ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Thursday, August 15, 1996 TAG: 9608150057
SECTION: NATIONAL/INTERNATIONAL PAGE: A-5 EDITION: METRO
SOURCE: MICHAEL VITEZ THE PHILADELPHIA INQUIRER
PHYSICIANS TEND TO TAKE LESS AGGRESSIVE measures for the elderly, but is this really a sign of their doing too much for the young?.
Doctors were more likely to write do-not-resuscitate orders for extremely sick hospital patients over the age of 75 than they were for equally sick patients under 75, a study has found.
The older patients were not sicker. They did not object to lifesaving measures more strongly. Their prognoses were no different. Yet doctors were more willing to scale back aggressive medical care for people over 75 merely because they were older.
However, Joan Teno, associate director of the Center to Improve Care of the Dying at George Washington University, a clinical geriatrician and a lead author of this study, concluded this does not mean that doctors are abandoning or dispatching old people. This is not agism.
On the contrary, she speculated, the results may indicate that doctors are ``overtreating'' younger patients, refusing to let them go.
Maybe it is the older people who are the lucky ones. They are the ones doctors are listening to. It is the younger ones whose wishes doctors are more likely to ignore.
``Either younger patients are overtreated, or older patients are undertreated,'' she said. ``From my clinical experience, we're making decisions much too late for people 75 and younger.
``Doctors are probably making decisions at the right time for people older than 75, but waiting too long for younger people.''
This finding, published today in the Annals of Internal Medicine, springs from the largest clinical study every conducted with seriously ill and dying patients. The Support study, as it is known, tracked more than 10,000 patients at five medical centers from 1986 to 1994.
The first results of the Support study, published in November, concluded that even when patients' preferences for care at the end of life were known - when they didn't want cardiopulmonary resuscitation - their wishes often were ignored by doctors.
Today's findings expand on that report.
The research also shows that doctors were more likely to write do-not-resuscitate orders for people who wanted them and needed them than for people who didn't.
But doctors still are far from being responsive to patients.
``Compared with stated patient preferences,'' the authors concluded, ``DNR orders were infrequent and late.''
Teno said doctors need to initiate discussions with patients about withdrawing life support or ending aggressive treatments much earlier.
``We need to learn to talk about dying when it's a possibility,'' she said. ``Not a high probability.''
Teno said she didn't think doctors put more value on younger people. She suspected doctors merely have an easier time talking about dying and withdrawing life support when patients are older.
In another finding - even with all the talk about fear of aggressive treatment, about avoiding machines and tubes - far more of these critically ill patients in the Support study said they ``would'' want CPR in the event of heart attack: 55 percent said yes; 29 percent said no.
Another examination of the data, also published this week, concluded that patients and families hammered financially by extensive medical care are more likely to choose comfort care for the future than more aggressive - and more expensive - care to extend life.
The researchers concluded that people with financial problems linked to their illness were one-third more likely to choose comfort care.
Doctors didn't define ``comfort care'' or ``life-extending treatment'' when interviewing patients and families in the study. And they didn't ask another important question: Are you choosing comfort care because it's less expensive? Still, Teno and other investigators believed the association is clear and its implications vital: Finances affect the care people select and receive.
About 24 percent of 3,100 subjects interviewed in this part of the study reported that medical costs had depleted most or all of their family savings.
The entire $28 million Support study is funded by a Robert Wood Johnson Foundation grant.
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