Who Gets the Last Say?

Opinions vary on the right time to end aggressive treatment.

As the director of the intensive care unit at Memorial Sloan-Kettering Cancer Center in New York City, Jeff Groeger, MD, often cares for patients who have been told they have little time left to live.

Once the bad news sinks in, he must help them decide whether they should choose the most aggressive medical treatment available. "It stinks," he says -- meaning the emotional drain on both health care providers and loved ones.

It's also a complicated process. Everything from the patient's age, to the chances of surviving aggressive treatment, to his or her wishes for end-of-life care must be taken into account.

Such difficult decisions will become more commonplace. The number of aged in America is growing at an astounding pace, and controversy is building over how to treat those who are sick.

Some believe elderly patients should not be put through aggressive treatments because they are less likely to survive the heroic efforts. But others believe a bias against the elderly may lead to beneficial care being withheld.

Studying Survival Rates

Now a new study on the relationship between age, intensity of treatment and survival of serious illness has yielded some interesting findings. Researchers at five teaching hospitals across the country looked at 9,105 patients, aged 18 to 100, who were hospitalized with serious illnesses. They looked at the connection between age and the likelihood of survival six months later -- and especially at whether the intensity of the treatment affected the outcome. After six months, more than half the patients were still alive, according to Mary Beth Hamel, MPH, MD, the lead author of the study and a researcher at Beth Israel Deaconess Medical Center in Boston.

Not surprisingly, the older the patient, the more likely he or she was to die during the six-month follow-up period. What was surprising was that the difference in death rates was smaller than expected. A 55-year-old, for instance, had a 44% chance of dying in the follow-up period; an 85-year-old, 60%. How severe the patient's illness was turned out to have more to do with survival than age did.

Researchers say they cannot tell from the study why older patients did slightly worse overall than their younger counterparts. "People think that as you get older you have no hope of surviving a devastating illness," Hamel says. "That's just not the case."

More Research Needed?

Some say more research is necessary. "From my vantage point, I do think the elderly are often undertreated," says Robert Butler, MD, a professor of geriatrics and the director of the International Longevity Center at Mt. Sinai Medical Center in New York. He cites studies that have found that elderly patients are treated less aggressively.

Yet no study can ever make it easy for loved ones to make a decision about medical treatment for a loved one, says Groeger. He does find, however, that elderly patients and their families often feel emotionally more at ease with refusing aggressive treatment than do younger patients and their families. "You can say you've lived a good, long, healthy life," he says.

Making the Tough Decisions

Whether the patient is young or old, it's often the caregivers who have to make the final decision about how he or she is treated, says Ira Byock, MD, director of the Promoting Excellence in End of Life Care Program at the Robert Wood Johnson Foundation. Advance communication to family members about end-of-life wishes can make decision-making easier, says Byock, who is also the author of Dying Well: The Prospect for Growth at the End of Life. Establishing living wills and durable powers of attorney are two ways people can make sure their wishes are carried out, he says.