End-of-Life Care

Living wills should be updated, since preferences for life-prolonging treatments change when health status changes

Life-prolonging treatment preferences change as an individual's health deteriorates, according to a new study. To be useful, living wills should be updated with changes in health status, suggest Laraine Winter, Ph.D., and Barbara Parker, B.A., of Thomas Jefferson University. They asked 304 community-dwelling people aged 60 and older about their preferences for life-prolonging treatments for 4 life-threatening conditions: gall bladder surgery for an inflamed or infected gall bladder, antibiotics for pneumonia, cardiopulmonary resuscitation (CPR) for cardiac or respiratory arrest, and tube feeding for inability to eat or drink. For each treatment, individuals were asked their preference given eight health scenarios that varied in severity, prognosis, and level of pain, and one scenario that involved a return to current health.

Individuals' current health status was measured by number of deficits in physical functioning. Life-prolonging treatments were more strongly preferred by lower-functioning people, compared with high functioning, with the preference strengthening as health prospects worsened. The highest functioning individuals tended to reject life-prolonging treatments in the worse-health scenarios. It is likely that, to healthy individuals, the prospect of life in poor health is remote and therefore indistinguishable from death. For less healthy individuals, by contrast, the difference between these two states seems larger, and life-prolonging treatment more acceptable, explain the researchers. Stronger preferences for life-prolonging treatment in most health scenarios were also associated with higher religiosity. Depressed mood did not seem to influence advanced care decisions.

The study was supported by the Agency for Healthcare Research and Quality (HS13785).

More details are in "Current health and preferences for life-prolonging treatments: An application of prospect theory to end-of-life decisionmaking," by Dr. Winter and Ms. Parker, in Social Science & Medicine 65, pp. 1695-1707, 2007.

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