End-of-life decision making - A qualitative study of elderly individuals

OBJECTIVE: To identify the desired features of end-of-life medical decision making from the perspective of elderly individuals. DESIGN: Qualitative study using in-depth interviews and analysis from a phe nomenologic perspective. SETTING: A senior center and a multilevel retirement community in Los Angel es. PARTICIPANTS: Twenty-one elderly informants (mean age 83 years) representin g a spectrum of functional status and prior experiences with end-of-life de cision making. MAIN RESULTS: Informants were concerned primarily with the outcomes of seri ous illness rather than the medical interventions that might be used, and d efined treatments as desirable to the extent they could return the patient to his or her valued life activities. Advanced age was a relevant considera tion in decision making, guided by concerns about personal losses and the m eaning of having lived a "full life." Decisionmaking authority was granted both to physicians (for their technical expertise) and family members (for their concern for the patient's interests), and shifted from physician to f amily as the patient's prognosis for functional recovery became grim. Expre ssions of care, both by patients and family members, were often important c ontributors to end-of-life treatment decisions. CONCLUSIONS: These findings suggest that advance directives and physician-p atient discussions that focus on acceptable health states and valued life a ctivities may be better suited to patients' end-of-Life care goals than tho se that focus on specific medical interventions, such as cardiopulmonary re suscitation. We propose a model of collaborative surrogate decision making by families and physicians that encourages physicians to assume responsibil ity for recommending treatment plans, including the provision or withholdin g of specific life-sustaining treatments, when such recommendations are con sistent with patients' and families' goals for care.