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Elder Care
Senior Citizens Choose More Drastic Treatment as
Health Declines
Poses challenge to
advance care planning for end-of-life care
April 25, 2006 Although it is difficult to find
this surprising, a study of older people with advanced chronic illnesses
has found them more likely to accept treatments that result in
mild-to-severe functional disability as their health declines.
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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 appearing in the April 24 issue of the Archives of Internal
Medicine, one of the JAMA/Archives journals.
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."
Editor's Note: This study was supported by grants
from VA Health Services Research & Development, the National Institute
on Aging and the Claude D. Pepper Older Americans Independence Center at
Yale University, and by a Paul Beeson Physician Faculty Scholars Award.
Dr. Fried is supported by a grant from the National Institute on Aging.
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