High Technology Medical Interventions: What Do Older People Want?

To the Editor: Prioritizing and rationing limited healthcare resources is high on the political agenda. Official policy is to focus healthcare purchasing on effective treatments.1 It has recently been suggested that the public should become involved in prioritizing health care interventions. However, the public perceive treatment for life-threatening diseases in patients over the age of 75 as a low priority,2 and at least one prominent bioethicist has suggested that such treatments should be withheld from them.3 There is evidence that old people are neither investigated as thoroughly nor treated as aggressively as young people with similarly serious illnesses, including heart disease and cancer, despite the evidence that chronological age alone rarely accounts for much of the variation in outcome.4–7 This may reflect an ageist bias of clinicians or lack of knowledge about likely outcomes.8 Alternatively, it may be based on the belief that old people will not want aggressive interventions for serious illnesses. However, evidence supports the contrary view.9–11 The purpose of this study was to elicit the views of a group of older people about their treatment preferences for life-threatening illnesses. A postal questionnaire was sent to 150 people aged 65 and older who were selected randomly from a panel of 3207 healthy volunteers maintained by the Age and Cognitive Performance Research Centre in Manchester, UK. The questionnaire comprised vignettes constructed around two investigations, bronchoscopy and coronary angiography, and four therapies, surgery for cancer and aortic valve diseas, radiotherapy, chemotherapy, and hormonal therapy for cancer. Each vignette contained a realistic description of the possible complications of investigation, the natural history of the illnesses with and without treatment, and the side effects of the treatments. In the case of cancer, postreatment survival was 6 months, except for surgery where it was stated that a complete cure was possible. For each vignette, respondents were asked whether they would want (1) an investigation (2) the results of the investigation, and (3) treatment. Responses were graded qualitatively from 1 (definitely Yes) to 5 (definitely No). We also assessed consistency by repeating a question asking the individual to rank the four health care professionals from whom they would wish to hear the results of investigations. Finally, we asked respondents whether the vignettes were explained clearly and whether any further information on which to base their decisions would have been helpful. Statistical analysis using kappa statistic was performed using the SPSS computer program (Windows version 6.1). One hundred thirteen (75%) questionnaires were returned (30 men; median age 70 years, range 61–89). Satisfaction for each vignettes within the questionnaire ranged from 77.9% to 92%. Analysis of reply consistency yielded a kappa statistic of 0.75. Most respondents stated they would want investigation and active treatment for cancer and valvular heart disease although chemotherapy was a less attractive treatment than surgery, radiotherapy, or hormonal therapy for cancer (Table 1). Most respondents would also like to be told the results of investigations (Table 2). Most of our respondents said that they would want investigation and interventions for life-threatening illnesses, and most would also like to be informed about the results of investigations. However, this group was selected from a panel of research volunteers, and may, therefore, represent a particularly motivated group of people. Despite this difficulty, it is striking to note that about 90% of the respondents would want coronary angiography and bronchoscopy. However, there is evidence that older patients may not be referred for intensive investigation and treatment. For example, older patients with angina referred for coronary angiography have more severe symptoms than younger patients and may, therefore, be at higher operative risk if they undergo subsequent surgery.7 Older patients with myocardial infarcts are also less likely to be admitted to the coronary care unit despite the well established benefits of early treatment in this age group.5 Our study also suggests that older people want treatment for life-threatening illnesses. Despite the risks, more than 80% of respondents replied ‘Yes’ or ‘maybe yes’ to surgery for lung cancer or heart disease, Radiotherapy and hormonal therapy were slightly less popular, but only 17% would definitely want chemotherapy. This may indicate anxieties about side effects or the perception that these therapies only palliate symptoms and do not offer a chance of a complete cure. Our findings are similar to those of two American studies, in which older patients differed from their younger counterparts only in accepting toxic treatments improving survival time.8,12 In summary, our study has shown that this group of old people want investigation and treatment of life threatening illnesses. This should be taken into account when prioritizing healthcare resources.