How older patient preferences are influenced by consideration of future health outcomes

Abstract

OBJECTIVE: To determine patients' willingness to accept intubation and ventilatory support (IVS) when the best outcome available is a state involving both cognitive and physical/behavioral deficits. DESIGN: Structured interviews with patients seen consecutively in a continuity care general medicine clinic. SETTING: A university-based Department of Veterans Affairs Medical Center. SUBJECTS: A total of 113 patients (mean age = 67.3 years, age range 42-89; mean level of formal education = 12.6 years, range 2-24). MEASUREMENTS: Patients were asked to consider whether they would permit their physicians to intubate them and put them on ventilatory support when the best outcome to be expected was one of three future health care states, presented in the following order: State 1, where their mental and physical state of recovery would be exactly like their current mental and physical states at the time of their visit to the general medicine clinic (the patient's current baseline mental and physical functioning); State 2, involving cognitive compromise; State 3, involving both cognitive and physical/behavioral compromise. RESULTS: One patient refused IVS on State 1; 20.4% (23/113) of patients refused IVS on State 2; 23.0% (26/113) refused IVS on State 3; and 49.6% (56/113) reported they would accept IVS resulting in all three states. Six of 113 patients (5.3%) reported they would leave the decision up to their physician beginning with State 1 and continuing through State 3. One patient reported that he would leave the decision (State 1 through State 3) up to his wife. A reported history of stroke is related to patients' expressed dislike of IVS that would leave them with residual deficits. CONCLUSION: The results suggest that a substantial number of our older male veteran population would prefer intubation and ventilatory support if presented with a situation in which the best outcome that a physician could offer them was cognitive, physical, and behavioral dysfunction. These results also indicate that those patients who have had a stroke seem to be less inclined to accept IVS in more severe outcomes states.