Gender differences in older adults' preferences for life-sustaining medical treatments and end-of-life values.

In the present study, we examined gender differences in preferences for life sustaining treatments in response to various health state scenarios and the endorsement of end-of-life values in 99 older adults. Men preferred life-sustaining treatments more than women overall, for specific treatments (i.e., CPR, surgery, and artificial feeding), and in response to specific health scenarios (i.e., current health, Alzheimer's disease, coma with a slight chance of recovery). In terms of values, women indicated a greater desire for a dignified death than men.

Advance directives as acts of communication: a randomized controlled trial.

BACKGROUND: Instructional advance directives are widely advocated as a means of preserving patient self-determination at the end of life based on the assumption that they improve surrogates' understanding of patients' life-sustaining treatment wishes. However, no research has examined whether instructional directives are effective in improving the accuracy of surrogate decisions. PARTICIPANTS AND METHODS: A total of 401 outpatients aged 65 years or older and their self-designated surrogate decision makers (62% spouses, 29% children) were randomized to 1 of 5 experimental conditions. In the control condition, surrogates predicted patients' preferences for 4 life-sustaining medical treatments in 9 illness scenarios without the benefit of a patient-completed advance directive. Accuracy in this condition was compared with that in 4 intervention conditions in which surrogates made predictions after reviewing either a scenario-based or a value-based directive completed by the patient and either discussing or not discussing the contents of the directive with the patient. Perceived benefits of advance directive completion were also measured. RESULTS: None of the interventions produced significant improvements in the accuracy of surrogate substituted judgment in any illness scenario or for any medical treatment. Discussion interventions improved perceived surrogate understanding and comfort for patient-surrogate pairs in which the patient had not completed an advance directive prior to study participation. CONCLUSIONS: Our results challenge current policy and law advocating instructional advance directives as a means of honoring specific patient wishes at the end of life. Future research should explore other methods of improving surrogate decision making and consider the value of other outcomes in evaluating the effectiveness of advance care planning.

Older adults' attitudes toward death: links to perceptions of health and concerns about end-of-life issues.

The current study had two primary goals, to determine whether: 1) self-rated mental and physical health, pain, and experience with health problems were predictors of elderly adults' attitudes toward death; and 2) death attitudes predict end-of-life medical treatment concerns. Participants were 109 adults, 65 years of age or older (M=78.74 years), recruited from the local community. Regression analysis indicated that poorer perceived physical health predicted a greater likelihood of viewing death as an escape, and poorer perceived mental health predicted a greater fear of death. Viewing death as an escape and fearing death predicted end-of-life medical treatment concerns; a greater endorsement of either attitude predicted more concern. Possible explanations for the links between perceived health, attitudes toward death, and concern about end-of-life issues are suggested.

A comparison of primary stressors, secondary stressors, and depressive symptoms between elderly caregiving husbands and wives: the Caregiver Health Effects Study.

The present study examined gender differences in the experience of primary and secondary caregiving stressors, depressive symptoms, and their interrelationships using a sample of 283 elderly spouse caregivers (145 women, 138 men). Two primary stressors, two secondary stressors, and depressive symptoms were assessed. In general, t-tests indicated that caregiving husbands experience fewer stressors and depressive symptoms than their female counterparts. Multiple group analysis revealed that the primary stressors were more useful in explaining variance associated with the secondary stressors for women than men and that the path coefficients linking amount of caregiving assistance to caregivers' activity restriction was significantly different across men and women. Other paths linking primary stressors, secondary stressors, and depressive symptoms, however, were statistically equivalent across men and women. Hence, although caregiving women and men may vary in their reports of caregiving stressors, the complexity of the caregiving experience appears to be quite uniform for both groups.

Elderly adults' preferences for life-sustaining treatments: the role of impairment, prognosis, and pain.

Elderly adults' preferences for life-sustaining treatment are known to vary by type of medical condition and treatment. Less is known about how treatment preferences vary based on underlying health dimensions, such as the nature of the impairment, prognostic information, and the experience of pain. Fifty elderly adults stated preferences for 4 life-sustaining treatments in response to 4 pairs of health state scenarios. Overall, life-sustaining treatments were preferred less in response to (a) cognitive versus physical impairment, (b) when the prognosis described no chance versus a very slight chance of recovery/improvement, and (c) if pain was present. These findings have implications for the way in which preferences for life-sustaining treatments are recorded in advance directives. Historically, advance directives have been limited by overly broad or overly specific statements about treatment preferences. Recording underlying health dimensions that guide treatment decisions may allow decision makers to generalize and apply patient preferences to novel health conditions.

The role of neuroticism and mastery in spouse caregivers' assessment of and response to a contextual stressor.

