Dataset Information

Stability of preferences for end-of-life treatment after 3 years of follow-up: the Johns Hopkins Precursors Study.

ABSTRACT: BACKGROUND:Preferences for life-sustaining treatment elicited in one state of health may not reflect preferences in another state of health. METHODS:We estimated the stability of preferences for end-of-life treatment across 3 years and whether declines in physical functioning and mental health were associated with changes in preferences for end-of-life treatment. In this longitudinal cohort study of medical students in the graduating classes of 1948 to 1964 at Johns Hopkins University, 818 physicians completed the life-sustaining treatment questionnaire in 1999 and 2002 (mean age at baseline, 69 years). RESULTS:Although the prevalence of the 3 clusters of life-sustaining treatment preferences remained stable across the 3-year follow-up, certain physicians changed their preferences with time. The probability that physicians were in the same cluster at follow-up as at baseline was 0.41 for "most aggressive," 0.50 for "intermediate care," and 0.80 for "least aggressive." Physicians without advance directives were more likely to transition to the most aggressive cluster than to the least aggressive cluster during the 3-year follow-up (odds ratio, 1.96; 95% confidence interval, 1.11-3.45). Age at baseline and decline in physical and mental health were not associated with transitions between 1999 and 2002. CONCLUSION:Periodic reassessment of preferences is most critical for patients who desire aggressive end-of-life care or who do not have advance directives.

SUBMITTER: Wittink MN

PROVIDER: S-EPMC2596594 | biostudies-literature | 2008 Oct

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Stability of preferences for end-of-life treatment after 3 years of follow-up: the Johns Hopkins Precursors Study.

Wittink Marsha N MN Morales Knashawn H KH Meoni Lucy A LA Ford Daniel E DE Wang Nae-Yuh NY Klag Michael J MJ Gallo Joseph J JJ

Archives of internal medicine 20081001 19

<h4>Background</h4>Preferences for life-sustaining treatment elicited in one state of health may not reflect preferences in another state of health.<h4>Methods</h4>We estimated the stability of preferences for end-of-life treatment across 3 years and whether declines in physical functioning and mental health were associated with changes in preferences for end-of-life treatment. In this longitudinal cohort study of medical students in the graduating classes of 1948 to 1964 at Johns Hopkins Univer ...[more]

PMID: 18955642

Similar Datasets

Project description:BACKGROUND:Stating preferences about care beforehand using advance care planning and advance directives has become increasingly common in current medicine. There is still lack of clarity what happens over the course of time in relation to these preferences. We wanted to determine whether the preferences about end-of-life care of a person owning an advance directive stay stable after the experience of a life-event; how often advance directives are altered and discussed with family members and physicians over time. DESIGN:A longitudinal cohort study with a population consisting of people owning the most common advance directives in the Netherlands, with a follow-up of 6-years from 2005 until 2011. Respondents were recruited using two associations that provided the advance directives, Right to Die-NL (n = 4463) and the Dutch Patient Organisation (n = 1263). Each 1.5 year a questionnaire was sent. We analyzed the relationship between variables using generalized estimated equations. RESULTS:96.9-98.1% of the respondents who had experienced a life-event had stable preferences. 89.9-93.7% of Right-to-Die-NL-members who had experienced a life-event didn't make any alterations in their advance directives. During the 6-year course of our study, a minority of both groups didn't discuss their advance directive with anyone (8.7-16.4%), while a majority didn't discuss it with physicians (ranging 58.1-95.1%). Factors related to health, such as deterioration in experienced health, increased the odds to discuss advance directives. CONCLUSION:Our results largely dispute criticism concerning usability of advance directives due to lack of stability of preferences. Whereas a change in health status and the experience of other life-events were not related to instability in preferences, they did increase the odds of communication about advance directives. Because our results show that the possession of an advance directive does not necessarily result in frequent discussions between patients and caregivers, a more structured approach like advance care planning might be a solution.

Project description:ImportancePolicies and practices that promote advance care planning and advance directive completion implicitly assume that patients' choices for end-of-life (EOL) care are stable over time, even with changes in health status.ObjectiveTo systematically evaluate the evidence on the stability of EOL preferences over time and with changes in health status.Evidence reviewWe searched for longitudinal studies of patients' preferences for EOL care in PubMed, EMBASE, and using citation review. Studies restricted to preferences regarding the place of care at the EOL were excluded.FindingsA total of 296 articles were assessed for eligibility, and 59 met inclusion criteria. Twenty-four articles had sufficient data to extract or calculate the percentage of individuals with stable preferences or the percentage of total preferences that were stable over time. In 17 studies (71%) more than 70% of patients' preferences for EOL care were stable over time. Preference stability was generally greater among inpatients and seriously ill outpatients than among older adults without serious illnesses (P < .002). Patients with higher education and who had engaged in advance care planning had greater preference stability, and preferences to forgo therapies were generally more stable than preferences to receive therapies. Among 9 of the 24 studies (38%) assessing changes in health status, no consistent relationship with preference changes was identified.Conclusions and relevanceConsiderable variability among studies in the methods of preference assessment, the time between assessments, and the definitions of stability preclude meta-analytic estimates of the stability of patients' preferences and the factors influencing these preferences. Although more seriously ill patients and those who engage in advance care planning most commonly have stable preferences for future treatments, further research in real-world settings is needed to confirm the utility of advance care plans for future decision making.

