Study says elderly may dismiss doctors’ orders

New research from Yale shows that a high percentage of chronically ill elderly patients are refusing to follow their doctors’ orders, but the researchers still do not fully understand the nature of the patients’ disagreements.

A study by researchers at the Yale School of Medicine indicates that elderly patients with advanced illnesses often reject the medical treatments suggested by their physicians. The patients said they they did not think the benefits would outweigh the burdens of possibly invasive medical procedures.

Terri Fried, Yale professor of medicine and geriatrics, said the study shows that there may be some disconnect between what physicians are recommending and the patients’ personal goals for their health care.

“It suggests to us that doctors are not offering the kinds of treatments that their patients want to be receiving,” Fried said. “It points to the idea of patient-centered medicine. Doctors need to understand the patient’s point of view.”

Cardiac catheterization and surgery were the most commonly refused treatments, as they were refused by the elderly patients in the study over 10 percent of the time. Chemotherapy, radiation, intubation, dialysis and transplantation were also identified as some of the more commonly refused treatments, but hospitalization was generally always accepted.

Marc Rothman, postdoctoral fellow in geriatrics at Yale, said the findings are interesting because they deal with a population that is often overlooked in medical studies.

The interventions that doctors recommend are typically studied in people with a much better state of health, Rothman said. Chronically ill patients may have undergone the same treatment multiple times, so they would be making informed decisions about the costs and benefits based on their personal experience, he said.

“You have people near the end of their life being offered interventions whose effectiveness and benefits may not be as clear as they would be in people less critically ill,” Rothman said.

The study, spurred by Fried’s clinical work in geriatrics, looked at the treatment preferences of 226 people over the age of 60 with advanced cancer, congestive heart failure or chronic obstructive pulmonary disease. All patients were from the greater New Haven area, allowing researchers to make in-home visits at least every four months for up to two years.

After collecting the data, researchers determined that 16 percent of the patients had turned down doctor-recommended treatment at least once. The patients were fearful of side effects and thought the treatments would be too burdensome.

“In taking care of older patients, what I knew clinically was that it’s very hard to make decisions for elderly people who are sick,” Fried said. “I was interested in understanding what the preferences of these people were, to see whether we were giving them care in the way they wanted.”

But the study does not offer a conclusive explanation of the reason for patients’ refusals. The authors said that because the study did not include a look at the actual interactions between physician and patient, they do not know if the problem lies in the way doctors are communicating or in the type of treatments being offered.

Rothman said the findings suggest that doctors are not offering elderly patients a wide enough range of treatments to give patients input into their care. But drawing that conclusion would require another study that looked at interactions between a patient and his or her physician.

“Sixteen percent is a very significant percentage of patients refusing the doctor’s intervention,” Rothman said. “It would be interesting to take the study further. Clearly more work is needed.”

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