Patient decision making about treatment preferences, particularly related to life-sustaining treatments and resuscitation, has been examined with various sub-groups of people with advanced illnesses. The treatment preferences of middle-aged and older adults with advanced cancer were examined by Rose, O’Toole, Dawson, Lawrence, Gurley, Thomas, et al. (2004). The positive correlation between what patients wanted and preferred in regard to treatments compared with the care they actually received was only found to be strong with the older adult group. Treatment burden, type of outcome, and likelihood of outcome were found to influence decision making in end of life treatment preferences of patients with advanced illnesses (Fried & Bradley, 2003). Patients were more apt to accept burden- some treatment with the likelihood of good outcomes; however, they would be willing to accept more burdensome treatment with poorer outcomes as their illness worsened. This suggests that their health status influenced the values of the burden and benefits of the treat- ment; however, these values and perceptions seemed to change over time as they became more ill. So patients themselves can weigh the benefits and burdens of their treatment and use those to make health related decisions about their care.
Type of diagnosis was not found to be associated with treatment preferences in another study, but decreased functional status was positively associated with decreased preference for a high burden treatment (Fried, Van Ness, Byers, Towle, O’Leary, & Dubin, 2007). Bambauer & Gillick (2007) examined treatment preferences for care at the end of life with 86 patients receiving palliative care consultation and found the vast majority to prefer max- imizing comfort (54%) and maintaining function (27%), with only 19% preferring to pro- long life. The majority (56%) of this sample were patients with non-cancer illnesses, 23% of which were diagnosed with heart disease.
Patients with heart failure (83%) were found to receive more life-sustaining treatments, such as cardiopulmonary resuscitation, mechanical ventilation, vasopressors, and admission to critical care units, than patients with cancer (43%) (Tanvetyanon & Leighton, 2003).
Forty percent of elderly cardiac patients hospitalized during an exacerbation said they did not want to have CPR to sustain life, and 50% preferred to receive care at home if there was no hope for recovery from the exacerbation (Formiga et al., 2004). The majority of patients with advanced heart failure wanted life-prolonging treatments withdrawn or with- held when appropriate; however, the appropriate time was not defined (Willems et al, 2004). Seventy-six percent of heart failure patients with do-not-resuscitate (DNR) orders still received some type of life-sustaining treatment before death compared with those with- out any DNR orders. Cardiopulmonary resuscitation (CPR) was the only intervention that was significantly less frequent for patients with a DNR order. Interestingly, although the prevalence of DNR orders were similar between cancer and heart failure patients in this sample, patients with heart failure received DNR orders much later during their hospital admission than patients with cancer.
What You Should Know
• Before any good plan for end-of-life care can be developed, nurses need to assess the patients’ goals of care.
• Difficulties with prognostication can contribute to late referrals for palliative care or hospice.
• Previous research has supported patients’ preferences to be told prognostic information, even if it is bad, in order to be able to make informed care decisions at the end of life.
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