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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, for the SUPPORT Investigators
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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.


Ann Intern Med. 1999;130(2):116-125. doi:10.7326/0003-4819-130-2-199901190-00005
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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.

Figures

Grahic Jump Location
Figure.
Relation between patient age and the adjusted probability of a decision to withhold each life-sustaining treatment by study day 30.

Results are calculated on the basis of Cox proportional-hazard models representing age as cubic spline functions and are adjusted for sex, income, education, insurance, prognosis, comorbid conditions, baseline function, study site, and preferences for cardiopulmonary resuscitation and life-extending care.

Grahic Jump Location

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