Views of Older Persons with Multiple Morbidities on Competing Outcomes and Clinical Decision-Making

Authors

  • Terri R. Fried MD,

    1. From the *Department of Internal Medicine, Yale University School of Medicine, New Haven, ConnecticutClinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, ConnecticutNew England Research Institutes, Watertown, Massachusetts.
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  • Sarah McGraw PhD,

    1. From the *Department of Internal Medicine, Yale University School of Medicine, New Haven, ConnecticutClinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, ConnecticutNew England Research Institutes, Watertown, Massachusetts.
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  • Joseph V. Agostini MD,

    1. From the *Department of Internal Medicine, Yale University School of Medicine, New Haven, ConnecticutClinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, ConnecticutNew England Research Institutes, Watertown, Massachusetts.
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  • Mary E. Tinetti MD

    1. From the *Department of Internal Medicine, Yale University School of Medicine, New Haven, ConnecticutClinical Epidemiology Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, ConnecticutNew England Research Institutes, Watertown, Massachusetts.
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Address correspondence to Terri R. Fried, MD, CERC 151B, VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516. E-mail: terri.fried@yale.edu

Abstract

OBJECTIVES: To examine the ways in which older persons with multiple conditions think about potentially competing outcomes in order to gain insight into how processes to elicit values regarding these outcomes can be grounded in the patient's perspective.

DESIGN: Qualitative study consisting of purposefully sampled focus groups.

SETTING: Community.

PARTICIPANTS: Persons aged 65 and older taking five or more medications.

MEASUREMENTS: Participants were asked their perceptions about whether their illnesses or treatment interacted with each other, goals of their treatment, and decisions to change or stop treatment.

RESULTS: Although participants were largely unaware that treatment of one condition could worsen another, many had experience with adverse medication effects as a competing outcome. Participants initially discussed their conditions in terms of disease-specific outcomes, such as achieving a target blood pressure or lipid level. In the context of decision-making, participants shifted their discussion from disease-specific to global, cross-disease health outcomes, such as survival, preservation of physical function, and relief of symptoms. Despite having some misconceptions regarding the likelihood of these outcomes, they weighed the outcomes against one another to consider what was most important to them. Their preference was for the treatment that would achieve the most desired outcome.

CONCLUSION: Because of their experience with adverse medication effects, older persons with multiple morbidities can understand the concept of competing outcomes. The task of prioritizing global, cross-disease outcomes can help to clarify what is most important to seniors who are faced with complex healthcare decisions.

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