Refusal of medical and surgical interventions common among chronically ill elderly

Chronically ill older persons frequently refuse medical and surgical interventions recommended by their physicians, according to a recent study by Yale School of Medicine researchers.

The study suggests that physicians continue to recommend invasive or risky interventions for people with advanced illness despite the patient's view that these treatments may be too burdensome, or that the treatment doesn't fit with their goals of care.

"Physicians need to offer treatment alternatives that better fit their patients goals and preferences," said first author Marc Rothman, M.D., postdoctoral fellow in geriatrics in the Department of Internal Medicine at Yale.

Published in the July Journal of General Internal Medicine, the study explored the treatment preferences of 226 persons age 60 and older with advanced cancer, congestive heart failure, or chronic obstructive pulmonary disease. Trained research assistants conducted in-home interviews with participants at least every four months for up to two years, but more frequently if the patient's health status changed (i.e., hospitalizations or initiation of hospice services). Patients were asked whether they had refused or undergone any treatments recommended by their physicians, and why. They were asked to estimate their own longevity, about their desire for prognostic information from physicians, and about their prior experiences with medical decision-making.

Researchers found that 16 percent of these patients reported refusing one or more medical or surgical interventions recommended by their physician. The most frequently refused interventions were cardiac catheterization and surgery, with refusal rates of over 10 percent. Other interventions refused included chemotherapy, radiation, intubation, dialysis, and transplantation. Hospitalization was rarely refused.

The most common reasons given for treatment refusals were fear of side effects. Patients who refused treatments were more likely to have congestive heart failure, to rate their own longevity at less than two years, and to want their physicians to discuss their prognosis with them. The mortality rate among those who had refused treatments was higher than those who had not.

"Our study highlights the frequency with which older persons with advanced illness refuse treatments recommended by their physicians," said Rothman. "This frequency of refusal suggests that physicians may be recommending treatments for these patients that pose unacceptable burdens or that fail to meet patients goals. Patients with advanced illness may require a broader range of treatment alternatives, so that they can select the option that best meets their goals of care."