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Health Care Decisionmaking

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Elderly people's decisions about end-of-life medical treatment may change over time

Elderly patients' views of health states they consider worse than death are only moderately stable over time. A state they might rate as "worse than death" at one point in time may become "better than death" just 6 months later, according to a study supported in part by the Agency for Healthcare Research and Quality (HS08180). Updating advance directives when patients are admitted to the hospital may help accommodate for these changed views, suggest the researchers who conducted the study.

They administered two questionnaires from 5 to 16 months apart to 50 elderly men and women. The subjects were asked to judge quality of life (QOL) possible in a number of hypothetical states of impaired health and indicate their desire to live or die (LOD) in each state. The states were coma, chronic severe pain that cannot be controlled, inability to communicate through any means, inability to reason or remember, confinement to bed, legal blindness, and functional deafness.

Both QOL and LOD judgments demonstrated only moderate stability regardless of the method of analysis used. LOD judgments revealed that for five of the seven health states, about 30 percent of elderly people changed their perception of the state from first to second measurement. Also, in four of the five most severe health states (coma, inability to reason or remember, inability to communicate, and chronic uncontrolled pain), from one-fourth to one-third of all participants who rated the states as worse than death at the initial interview changed their ratings to better than death at followup.

Judgment instability increased with longer elapsed time between interviews. If this initial view is documented in an advance directive ("living will") that is then used to guide later end-of-life treatment decisions made by surrogates, this moderation effect could lead to less or more aggressive treatment than the patient would actually desire.

More details are in "The stability of older adults' judgments of fates better and worse than death," by Lisa K. Lockhart, Ph.D., Peter H. Ditto, Ph.D., Joseph H. Danks, Ph.D., and others, in Death Studies 25, pp. 299-317, 2001.

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