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.

Projection in surrogate decisions about life-sustaining medical treatments.

To honor the wishes of an incapacitated patient, surrogate decision makers must predict the treatment decisions patients would make for themselves if able. Social psychological research, however, suggests that surrogates' own treatment preferences may influence their predictions of others' preferences. In 2 studies (1 involving 60 college student surrogates and a parent, the other involving 361 elderly outpatients and their chosen surrogate decision maker), surrogates predicted whether a close other would want life-sustaining treatment in hypothetical end-of-life scenarios and stated their own treatment preferences in the same scenarios. Surrogate predictions more closely resembled surrogates' own treatment wishes than they did the wishes of the individual they were trying to predict. Although the majority of prediction errors reflected inaccurate use of surrogates' own treatment preferences, projection was also found to result in accurate prediction more often than counterprojective predictions. The rationality and accuracy of projection in surrogate decision making is discussed.

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.

Accuracy of primary care and hospital-based physicians' predictions of elderly outpatients' treatment preferences with and without advance directives.

BACKGROUND: Past research has documented that primary care physicians and family members are often inaccurate when making substituted judgments for patients without advance directives (ADs). This study compared the accuracy of substituted judgments made by primary care physicians, hospital-based physicians, and family surrogates on behalf of elderly outpatients and examined the effectiveness of ADs in improving the accuracy of these judgments. PARTICIPANTS AND METHODS: Participants were 24 primary care physicians of 82 elderly outpatients, 17 emergency and critical care physicians who had no prior experience with the patients, and a baseline comparison group of family surrogates. The primary outcome was accuracy of physicians' predictions of patients' preferences for 4 life-sustaining treatments in 9 hypothetical illness scenarios. Physicians made substituted judgments after being provided with no patient AD, patient's value-based AD, or patient's scenario-based AD. RESULTS: Family surrogates' judgments were more accurate than physicians'. Hospital-based physicians making predictions without ADs had the lowest accuracy. Primary care physicians' accuracy was not improved by either AD. Accuracy and confidence in predictions of hospital-based physicians was significantly improved for some scenarios using a scenario-based AD. CONCLUSIONS: Although ADs do not improve the accuracy of substituted judgments for primary care physicians or family surrogates, they increase the accuracy of hospital-based physicians. Primary care physicians are withdrawing from hospital-based care in growing numbers, and emergency medicine and critical care specialists most often are involved in decisions about whether to begin life-sustaining treatments. If ADs can help these physicians better understand patients' preferences, patient autonomy more likely will be preserved when patients become incapacitated.

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.

The stability of older adults' judgments of fates better and worse than death.

Decisions about specific life-sustaining medical treatments have been found to be only moderately stable over time. This study examined whether more general judgments, such as whether a particular health condition is better or worse than death, would exhibit greater stability. Fifty adults (aged 65 yrs and older) made judgments about the perceived quality of life (QOL) possible in a number of hypothetical states of impaired health and their desire to live or die (LOD) in each state. Judgments were made twice from 5 to 16 months apart (M = 10.7 mo). Both QOL and LOD judgments demonstrated only moderate stability regardless of the method of analysis used. Judgments about states characterized by severe impairment became more moderate over time with a substantial minority of participants viewing the states as worse than death at the initial interview viewing them as better than death at follow-up. Participants who did not have a living will, did not have children, had a lower perceived QOL at the follow-up interview, and had a longer time between interviews had more unstable judgments. The implications of these findings for the use of instructional advance directives are discussed.

Modal preferences predict elderly patients' life-sustaining treatment choices as well as patients' chosen surrogates do.

The purpose of this study was to compare the accuracy of an actuarial method of predicting patients' preferences for life-sustaining treatment with the accuracy of surrogate decision makers. 401 outpatients 65 years old or older (mean = 73 years) and their self-designated surrogate decision makers recorded preferences for four life-sustaining medical treatments in nine hypothetical illness scenarios. The surrogates did not predict the patients' preferences more accurately than did an actuarial model using modal preferences. Surrogates' accuracy was not influenced by the use of an advance directive (AD) or discussion of life-sustaining treatment choices. In clinical practice, an actuarial model could assist surrogate decision makers when a patient has no AD, an AD is unavailable, a patient's AD is vague or describes treatment choices for only extreme or unlikely disease states, no proxy decision maker has been designated, or a patient was never competent.

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.

Elderly outpatients' understanding of a physician-initiated advance directive discussion.

