• decision-making;
  • depression;
  • quality of life;
  • advance directives;
  • resuscitation

(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.