What matters to seriously ill older persons making end-of-life treatment decisions?: A qualitative study.
ABSTRACT Several methods exist to elicit end-of-life treatment preferences. However, little work has been done to elicit from patients themselves the aspects of treatment decision-making most important to them when making end-of-life treatment decisions.
Participants consisted of 23 patients, 60 years of age and older with a primary diagnosis of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or cancer identified by their physicians as having a limited life expectancy. They took part in in-depth semistructured interviews and focus groups in which they were asked to discuss how they had made previous decisions about the treatment of their illness and/or would think about making future decisions. Transcripts were analyzed qualitatively using the constant comparative method.
There were three major influences on treatment preferences: treatment burden, treatment outcome, and the likelihood of the outcome. Treatment burden was bearable if the outcome of treatment was desirable, but participants were less willing to endure the burden for more marginal outcomes. Certain outcomes were so unacceptable that they determined preference regardless of burden. However, some participants revealed that their willingness to tolerate these adverse outcomes may increase as their illness progresses. Although participants generally believed that physicians know with certainty the outcomes of treatment, most understood the concept of uncertainty, and the likelihood of a given outcome influenced their preferences.
A patient-centered approach to advance care planning needs to incorporate a consideration of both treatment burdens and treatment outcomes, including the likelihood of these outcomes. Patients' valuations of these outcomes may change over time.
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ABSTRACT: The objective was to determine if participants' strength-of-preference scores for elective health care interventions at the end-of-life (EOL) elicited using a non-engaging technique are affected by their prior use of an engaging elicitation technique. Medicare beneficiaries were randomly selected from a larger survey sample. During a standardized interview, participants considered four scenarios involving a choice between a relatively less- or more-intense EOL intervention. For each scenario, participants indicated their favoured intervention, then used a 7-point Leaning Scale (LS1) to indicate how strongly they preferred their favoured intervention relative to the alternative. Next, participants engaged in a Threshold Technique (TT), which, depending on the participant's initially favoured intervention, systematically altered a particular attribute of the scenario until the participant switched preferences. Finally, they repeated the LS (LS2) to indicate how strongly they preferred their initially-favoured intervention. Two hundred and two participants were interviewed (189-198 were included in this study). The concordance of individual participants' LS1 and LS2 scores was assessed using Kendall tau-b correlation coefficients; scores of 0.74, 0.84, 0.85 and 0.89 for scenarios 1-4, respectively, were observed. Kendall tau-b statistics indicate a high concordance between LS scores, implying that the interposing engaging TT exercise had no significant effects on the LS2 strength-of-preference scores. Future investigators attempting to characterize the distributions of strength-of-preference scores for EOL care from a large, diverse community could use non-engaging elicitation methods. The potential limitations of this study require that further investigation be conducted into this methodological issue.Health expectations: an international journal of public participation in health care and health policy 03/2011; 14 Suppl 1:33-45. · 1.80 Impact Factor
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ABSTRACT: To determine whether poor functional status is associated with worse outcomes after attempted cardiopulmonary resuscitation (CPR). Retrospective study of individuals who experienced cardiac arrest stratified according to dependence in activities of daily living (ADLs) and residential status (nursing home (NH) or community dwelling). Two hundred thirty-five hospitals throughout North America. Adult inpatients aged 65 and older who had experienced a cardiac arrest as reported to the Get with the Guidelines-Resuscitation registry between 2000 and 2008. Primary outcomes were return of spontaneous circulation (ROSC) and survival to discharge. Twenty-six thousand three hundred twenty-nine individuals who experienced cardiac arrest met inclusion criteria. NH residents dependent in ADLs had a lower odds than community-dwelling independent participants of achieving ROSC (odds ratio (OR) = 0.73, 95% confidence interval (CI) = 0.63-0.85), whereas participants dependent in ADLs from either residential setting had lower odds of survival (community-dwelling: OR = 0.76, 95% CI = 0.63-0.92; NH: OR = 0.79, 95% CI = 0.64-0.96) after adjusting for participant and arrest characteristics. Duration of resuscitation and doses of epinephrine or vasopressin were similar between groups and had no significant effect on ROSC or survival, although participants dependent in ADLs were more likely to have a do-not-resuscitate (DNR) order placed after ROSC. Overall, median time to signing a DNR order after resuscitation was 10 hours (interquartile range 2-70). Functional and residential status are important predictors of survival after in-hospital cardiac arrest. Contrary to the hypothesis but reassuring from a quality-of-care perspective, less-aggressive attempts at resuscitation do not appear to contribute to poorer outcomes in individuals dependent in ADL, regardless of residential status.Journal of the American Geriatrics Society 01/2013; 61(1):34-9. · 4.22 Impact Factor
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ABSTRACT: This narrative review of the literature examines the issues influencing chemotherapy treatment of older patients with cancer. Increasing age is associated with physical, social and psychological changes, but the rate of change differs widely between people, such that chronological age is not a good determinant of fitness for treatment. Changes in old age can affect disease processes and treatments that are offered. Clinical trials suggest that older patients gain benefits from chemotherapy, but with increased toxicity profile. Dose reductions may be required, but the effect on outcome is not known. Adjuvant chemotherapy is likely to benefit patients with a life expectancy over 5 years, although mortality benefits become less pronounced with increasing age. Older patients want chemotherapy, as long as side effects do not reduce quality of life or ability to function independently. Older patients face barriers to communication with professionals, including sensory and memory problems and poorer health literacy. Patients should be assessed covering functional, physiological and socio-economic domains that identify significant comorbid disease and frailty, to ensure that planned chemotherapy is appropriate. Successful treatment of older patients with chemotherapy may require interventions to support them to ensure all patients who may derive benefit can undergo treatment, if they so wish.European Journal of Cancer Care 09/2011; 21(1):3-9. · 1.31 Impact Factor