Patient Age and Decisions to Withhold Life-Sustaining Treatments from Seriously Ill, Hospitalized Adults

Published in: Annals of Internal Medicine, v. 130, no. 2, Jan. 19, 1999, p. 116-125

by Mary Beth Hamel, Joan M. Teno, Lee Goldman, Joanne Lynn, Roger B. Davis, Anthony N. Galanos, Norman A. Desbiens, Alfred F. Connors, Jr., Neil S. Wenger, Russell S. Phillips

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BACKGROUND: Patient age may influence decisions to withhold life-sustaining treatments, independent of patients' preferences for or ability to benefit from such treatments. Controversy exists about the appropriateness of using age as a criterion for making treatment decisions. OBJECTIVE: To determine the effect of age on decisions to withhold life-sustaining therapies. DESIGN: Prospective cohort study. Setting: Five medical centers participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). PATIENTS: 9105 hospitalized adults who had one of nine illnesses associated with an average 6-month mortality rate of 50%. MEASUREMENTS: Outcomes were the presence and timing of decisions to withhold ventilator support, surgery, and dialysis. Adjustment was made for sociodemographic characteristics, prognoses, baseline function, patients' preferences for life-extending care, and physicians' under- standing of patients' preferences for life-extending care. RESULTS: The median patient age was 63 years; 44% of patients were women, and 53% survived to 180 days. In adjusted analyses, older age was associated with higher rates of withholding each of the three life-sustaining treatments studied. For ventilator support, the rate of decisions to withhold therapy increased 15% with each decade of age (hazard ratio, 1.15 [95% Cl, 1.12 to 1.19]); for surgery, the increase per decade was 19% (hazard ratio, 1.19 [Cl, 1.12 to 1.27]); and for dialysis, the increase per decade was 12% (hazard ratio, 1.12 [Cl, 1.06 to 1. 1 9]). Physicians underestimated older patients' preferences for life-extending care; adjustment for this underestimation resulted in an attenuation of the association between age and decisions to withhold treatments. CONCLUSION: Even after adjustment for differences in patients' prognoses and preferences, older age was associated with higher rates of decisions to withhold ventilator support, surgery, and dialysis.

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