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Kenneth E. Rosenfeld, MD; Neil S. Wenger, MD, MPH; Russell S. Phillips, MD; Alfred F. Connors, MD; Neal V. Dawson, MD; Peter Layde, MD; Robert M. Califf, MD; Honghu Liu, PhD; Joanne Lynn, MD, MS; Robert K. Oye, MD

Arch Intern Med. 1996;156(14):1558-1564.

Abstract
Background
During serious illness, patient preferences regarding life-sustaining treatments play an important role in medical decisions. However, little is known about life-sustaining preference stability in this population or about factors associated with preference change.

Methods
We evaluated 2-month cardiopulmonary resuscitation (CPR) preference stability in a cohort of 1590 seriously ill hospitalized patients at 5 acute care teaching hospitals. Using multiple logistic regression, we measured the association of patient demographic and health-related factors (quality of life, function, depression, prognosis, and diagnostic group) with change in CPR preference between interviews.

Results
Of 1590 patients analyzed, 73% of patients preferred CPR at baseline interview and 70% chose CPR at follow-up. Preference stability was 80% overall—85% in patients initially preferring CPR and 69% in those initially choosing do not resuscitate (DNR). For patients initially preferring CPR, older age, non—African American race, and greater depression at baseline were independently associated with a change to preferring DNR at follow-up. For patients initially preferring DNR, younger age, male gender, less depression at baseline, improvement in depression between interviews, and an initial admission diagnosis of acute respiratory failure or multiorgan system failure were associated with a change to preferring CPR at follow-up. For patients initially preferring DNR, patients with substantial improvements in depression score between interviews were more than 5 times as likely to change preference to CPR than were patients with substantial worsening in depression score.

Conclusions
More than two thirds of seriously ill patients prefer CPR for cardiac arrest and 80% had stable preferences over 2 months. Factors associated with preference change suggest that depression may lead patients to refuse life-sustaining care. Providers should evaluate mood state when eliciting patients' preferences for life-sustaining treatments.

Arch Intern Med. 1996;156:1558-1564

Author Affiliations
From the UCLA Robert Wood Johnson Clinical Scholars Program (Dr Rosenfeld) and the UCLA School of Medicine (Drs Wenger, Liu, and Oye), Los Angeles, Calif; Beth Israel Hospital, Boston, Mass (Dr Phillips); Cleveland Metrohealth Medical Center (Dr Connors) and Case Western Reserve University (Dr Dawson), Cleveland, Ohio; Medical College of Wisconsin, Milwaukee (Dr Layde); Duke University Medical Center, Durham, NC (Dr Califf); and Center to Improve Care of the Dying, George Washington University, Washington, DC (Dr Lynn).

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