Blog | Wednesday, November 30, 2011

QD: News Every Day--Elderly want longevity over quality, but it's tough to predict

Don't assume elderly heart failure patients are assumed to prefer improved quality of life over longevity, study authors noted. The majority of them prefer longevity over quality of life, half expressed a desire for resuscitation if needed, and it was difficult to predict individual preferences.

Researchers looked at patients' willingness to trade survival time for quality-of-life and the preferences for among 622 heart failure patients aged 60 or older participating in the Trial of Intensified vs. Standard Medical Therapy in Elderly Patients with Congestive Heart Failure.

End-of-life preferences were assessed by using a time trade-off tool and one question concerning CPR preference. To assess time trade-off, patients were asked whether they preferred living 2 years in their current state of health or living 1 year in excellent health. If 1 year in excellent health was chosen, the patients were asked whether they would prefer 2 years in their current state of health or 6 months in perfect health. If 2 years in the current state were chosen, then they were asked whether they would prefer 2 years in their current state of health or 18 months in perfect health. The series continued until the choices were the same. This time point subtracted from 24 months derived the number of months of survival time that the patient would be willing to trade.

End-of-life preferences were assessed at baseline, and at 12 and 18 months. In addition, CPR order during last hospitalization was assessed in patients who were included presently after discharge. Patients were divided into four groups: not willing to trade any survival time, willing to trade less than 6 months, 6 to 12 months, and 12 months. Results appeared in the European Heart Journal.

In multivariable analysis, willingness to trade survival time increased with age, female sex, a reduced Duke Activity Status Index, Geriatric Depression Score, and history of gout, exercise intolerance, constipation and edema. But, the authors noted, even combining these variables did not result in reliable prediction. Of 603 (97%) patients who had a resuscitation preference, 51% wanted resuscitation, 39% did not, and 10% were undecided, with little change over time. Resuscitation orders were known in 430 patients, but they differed from patients' preferences 32% of the time.

At baseline, 74% of the patients were not willing to trade any survival time for excellent health. Of the remaining patients, approximately equal groups were willing to trade up to 6 months, 6 months to 1 year, or more than 1 year. Patients aged 75 years and older were slightly more likely to be willing to trade any survival time, the proportion of those not willing to trade would still be 72% (at month 18, 75%).

Patients indicating any willingness to trade survival time for symptom-free living differed in many ways from those unwilling to trade, the authors wrote. They were older, more often female, lived more often on their own and/or were not married, had more signs and symptoms of congestive heart failure and poorer quality of life.

The authors wrote, "Openness and communication about prognosis, trajectories, and realistic treatment possibilities engender hope and allow patients to plan for their future. This applies to various decisions that confront (congestive heart failure) CHF patients, but may be particularly important with respect to (implantable cardioverter-defibrillator) ICD implantation, turning off the device, and treatment with purely symptomatic medical therapy that may even reduce survival."

An editorial commented that patients must receive accurate information about life expectancy in order to make better choice about their end-of-life. This requires open and repeated conversations in a patient-centered environment.

"In patients whose prognosis is grim, the real question we should be asking is 'Given limited quantity of life, how can we maximize quality?'" the editorial stated. "As the end of life nears, the goals of care should also change, and the alleviation of adverse symptoms becomes the most important objective."