title: Life-sustaining treatment preferences: matches and mismatches between patients' preferences and clinicians' perceptions.
abstract: BACKGROUND
  Better clinician understanding of patients' end-of-life treatment preferences has the potential for reducing unwanted treatment, decreasing health care costs, and improving end-of-life care.
  
  
  OBJECTIVE
  To investigate patient preferences for life-sustaining therapies, clinicians' accuracy in understanding those preferences, and predictors of patient preference and clinician error.
  
  
  METHODS
  This was an observational study of 196 male veterans with chronic obstructive pulmonary disease who participated in a randomized trial. Measures included patients' preferences for mechanical ventilation (MV) and cardiopulmonary resuscitation (CPR) if needed in their current state of health, and outpatient clinicians' beliefs about those preferences.
  
  
  RESULTS
  Analyses were based on 54% of participants in the trial who had complete patient/clinician data on treatment preferences. Patients were more receptive to CPR than MV (76% vs. 61%; P<0.001). Preferences for both treatments were significantly associated with the importance patients assigned to avoiding life-sustaining therapies during the final week of life (MV: b=-0.11, P<0.001; CPR: b=-0.09, P=0.001). When responses were dichotomized (would/would not want treatment), clinicians' perceptions matched patient preferences in 75% of CPR cases and 61% of MV cases. Clinician errors increased as patients preferred less aggressive treatment (MV: b=-0.28, P<0.001; CPR: b=-0.32, P<0.001).
  
  
  CONCLUSIONS
  Clinicians erred more often about patients' wishes when patients did not want treatment than when they wanted it. Treatment decisions based on clinicians' perceptions could result in costly and unwanted treatments. End-of-life care could benefit from increased clinician-patient discussion about end-of-life care, particularly if discussions included patient education about risks of treatment and allowed clinicians to form and maintain accurate impressions of patients' preferences.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA 98104, USA. ldowney@uw.edu
authors.forename: Lois
authors.initials: L
authors.lastname: Downey
authors.forename: David H
authors.initials: DH
authors.lastname: Au
authors.forename: J Randall
authors.initials: JR
authors.lastname: Curtis
authors.forename: Ruth A
authors.initials: RA
authors.lastname: Engelberg
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016887:Cardiopulmonary Resuscitation; D003142:Communication; D032882:Comprehension; D005260:Female; D019538:Health Care Surveys; D017051:Hospice Care; D006801:Humans; D008297:Male; D008875:Middle Aged; D057240:Patient Preference; D010817:Physician-Patient Relations; D029424:Pulmonary Disease, Chronic Obstructive / Q000628:therapy*; D012121:Respiration, Artificial; D013727:Terminal Care; D014728:Veterans