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Context Changes Choices: A Prospective Study of the Effects of Hospitalization on Life-Sustaining Treatment Preferences

Department of Psychology & Social Behavior, 3340 Social Ecology II, University of California, Irvine, Irvine, CA 92697-7085; phditto{at}uci.edu

Jill A. Jacobson, PhD

Department of Psychology, Queen's University

William D. Smucker, MD

Department of Family Practice, Summa Health System

Joseph H. Danks, PhD

Center for Advanced Study of Language, University of Maryland

Angela Fagerlin, PhD

VA Center for Practice Management and Outcomes Research, University of Michigan

Objective.Policy and law encouraging individuals to document their wishes for life-sustaining medical treatment in advance of serious illness assumes that these wishes are unaffected by changes in health condition. To test this assumption, the authors examine the life-sustaining treatment preferences of a sample of elderly adults prior to, soon after, and several months after a hospitalization experience. Subjects and Methods. As part of the Advance Directives, Values Assessment, and Communication Enhancement (ADVANCE) project, 401 individuals older than age 65 participated in 3 annual interviews. A subsample of 88 individuals who were hospitalized for greater than 48 hours during the course of the study participated in an additional "recovery" interview conducted soon after their release from the hospital (M = 14 days postdischarge). At each interview, subjects indicated their desire to receive 4 life-sustaining medical treatments in 4 serious illness scenarios.Results. Treatment preferences showed a significant "hospitalization dip," with subjects reporting less desire to receive life-sustaining treatment at the recovery interview than they did at the annual interview conducted prior to hospitalization, but with desire returning to near prehospitalization levels at the annual interview conducted several months after hospitalization. This dip was more pronounced in preferences for cardiopulmonary resuscitation and artificial nutrition and hydration than in preferences for less invasive treatments. Conclusions. Preferences for life-sustaining treatment are dependent on the context in which they are made, and thus individuals may express different treatment preferences when they are healthy than when they are ill. These results challenge a key psychological assumption underlying the use of instructional advance directives in end-of-life decision making.

Key Words: end-of-life decision making • advance directives • life-sustaining treatment preferences

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