title: Informing shared decisions about advance directives for patients with severe chronic obstructive pulmonary disease: a modeling approach.
abstract: OBJECTIVE
  To estimate the survival and quality-adjusted life-years (QALYs) of Full Code versus Do Not Intubate (DNI) advance directives in patients with severe chronic obstructive pulmonary disease and to evaluate how patient preferences and place of residence influence these outcomes.
  
  
  METHODS
  A Markov decision model using published data for COPD exacerbation outcomes. The advance directives that were modeled were as follows: DNI, allowing only noninvasive mechanical ventilation, or Full Code, allowing all forms of mechanical ventilation including invasive mechanical ventilation with endotracheal tube (ETT) insertion.
  
  
  RESULTS
  In community-dwellers, Full Code resulted in a greater likelihood of survival and higher QALYs (4-year survival: 23% Full Code, 18% DNI; QALYs: 1.34 Full Code, 1.24 DNI). When considering patient preferences regarding complications, however, if patients were willing to give up >3 months of life expectancy to avoid ETT complications, or >1 month of life expectancy to avoid long-term institutionalization, DNI resulted in higher QALYs. For patients in long-term institutions, DNI resulted in a greater likelihood of survival and higher QALYs (4-year survival: 2% DNI, 1% Full Code; QALYs: 0.29 DNI, 0.24 Full Code). In sensitivity analyses, the model was sensitive to the probabilities of ETT complication and noninvasive mechanical ventilation failure and to patient preferences about ETT complications and long-term institutionalization.
  
  
  CONCLUSIONS
  Our model demonstrates that patient preferences regarding ETT complications and long-term institutionalization, as well as baseline place of residence, affect the advance directive recommendation when considered in terms of both survival and QALYs. Decision modeling can demonstrate the potential trade-off between survival and quality of life, using patient preferences and disease-specific data, to inform the shared advance directive decision.
authors.affiliation: Division of General Internal Medicine, New York University, New York, NY 10010, USA. negin.hajizadeh@nyumc.org
authors.forename: Negin
authors.initials: N
authors.lastname: Hajizadeh
authors.forename: Kristina
authors.initials: K
authors.lastname: Crothers
authors.forename: R Scott
authors.initials: RS
authors.lastname: Braithwaite
mesh_terms: D032722:Advance Care Planning; D000368:Aged; D000369:Aged, 80 and over; D003657:Decision Making; D003661:Decision Support Techniques; D006304:Health Status; D006801:Humans; D007442:Intubation, Intratracheal; D008017:Life Expectancy; D008390:Markov Chains; D008875:Middle Aged; D010358:Patient Participation; D057240:Patient Preference; D029424:Pulmonary Disease, Chronic Obstructive / Q000503:physiopathology / Q000628:therapy*; D019057:Quality-Adjusted Life Years; D012720:Severity of Illness Index; D016019:Survival Analysis; D013727:Terminal Care / Q000379:methods; D014481:United States