Stability of Patient Preferences Regarding Life-Sustaining Treatments: METHODS

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We interviewed Seattle Veterans Administration Medical Center patients sampled from intensive care units from October to Decem­ber 1987. All interview and questionnaire content was approved by the University of Washington Human Subjects Review Committee. Informed consent was obtained from willing patients.

Subjects

Consecutive patients who had survived a medical intensive care unit or coronary care unit stay of at least 48 hours were recruited for participation. Entry criteria also included male gender, age greater than 50 years, English speaking, and ability to provide informed consent and complete the interview. Patients transferred to a surgical service were excluded from participation.

During the study period, 80 patients survived an ICU stay of at least 48 hours and were transferred out of the ICU. Forty-six of these patients did not meet the other study criteria: 25 were under 50 years of age; seven were women; seven were unable to complete the questionnaire; five were transferred to a surgical service; and two were previously interviewed. Thirty-four patients met the study criteria and were asked to participate. Thirty (88 percent) agreed.

Procedures

One member of the study team (M.A.E.) interviewed all patients either in the ICU immediately prior to transfer (n = 15) or within 24 hours following transfer to a medical ward (n = 15).

The patient interview was divided into five sections.
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Mental Status: Mental status was evaluated with the Short Portable Mental Status Questionnaire (SPMSQ). The SPMSQ is a reliable and valid ten-question instrument with four-week test- retest reliability correlation coefficients for elderly subjects of greater than 0.82.

Treatment Preference Questionnaire: Study participants com­pleted a questionnaire in which they indicated their preferences regarding life-sustaining therapies. This questionnaire presented scenarios in three clinical situations: the patients current health and two hypothetical illness conditions (stroke with resultant hemiparesis but without mental disabilities, and dementia with inability for self-care). The two hypothetical scenarios were designed to obtain preferences regarding life-sustaining therapies under two unique states of health and quality of life. (Appendix contains verbatim dCcsriptions of the hypothetical scenarios. Copies of the questionnaire are available upon request.)

After reading each scenario, patients specified their preferences regarding several life-sustaining treatments. Patients indicated if they would want to be (1) revived if their heart stopped (resuscita­tion); (2) revived and then put on a “breathing machine” for an unknown period of time if this was the only way to remain conscious (resuscitation with mechanical ventilation); and (3) provided food and fluids with a nasogastic tube and an intravenous line for an unknown period of time if unable to eat and drink (artificial hydration and nutrition). After the hypothetical stroke and dementia scenarios, patients reported their desire for hospitalization for medical treat­ment of pneumonia. Possible answers to questions regarding the life-sustaining therapies were recorded on a four-point, visual analog scale: 1, “definitely yes;” 2, “probably yes;” 3, “probably no;”

Following the mechanical ventilation and artificial hydration and nutrition questions, patients selected the length of time they would be willing to continue these therapies if the necessary duration was unknown and “if stopping would lead to death.” Finally, patients indicated whether they had ever discussed life-prolonging treat­ments with another person, and if so, the relationship to that person.

Subjective Health Status and Quality of Life Rating: Patients rated their current health status and compared their current health to their health three months ago. Current health status ratings included: 1, “excellent;” 2, “very good;” 3, “good;” 4, “fair;” tadalis sx 20

Depression Screen: We administered the Center for Epidemio­logical Studies Depression (CES-D) scale questionnaire. The CES-D questionnaire is a reliable 20 item self-report of depressive symptoms experienced in the previous week (Cronbach alpha coefficient = .85-.91). Scores range from 0 to 60, with higher scores indicating more depressive symptoms.

Rationale: After completion of these procedures, patients ex­plained open-endedly each of their choices regarding life-sustaining treatments in the three scenarios. All responses were recorded. Patients then selected the “most important reason” for acceptance or refusal of each life-sustaining treatment.

Objective Medical and Social Information: The following supple­mental information was obtained from the patients’ medical records: (1) chronic illnesses/health problems; (2) reason for current hospital admission; and (3) reason for ICU admission. The overall severity of each patients illness was measured using the Acute Physiology and Chronic Health Evaluation II (APACHE II) system. Each APACHE II score reflects the most abnormal of 12 specified laboratory and physical examination findings during the first 24 hours of ICU stay, and any history of severe organ system insuffi­ciency and/or of immune system compromise. APACHE II scores range from 0 to 71, with higher scores indicating greater risk of hospital mortality. In the development of APACHE II, no patient (of 5,815 patients from 13 hospitals) had a score greater than 55.

Follow-up

Follow-up interviews using the same questionnaire Were con­ducted approximately one month (20 to 40 days) after the patient s discharge or transfer from the ICU. Of the original 30 patients, seven were lost to follow-up, two died, and one declined to be interviewed. No patients were in an ICU at the time of the follow- up interview.

Data Analysis

The original 4-point scale to assess patient life-sustaining treat­ment preferences was condensed into a 2-point Scale (yes and no) for simplicity and clinical relevance. Friedman chi-square analysis was used to determine consistency of patient preferences regarding different life-sustaining treatments within the same scenario and regarding the same life-sustaining treatment across the three scenarios. Differences in patient self-assessed health status, CES- D scores and preferences regarding life-sustaining treatments between the ICU interview and the follow-up interview one month later were evaluated using the Wilcoxon two-tailed t-test. Kappa statistics were also used to assess the level of agreement (controlling for chance) of patient preferences between the two interviews. Unless otherwise specified, data are presented as means ± SD. Viagra Professional