The Natural History of Changes in Preferences for Life-Sustaining Treatments and Implications for Inpatient Mortality in Younger and Older Hospitalized Adults

ObjectivesTo compare changes in preferences for life-sustaining treatments (LSTs) and subsequent mortality of younger and older inpatients. DesignRetrospective cohort study. SettingKaiser Permanente Northern California (KPNC). ParticipantsIndividuals hospitalized at 21 KPNC hospitals between 2008 and 2012 (N=227,525). MeasurementsParticipants were divided according to age (<65, 65-84, 85). The effect of age on adding new and reversing prior LST limitations was evaluated. Survival to inpatient discharge was compared according to age group after adding new LST limitations. ResultsAt admission, 18,254 (54.2%) of those aged 85 and older, 18,349 (20.8%) of those aged 65 to 84, and 3,258 (3.1%) of those younger than 65 had requested that the use of LST be limited. Of the 187,664 participants who initially did not request limitations on the use of LST, 15,932 (8.5%) had new LST limitations added; of the 39,861 admitted with LST limitations, 3,017 (7.6%) had these reversed. New limitations were more likely to be seen in older participants (aged 65-84, odds ratio (OR)=2.27, 95% confidence interval (CI)=2.16-2.39; aged 85, OR=6.43, 95% CI=6.05-6.84), and reversals of prior limitations were less likely to be seen in older individuals (aged 65-84, OR=0.73, 95% CI=0.65-0.83; aged 85, OR=0.46, 95% CI=0.41-0.53) than in those younger than 65. Survival rates to inpatient discharge were 71.7% of subjects aged 85 and older who added new limitations, 57.2% of those aged 65 to 84, and 43.4% of those younger than 65 (P<.001). ConclusionChanges in preferences for LSTs were common in hospitalized individuals. Age was an important determinant of likelihood of adding new or reversing prior LST limitations. Of subjects who added LST limitations, those who were older were more likely than those who were younger to survive to hospital discharge.