Physical Functioning, Depression, and Preferences for Treatment at the End of Life: The Johns Hopkins Precursors Study

Authors

  • Joseph B. Straton MD, MSCE,

    1. Department of Family Practice and Community Medicine
    2. Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology
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  • Nae-Yuh Wang PhD,

    1. Department of Medicine, School of Medicine, and Departments of
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  • Lucy A. Meoni ScM,

    1. Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology
    2. Biostatistics
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  • Daniel E. Ford MD, MPH,

    1. Department of Medicine, School of Medicine, and Departments of
    2. Epidemiology
    3. Health Policy and Management, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland
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  • Michael J. Klag MD, MPH,

    1. Department of Medicine, School of Medicine, and Departments of
    2. Epidemiology
    3. Health Policy and Management, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland
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  • David Casarett MD, MA,

    1. Division of Geriatrics, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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  • Joseph J. Gallo MD, MPH

    1. Department of Family Practice and Community Medicine
    2. Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics and Epidemiology
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  • The Johns Hopkins Precursors Study was supported by Grant AG01760 from the National Institutes of Health, Bethesda, Maryland. Data analysis manuscript preparation was supported by Grant 1-D14-HP-000084 from the Health Resources and Services Administration and by a National Research Service Award AG00253-04 granted to Dr. Straton. Presented at the American Geriatrics Society annual meeting, Washington DC, May 2002.

Address correspondence to Joseph B. Straton, MD, MSCE, Department of Family Practice and Community Medicine, University of Pennsylvania, 3400 Spruce Street/2 Gates, Philadelphia, PA 19104. E-mail: joseph.straton@uphs.upenn.edu

Abstract

(See editorial comments by Dr. Linda Emanuel on pp 641–642.)

Objectives:  To examine the relationship between worsening physical function and depression and preferences for life-sustaining treatment.

Design:  Mailed survey of older physicians.

Setting:  Longitudinal cohort study of medical students in the graduating classes from 1948 to 1964 at Johns Hopkins University.

Participants:  Physicians who completed the life-sustaining treatment questionnaire in 1998 and provided information about health status in 1992 and 1998 (n=645, 83% of respondents to the 1998 questionnaire; mean age 68).

Measurements:  Preferences for life-sustaining treatment, assessed using a checklist questionnaire in response to a standard vignette.

Results:  Of 645 physicians, 11% experienced clinically significant decline in physical functioning, and 18% experienced worsening depression over the 6-year period. Physicians with clinically significant functional decline were more likely (adjusted odds ratio (AOR)=2.14, 95% confidence interval (CI)=1.18–3.88) to prefer high-burden life-sustaining treatment. Worsening depression substantially modified the association between declining functioning and treatment preferences. Physicians with declining functioning and worsening depression were more likely (AOR=5.33, 95% CI=1.60–17.8) to prefer high-burden treatment than respondents without declining function or worsening depression.

Conclusion:  This study calls attention to the need for clinical reassessment of preferences for potentially life-sustaining treatment when health has declined to prevent underestimating the preferences of older patients.

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