patient.
The researchers found that when asked to
When asked to identify the single most important
factor in making decisions for their patient, the doctors produced these
results:
● "what was best for the patient overall" (33 percent),
● “what the patient would have wanted you to do" (29 percent),
● "the patient's pain and suffering" (13 percent), and
● "the patient's prognosis" (12 percent).
"Even though standard ethical models say that
patient preferences should be the most important factor in surrogate
decision making, in reality doctors consider many factors and weight
them differently in each case," said Dr. Torke.
"We have come to consensus in our society that
people should have a lot of input into their own medical decisions. But
when the patient can't made decisions we have much less consensus on how
to proceed. While physicians weigh various factors, we learned from our
study that what's going on at the time the treatment decision is being
made is as important as previous medical directives. We did not find
evidence that living wills or prior discussions with patients about
their preferences for care made a difference in the decision making for
most patients," she said.
Decreased Reliance on Patient Preference
Increases with Age
"We also found a decreased reliance on patient
preferences with increasing age. This may reflect ageist assumptions
that the preferences and values of older adults are less important than
those of younger adults. Another possible explanation is that when
caring for older adults, physicians may accept that death is an
unavoidable event and that for many patients, health care in advanced
age should focus more on quality of life than extension of life," said
Dr. Torke, who is also affiliated with the Fairbanks Center for Medical
Ethics at Clarian Health.
In a study published last year in the Journal of
General Internal Medicine, Dr. Torke and colleagues found that one
in five of the same doctors surveyed for the new study are not
comfortable working with a surrogate decision maker. The doctors
reported ineffective communication, lack of satisfaction with the
outcome of the decision, and an increase in stress level as a result of
the surrogate decision making process.
The new JAGS study was funded by the Department of
Health and Human Services' Health Resources Services Administration.
Co-authors are Mark Siegler, M.D., Rachael M. Moloney, B.A., and G.
Caleb Alexander, M.D., of the University of Chicago, and Anna Abalos,
M.D., of Rocklin, California.
The IU School of Medicine and the Regenstrief
Institute are located on the campus of Indiana University-Purdue
University Indianapolis.
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March 22, 2010 - When doctors have to make a
medical decision on behalf of a patient incapable of making the
decision, their most frequent choice is to do what they think is best
for the patient. Coming in second, however, is the more accepted
decision – doing what would be the patient’s choice. This option may be
in second place because the researchers found doctors less likely to
choose it for elderly patients.