Long Life Rates Over Health, Aged Say
Forget quality of life. For many very old people, what matters more is quantity of life.
That’s what the majority of patients between 80 and 98 at four academic medical centers told researchers who asked the patients whether they would trade living one year in their current condition for living less time in excellent health. The study, published earlier this month in the Journal of the American Medical Assn., is one of the few to examine the health values of very old patients.
A team of researchers led by Joel Tsevat of the Section of Outcomes Research at the University of Cincinnati Medical Center also asked 300 surrogate decision-makers what they thought these patients would want. These surrogates, who in most cases were spouses or adult children, often guessed wrong: 20% incorrectly hypothesized that patients were willing to give up three months of life in exchange for excellent health.
“What we have found is that age, the ability to function independently and surrogates are not that accurate” as predictors of patients’ wishes, Tsevat said. “Our clinical message is that we need better communication directly with patients themselves. There is something more than health that matters a lot.”
To determine the values of elderly patients, Tsevat and his colleagues surveyed a group of people who in 1993 and 1994 were hospitalized for more than three days at four teaching hospitals: Beth Israel-Deaconness Medical Center in Boston, MetroHealth Medical Center in Cleveland, the Marshfield Clinic in Wisconsin and UCLA Medical Center. Patients were interviewed on their fourth day in the hospital; one year later, those who were still alive were interviewed again. The results were similar.
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The median age of patients, 60% of whom were women, was 84.2. Twenty-one percent said they were in pain at least half of the time. Tsevat said they resembled typical hospitalized geriatric patients: They were being treated for a host of chronic ailments, including pneumonia, heart disease and diabetes; most had multiple problems.
Patients who did not speak English were excluded, as were those who had sustained multiple trauma, those who were admitted to the psychiatry service or to hospice, those transferred from other institutions, and short-stay patients who were scheduled to be discharged within 72 hours of admission.
“We didn’t want people who were there for short-term, elective procedures like cardiac catheterization,” Tsevat said, or those who were terminally ill. “These were interviewable patients.”
The health of these patients varied considerably and was only modestly correlated with their views about quality of life. Slightly less than 31% rated their health as excellent or very good. Yet overall, 41% said they were unwilling to give up any time for excellent health, while 28% said they would give up one month at most.
A minority of patients felt differently: 6% said they would prefer to live two weeks or less in excellent health rather than one year in their current state. There was a modest correlation with depression--patients who were depressed were more willing to give up time than those who weren’t. But researchers found no correlation with age, sex, race or level of education.
Tsevat said patients who were unwilling to trade time for excellent health were more likely to want to receive CPR and other life-prolonging measures.
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To Tsevat, the results suggest that a powerful force may underlie the reluctance to trade time for health: adaptation. Numerous studies, he noted, have found that people tend to adapt to illness or disability that they might have previously considered unendurable.
Several years ago, Tsevat and his colleagues asked patients who had been found to have AIDS or the virus that causes it whether they would trade time for better health. Many said no. And Tsevat’s team found that even as the disease progressed, the patients’ responses remained stable.
Christine K. Cassel, chairwoman of the department of geriatrics at Mount Sinai Medical Center in New York, says this is a phenomenon she often sees with her patients.
“I think many older people are very realistic about accepting health problems that come with old age,” Cassel said.
The results of Tsevat’s study do not surprise her. “There’s no reason why someone who’s living with some chronic illnesses should feel that life is not worth living. It tells us that human beings are adaptable and resourceful.”
Nor is Cassel surprised that surrogates are often wrong about patients’ wishes: “Every study I know of has found significant discrepancies between the wishes of patients and surrogates’ responses.”
Such disparities are the reason Tsevat believes doctors must talk to patients directly about which treatments they want and don’t want.
“We’ve shown that communication [between doctors and patients] at the end of life isn’t so good,” Tsevat said, citing a study that found that elderly patients tend to receive fewer invasive procedures than younger patients. “Maybe there is a mismatch between what patients want and what we’re giving them in either direction--whether it’s too much treatment or too little.”