Data from more than 300 spousal caregivers and their care recipients were analyzed to demonstrate the effects of caregivers' personality attributes--neuroticism and mastery--on their assessment of a contextual stressor (the care recipient's behavioral and functional impairment) and on their experience of distress associated with that stressor. Caregivers who were high in neuroticism and/or low in mastery reported higher levels of behavioral and functional impairment in their disabled spouse and experienced more strain and depressive symptoms associated with caregiving relative to caregivers with lower neuroticism or higher mastery scores. We further showed that the widely reported association between caregiver-assessed impairment of the care recipient and caregiver outcomes can in part be explained by caregivers' personality attributes, such as neuroticism and mastery. Our findings that caregivers' personality variables are related to their assessment of a given objective stressor and their response to a given level of stress have implications for interventions targeting caregivers and for the use of caregivers as proxy informants.

Spousal similarity in subjective well-being: the Cardiovascular Health Study.

This study examines the extent to which one spouse's subjective well-being predicts that of the partner (N = 1,040 spousal pairs, 65 years or older). Prior research is extended in two ways: (a) The similarity of both affective domains (depressive symptoms, feelings about life as a whole, and satisfaction with the meaning and purpose of life) and nonaffective domains (perceived health) are examined, and (b) known predictors of well-being in older adults (sociodemographic variables, self and spouse health status variables, and exposure to common environmental events) are statistically controlled. Results indicate that one spouse's assessments of well-being and depression predict the other's well-being even after controlling for known predictors of these outcomes. Given the similarity of findings for affective and nonaffective domains, multiple mechanisms, including contagion, mate selection, and common environmental influences, are speculated as likely to contribute to this phenomenon.

Pessimism, age, and cancer mortality.

Cancer patients (N = 238) receiving palliative radiation treatment were followed for 8 months; 70 patients had died by the 8-month follow-up. Controlling for site of cancer and level of symptomatology at baseline, the authors studied the independent effects on mortality of pessimism, optimism, and depression. The findings show that the endorsement of a pessimistic life orientation is an important risk factor for mortality, but only among younger patients (ages 30-59). Attempts to replicate this finding with conceptually related constructs such as depression or optimism did not yield significant associations for either younger or older patients, suggesting that negative expectations about the future may contribute to mortality in unique ways. The authors conclude that attempts to link psychosocial factors to mortality should focus on specific psychological constructs instead of diffuse, global measures that cover many psychological phenomena and that the role of psychological processes in mortality may vary dramatically depending on age.

Psychiatric and physical morbidity effects of dementia caregiving: prevalence, correlates, and causes.

The dementia caregiving literature is reviewed with the goals of (a) assessing the prevalence and magnitude of psychiatric and physical morbidity effects among caregivers, (b) identifying individual and contextual correlates of reported health effects and their underlying causes, and (c) examining the policy relevance of observed findings. Virtually all studies report elevated levels of depressive symptomatology among caregivers, and those using diagnostic interviews report high rates of clinical depression and anxiety. The evidence is more equivocal and generally weaker for the association between caregiving and physical morbidity, such as self-rated health, number of illnesses, symptomatology, health care utilization, preventive health behaviors, and cardiovascular functioning. Across studies, psychiatric morbidity in caregivers was linked to patient problem behaviors, income, self-rated health, perceived stress, and life satisfaction. Physical morbidity was associated with patient problem behaviors and cognitive impairment, and with caregiver depression, anxiety, and perceived social support. Possible causes of reported effects and policy implications are discussed.

Predictors of perceived health status in elderly men and women. The Cardiovascular Health Study.

Baseline data on the perceived health status of participants (N = 5,201) in the Cardiovascular Health Study of the Elderly (CHS) are reported. The authors examined the predictive utility of health-related factors representing eight different domains, assessed gender differences in the prediction of perceived health, and tested a hypothesis regarding the role of known clinical conditions versus subclinical disease in predicting perceived health. Multivariate analyses showed that the majority of the explained variance in self-assessed health is accounted for by variables that fall into four general categories. Although gender differences were small, the analysis showed that the relative importance of several predictor variables did vary by gender.

Predictors of dating violence: a multivariate analysis.

A multivariate approach was used to determine the pattern of predictors associated with engaging in dating violence. Predictors were selected whose relationship to dating violence has been established by earlier research: attitudes toward violence, sex-role attitudes, romantic jealousy, general levels of interpersonal aggression, verbal aggression, and verbal and physical aggression received from one's partner. Participants included 305 introductory psychology student volunteers (227 females and 78 males) who completed a set of scales related to dating relationships. Expecting different patterns of predictors to emerge for men and women, we performed separate multiple regression analyses for each. Of the set of predictors employed, receipt of physical violence from one's partner emerged as the largest predictor of expressed violence for both men and women. In addition, higher scores on attitudes toward violence and verbal aggression, and less traditional sex-role attitudes emerged as significant predictors of expressed violence for men. For women, less accepting attitudes toward violence, more traditional sex-role attitudes, feelings of romantic jealousy, higher general levels of interpersonal aggression, and verbal aggression were predictive of expressed violence. The implications of our findings for future research are discussed.