OBJECTIVE: To examine elderly outpatients' understanding of advance directives (ADs), cardiopulmonary resuscitation (CPR), and artificial nutrition and hydration (ANH) with and without the benefit of a physician-initiated discussion. DESIGN: Randomized controlled trial. SETTING: University-affiliated, community-based, urban family practice residency training program. PATIENTS: One hundred patients aged 65 and older, consecutively sampled and randomly assigned to one of two discussion groups. INTERVENTIONS: Physicians' discussions based on a prepared script consisting of AD issues or health promotion issues. MAIN OUTCOME MEASURES: Test of comprehension of AD, CPR, and ANH information, using open-ended and yes-or-no questions. RESULTS: Patients in the AD and health promotion discussion groups showed good basic understanding. Younger and better-educated patients had a better working knowledge of AD-related information. Understanding of ADs was higher when the physician spent more time talking about AD-related issues after the discussion was completed. CONCLUSIONS: Many elderly outpatients have a good basic understanding of ADs, CPR, and ANH, even without explicit explanations from physicians. However, younger, better-educated patients and those who had longer unstructured discussions had greater AD-related knowledge. These factors need to be considered when framing discussions with patients about ADs and life-sustaining treatments.

Physicians' predictions of elderly outpatients' preferences for life-sustaining treatment.

BACKGROUND: Research has shown that physicians are poor predictors of patients' life-sustaining treatment preferences. Our study examined the association between three aspects of physician experience and their ability to accurately predict patients' preferences for two different life-sustaining treatments in the event of two serious medical conditions. METHODS: Seventeen physicians predicted the treatment preferences of 57 patients and then interviewed patients regarding their actual treatment preferences. Physicians' professional experience, length of their relationship with the patient, and experience with direct feedback were measured to determine the association of these factors with the accuracy of the physicians' predictions. RESULTS: Physicians became more accurate predictors as they interviewed more patients and received direct feedback regarding the accuracy of their predictions (P < .001). Residents were more accurate than faculty in predicting patients' preferences (P < .05). CONCLUSIONS: Increased experience with life-sustaining treatment discussions improved the physicians' abilities to accurately predict patient preferences. Although possibly resulting from small sample size, neither greater professional experience nor longer relationship with a patient improved the accuracy of physicians' predictions. Future research should examine whether discussing end-of-life issues with patients more often makes physicians more sensitive predictors of patients' life-sustaining treatment preferences.

Elderly outpatients respond favorably to a physician-initiated advance directive discussion.

BACKGROUND: Little is known about the emotional impact of physician-initiated advance directive discussions. METHODS: One hundred ambulatory patients aged 65 years and older were randomly assigned to receive either a physician-initiated discussion of advance directive choices of a discussion of health promotion issues. Prediscussion, immediate postdiscussion, and 1-week postdiscussion measures of positive and negative affect were measured for both groups. RESULTS: Neither discussion topic resulted in adverse emotional or attitudinal responses. Only the advance directive participants showed positive affective and attitudinal responses to the discussion, including an increase in positive affect, an increased sense of physician-patient understanding, and increased thought and discussion about life-support issues in the week following the discussion. For those participants receiving the advance directive discussion, longer physician-patient relationships and higher educational levels significantly predicted a more positive affective response. Lower scores on indices of mental and physical health and a stronger belief that physicians should discuss advance directive issues significantly predicted a more negative affective response to the advance directive discussion. CONCLUSIONS: Physicians should anticipate positive emotional responses when they initiate advance directive discussions with their elderly outpatients. Advance directive discussions will be received most positively by patients who enjoy good psychological and physical health and when initiated in the context of an established physician-patient relationship.

Comprehension of prenominal adjective orders.

In two experiments, phrases descrying a referent object contained two prenominal adjectives in either normal or inverted order. The time to identify the position of the referent in a display was a function of both the adjective order and the nortreferent context. If the referent appeared with a nonreferent differing from it only in size or number, the normal order of adjectives facilitated responding. However. if the referent appeared with a nonreferent differing from it only in color, the inverted order of adjectives resulted in faster identification times. These results support a pragmatic communication rule that. when the more discriminating adjectives are ordered earlier in a series, comprehension is facilitated.

A developmental study of the pragmatic communication rule for prenominal adjective ordering*.

First-, fourth-, and eighth-grade children and college undergraduates indicated preference for either normal or inverted orders of prenominal adjectives (for example,the large red car or the red large car, respectively) to describe a pictorial referent. Preference for the normal order of adjectives first appeared with the fourth graders. When communication context was vaxied by presenting a nonreferent that required a color adjective for discrimination from the referent, college students increased their preference for the inverted order. This separation of the acquisition of a linguistic rule from its utilization in communication was discussed.