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When an elderly person's chronic disease is impossible to cure, many doctors might assume that patient would choose to improve the quality of his or her remaining life, rather than to extend it as is. Those doctors would be mistaken most of the time, according to a new study published online November 8th in the European Heart Journal.
Swiss researchers who surveyed more than 500 elderly heart failure patients found three quarters wouldn't trade a longer life with symptoms for a shorter life without them, and the severity of symptoms was not a good predictor of who would pick a measure of relief over more time.
I was quite surprised by the results, said lead author Dr Hans-Peter Brunner-La Rocca, of University Hospital Basel in Switzerland.
Often we think we know what is best for a patient, but this is often wrong, he told Reuters Health in an email.
Pure survival more important
When patients get to an age where the chance of dying in the near future becomes more evident, pure survival may be more important, said Dr Brunner-La Rocca, who is also affiliated with the Cardiovascular Research Institute at Maastricht University Medical Centre in the Netherlands.
The researchers surveyed 555 heart failure patients, most in their seventies and eighties, asking a series of questions about end-of-life preferences. Then they repeated the survey after 12 months, and again after another six months.
At the start of the study, 74% of the respondents said they would not choose to live one more year in excellent health over living two more years in their current state.
After a year had elapsed, 80% were unwilling to trade more time for symptom relief. At 18 months, few had changed their minds.
CPR in a crisis
When asked about whether they wanted CPR in a crisis, about a third said they didn't want to be resuscitated. Even among people with do not resuscitate orders in their medical files, about a third said they in fact did want CPR.
Dr Eugene Storozynsky, a cardiologist at the University of Rochester Medical Centre, noted that the study participants represented a broad range of people with heart failure – from those with a just a few symptoms to those with many more severe problems. Those with milder disease might not consider it bad enough to trade-off their remaining time.
For these patients, it seems oral medications are still adequate enough to relieve their symptoms so they don't need to be frequently hospitalised, said Dr Storozynsky, who was not part of the study.
Upfront with patients
Participants in the study who were willing to trade more time for symptom relief were older, often female and had more heart failure symptoms, suggesting people may change how they manage their disease over time.
We couldn't find particular patterns to predict what individuals would want, Dr Brunner-La Rocca told Reuters Health. So it's crucial to individually discuss these issues with the patient.
Dr Storozynsky also thinks doctors should be upfront with patients. We should discuss all stages of heart failure to make them aware that at its end stage, their life will likely shorten, he said. This is not to scare them, but to inform them and tailor our treatment to their wishes.
(Reuters Health, November 2011)
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