Stability of Patient Preferences Regarding Life-Sustaining Treatments: DISCUSSION part 2

Posted by James

In regard to our second study question, we found no significant differences in the life-sustaining treat­ment preferences, including preferences about dura­tion of treatments expressed by ICU patients at the time of transfer from the ICU compared to those expressed by the same patients one month later when no longer in the ICU nor under the stress of an acute illness. These results suggest that patient preferences regarding life-sustaining treatments are stable over one month despite changes in health and mood. Two
studies of cancer patients’ preferences obtained similar results. One study found that cancer patient prefer­ences for treatment did not change significantly when measured before and then six months following treat­ment despite significant treatment toxicity. Another study of patients with laryngeal cancer showed stabil­ity of values regarding voice expressed before and after treatment despite changes in clinical state. In contrast, women’s preferences about anesthesia during childbirth changed significantly during labor when compared to those expressed before and after labor. Our results may be more consistent with those found in the studies of cancer patient preferences because of similarities in the two populations. Our study patients, like the cancer patients, are older, have more chronic disease and are confronting choices about life- sustaining treatments and not about treatment of a symptom during a limited situation such as childbirth.

Our finding of stability in ICU patient life-sustaining treatment preferences provides support for reliance on attitudes which are expressed by competent pa­tients in the setting of critical illness. In order to make appropriate decisions about the implementation and continuation of life-sustaining therapies, physicians should elicit ICU patient preferences. Obtaining these preferences is important even when ICU patients do not immediately require life-sustaining treatment be­cause these patients are at increased risk for mental status changes, the need for a life-sustaining treatment while in the ICU, and the possible need for a life- sustaining treatment in the future. Although discus­sions regarding these therapies have sometimes been avoided due to concerns about disturbing patients, we found ICU patients very willing to indicate their opinions. However, few (10 percent) had talked with their physicians about life-sustaining treatment pre­ferences. Other investigators report similar find­ings.
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In most cases when patients are mentally incapaci­tated and decisions about therapy must be made, family members are approached to supply information about “what the patient would want.” Unfortunately, family members may not know specific patient prefer­ences. Knowledge of previously expressed patient preferences may help surrogate decision makers to more accurately represent patient wishes. Considera­tion of a patient’s previously stated opinions about life- sustaining therapies may also alleviate family feelings of insecurity and guilt about choices to forego or withdraw these treatments. Our results encourage the use of previously expressed preferences when patients become unable to state their wishes. However, further research must address the questions of whether pa­tients change their pre-ICU preferences once in the ICU and whether patients change their preferences during their ICU stay.

There are several limitations of this study. First, the number of participants is small and restricted to men over 50 years of age who were admitted, remained in the ICU for at least 48 hours, and survived the experience. Caution may be warranted in applying these results to other patient populations. The small number of participants limited the statistical power of negative results. Second, our study did not control for the amount of experience or knowledge of intensive care or life-sustaining therapies. Finally, patients were interviewed at the conclusion of their ICU stay, at a time when their condition was presumably more stable than an admission. Patient preferences regarding life- sustaining treatments on admission may have differed from those obtained at the end of their ICU stay.
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In summary, an accurate knowledge of patient preferences is frequently necessary in order for phy­sicians and surrogate decision makers to make appro­priate decisions regarding the implementation or con­tinuation of life-sustaining treatments. Our results suggest that patients are willing to discuss their preferences about life-sustaining treatments in current and hypothetical situations while in the ICU, and that their responses are likely to be stable for at least 30 days. This provides support for an approach that involves the ICU patient actively in decisions regard­ing the use of life-sustaining treatments.