Project description:UNLABELLED: BACKGROUND: The "Patients' Rights and End of Life Care" Act came into force in France in 2005. It allows withholding/withdrawal of life-support treatment, and intensified use of medications that may hasten death through a double effect, as long as hastening death is not the purpose of the decision. It also specifies the requirements of the decision-making process. This study assesses the situation by examining the frequency of end-of-life decisions by patients' and physicians' characteristics, and describes the decision-making processes. METHODS: We conducted a nationwide retrospective study of a random sample of adult patients who died in December 2009. Questionnaires were mailed to the physicians who certified/attended these deaths. Cases were weighted to adjust for response rate bias. Bivariate analyses and logistic regressions were performed for each decision. RESULTS: Of all deaths, 16.9% were sudden deaths with no information about end of life, 12.2% followed a decision to do everything possible to prolong life, and 47.7% followed at least one medical decision that may certainly or probably hasten death: withholding (14.6%) or withdrawal (4.2%) of treatments, intensified use of opioids and/or benzodiazepines (28.1%), use of medications to deliberately hasten death (i.e. not legally authorized) (0.8%), at the patient's request (0.2%) or not (0.6%). All other variables held constant, cause of death, patient's age, doctor's age and specialty, and place of death, influenced the frequencies of decisions. When a decision was made, 20% of the persons concerned were considered to be competent. The decision was discussed with the patient if competent in 40% (everything done) to 86% (intensification of alleviation of symptoms) of cases. Legal requirements regarding decision-making for incompetent patients were frequently not complied with. CONCLUSIONS: This study shows that end-of-life medical decisions are common in France. Most are in compliance with the 2005 law (similar to some other European countries). Nonetheless, the study revealed cases where not all legal obligations were met or where the decision was totally illegal. There is still a lot to be done through medical education and population awareness-raising to ensure that the decision-making process is compatible with current legislation, the physician's duty of care and the patient's rights.

Project description:PurposeThe use of radiation therapy (RT) in consolidating oligometastatic prostate cancer (OPCa) is a rapidly evolving treatment paradigm. We review our institutional experience using metastasis-directed therapy in the definitive management of men with OPCa.Methods and materialsPatients with OPCa treated with definitive RT were included. The Kaplan-Meier method and multivariable Cox regression analysis were performed to assess biochemical progression-free survival (bPFS) and time to next intervention. Cumulative incidence functions were used to calculate rates of local failure. Toxicity was assessed using Common Terminology Criteria for Adverse Events (version 4).ResultsThis study analyzed 156 patients with OPCa and 354 metastatic lesions with median follow-up of 24.6 months. Of 150 patients with toxicity data, 53 (35%) experienced acute grade 1 toxicity, 8 (5%) had grade 2, and none had grade 3 toxicity. Only 13 patients (9%) had late toxicities. At 24 months, the cumulative incidence of local failure was 7.4%. Median bPFS for the entire cohort was 12.9 months and 52% at 1 year. On multivariable analysis, factors associated with prolonged bPFS were peri-RT androgen deprivation therapy (ADT), lower gross tumor volume, and hormone-sensitive (HS) OPCa. Median time to next intervention, including repeat RT, was 21.6 months. Median bPFS for men with HS prostate cancer was 17.2 months compared with 7.2 months in men with castrate-resistant OPCa (P < .0001), and cumulative incidence of local failure at 24 months was lower with HS OPCa (4.8% vs 12.1%; P = .034). We analyzed 28 men with HS OPCa treated with a course of peri-RT ADT (median, 4.3 months) with recovery of testosterone. At a median follow-up of 33.5 months, 20 patients had not developed bPFS, median bPFS had not been reached, and 24-month bPFS was 77%.ConclusionsMetastasis-directed therapy can be effective across a wide range of OPCa subtypes, but with differential efficacy. Further study is warranted to investigate the use of RT across the wide range of patients with OPCa.

Project description:BACKGROUND: The estimation of healthy life years (HLY) by socio-economic status (SES) requires two types of data: the prevalence of activity limitation by SES generally extracted from surveys and mortality rates by SES generally derived from a linkage between the SES information in population databases (census, register) and mortality records. In some situations, no population-wide databases are available to produce mortality rates by SES, and therefore some alternatives must be explored. This paper assesses the validity of calculating HLY by SES using mortality rates derived from a linkage between surveys and mortality records. METHODS: TWO SURVEYS WERE CHOSEN TO EXPLORE THE VALIDITY OF THE PROPOSED APPROACH: The Belgian Health Interview Survey (HIS) and the Belgian Survey on Income and Living Conditions (SILC). The mortality follow-up of these surveys were used to calculate HLY by educational level at age 25. These HLY were compared with HLY estimates calculated using the mortality follow-up of the 2001 census. The validity of this approach was evaluated against two criteria. First, the HLY calculated using the census and those calculated using the surveys must not be significantly different. Second, survey-based HLY must show significant social inequalities since such inequalities have been consistently reported with census-based HLY. RESULTS: Both criteria were met. First, for each educational category, no statistically significant difference was found when comparing census-based and survey-based HLY estimates. For instance, men in the lowest educational category have shown a HLY of 34 years according to the HIS, and while this figure was 35.5 years according to the census, this difference was not statistically significant. Second, the survey-based HLY have shown a significant social gradient. For instance, men in the highest educational category are expected to live 9.5 more HLY than their counterparts in the lowest educational category based on the HIS estimates, compared with 7.3 HLY based on the census estimates. CONCLUSIONS: This article suggests that using the mortality follow-up of a nationally representative cross-sectional survey is a valid approach to monitor social inequalities in HLY in the absence of population-wide data.

Dataset Information

Stability of preferences for end-of-life treatment after 3 years of follow-up: the Johns Hopkins Precursors Study.

Publications

Stability of preferences for end-of-life treatment after 3 years of follow-up: the Johns Hopkins Precursors Study.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets