Advance directives, medical conditions, and preferences for end-of-life care among physicians : 12-year follow-up of the Johns Hopkins precursors study

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GALLO, Joseph J. | ABSHIRE, Martha | HWANG, Seungyoung | NOLAN, Marie T.

BACKGROUND: Stability of preferences for life-sustaining treatment may vary depending on personal characteristics. OBJECTIVE: We estimated the stability of preferences for end-of-life treatment over 12 years and whether advance directives and medical conditions were associated with change in preferences for end-of-life treatment. DESIGN: Mailed survey of older physicians. SETTING: Longitudinal cohort study of medical students in the graduating classes from 1948 to 1964 at Johns Hopkins University. PARTICIPANTS: 898 physicians who completed the life-sustaining treatment questionnaire anytime in 1999, 2002, 2005 and 2011 (mean age 68.2 years at baseline). MEASUREMENTS: Preferences for life-sustaining treatment, assessed using a checklist questionnaire in response to a standard 'brain injury' scenario, and considered as a package using the latent class transition model. RESULTS: End-of-life preferences grouped into three classes, most aggressive (wanting most interventions; 14% of physicians); least aggressive (declining most interventions; 61%); and an intermediate class (declining most interventions except intravenous fluids and antibiotics; 25%). Physicians without an advance directive were more likely to desire more treatment, and were less likely to transition out the most aggressive class. Transition probabilities from class to class did not vary over time. Persons with cancer expressed preference for the least aggressive treatment while persons with cardiovascular disease and depression had preferences for more aggressive treatment. LIMITATIONS: The study cohort consisted of mostly older white, male physicians who graduated from the same medical school and participated in a longitudinal study. CONCLUSION: Transitions in end-of-life preferences and the factors influencing change and stability suggest that periodic reassessment for planning end-of-life care is needed.

http://dx.doi.org/10.1016/j.jpainsymman.2018.12.328

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