Patient Age and Decisions To Withhold Life-Sustaining Treatments from Seriously Ill, Hospitalized Adults

Patient Age and Decisions To Withhold Life-Sustaining Treatments from Seriously Ill, Hospitalized Adults

Mary Beth Hamel, MD, MPH;
Joan M. Teno, MD, MS;
Lee Goldman, MD, MPH;
Joanne Lynn, MD, MA;
Roger B. Davis, ScD;
Anthony N. Galanos, MD;
Norman Desbiens, MD;
Alfred F. Connors, Jr., MD;
Neil Wenger, MD, MPH;
Russell S. Phillips, MD; and
for the SUPPORT Investigators

From Beth Israel Deaconess Medical Center, Boston, Massachusetts; Brown University, Providence, Rhode Island; University of California, San Francisco, School of Medicine, San Francisco, California; George Washington University, Washington, D.C.; Duke University Medical Center, Durham, North Carolina; University of Tennessee College of Medicine, Chattanooga, Tennessee; University of Virginia School of Medicine, Charlottesville, Virginia; and University of California, Los Angeles, School of Medicine, Los Angeles, California.

Abstract

Background: Patient age may influence decisions to withhold life-sustaining treatments, independent of patients' preferences for or ability to benefit from such treatments. Controversy exists about the appropriateness of using age as a criterion for making treatment decisions.

Objective: To determine the effect of age on decisions to withhold life-sustaining therapies.

Design: Prospective cohort study.

Setting: Five medical centers participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).

Patients: 9105 hospitalized adults who had one of nine illnesses associated with an average 6-month mortality rate of 50%.

Measurements: Outcomes were the presence and timing of decisions to withhold ventilator support, surgery, and dialysis. Adjustment was made for sociodemographic characteristics, prognoses, baseline function, patients' preferences for life-extending care, and physicians' understanding of patients' preferences for life-extending care.

Results: The median patient age was 63 years; 44% of patients were women, and 53% survived to 180 days. In adjusted analyses, older age was associated with higher rates of withholding each of the three life-sustaining treatments studied. For ventilator support, the rate of decisions to withhold therapy increased 15% with each decade of age (hazard ratio, 1.15 [95% CI, 1.12 to 1.19]); for surgery, the increase per decade was 19% (hazard ratio, 1.19 [CI, 1.12 to 1.27]); and for dialysis, the increase per decade was 12% (hazard ratio, 1.12 [CI, 1.06 to 1.19]). Physicians underestimated older patients' preferences for life-extending care; adjustment for this underestimation resulted in an attenuation of the association between age and decisions to withhold treatments.

Conclusion: Even after adjustment for differences in patients' prognoses and preferences, older age was associated with higher rates of decisions to withhold ventilator support, surgery, and dialysis.

Article and Author Information

Note: This paper was presented in part at the National Meeting of the Society of General Internal Medicine, Washington, D.C., April 1994.
Disclaimer: The opinions and findings contained in this manuscript are those of the authors and do not necessarily represent the views of the Robert Wood Johnson Foundation or its Board of Trustees.
Grant Support: By the Robert Wood Johnson Foundation. Dr. Hamel is supported by a Career Development Award from the National Institute on Aging (K08 AG0075-02).
Requests for Reprints: Mary Beth Hamel, MD, MPH, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.
Current Author Addresses: Drs. Hamel, Davis, and Phillips: Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.
Dr. Teno: Center for Gerontology and Health Care Research, Brown University, Box 6B-222, Providence, RI 02912.
Dr. Goldman: Department of Medicine, University of California, San Francisco, School of Medicine, 505 Parnassus Avenue, San Francisco, CA 94143-0120.
Dr. Lynn: Center to Improve Care of the Dying, George Washington University, 2175 K Street, NW, Suite 820, Washington, DC 20037.
Dr. Galanos: Division of Geriatrics, Duke University Medical Center, 353-Blue Zone, Durham, NC 27710.
Dr. Desbiens: Chattanooga Unit, University of Tennessee College of Medicine, 921 East Third Street, Chattanooga, TN 37403.
Dr. Connors: Department of Health Evaluation Sciences, University of Virginia School of Medicine, Box 600, Charlottesville, VA 22908.
Dr. Wenger: Department ot Medicine, University of California, Los Angeles, School of Medicine, B-564/Factor, 10833 Le Conte Avenue, Los Angeles, CA 90095-1736.