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The Johns Hopkins Precursors Study

Marsha N. Wittink, MD, MBE; Knashawn H. Morales, ScD; Lucy A. Meoni, ScM; Daniel E. Ford, MD, MPH; Nae-yuh Wang, PhD; Michael J. Klag, MD, MPH; Joseph J. Gallo, MD, MPH

Arch Intern Med. 2008;168(19):2125-2130.

Background  Preferences for life-sustaining treatment elicited in one state of health may not reflect preferences in another state of health.

Methods  We estimated the stability of preferences for end-of-life treatment across 3 years and whether declines in physical functioning and mental health were associated with changes in preferences for end-of-life treatment.

In this longitudinal cohort study of medical students in the graduating classes of 1948 to 1964 at Johns Hopkins University, 818 physicians completed the life-sustaining treatment questionnaire in 1999 and 2002 (mean age at baseline, 69 years).

Results  Although the prevalence of the 3 clusters of life-sustaining treatment preferences remained stable across the 3-year follow-up, certain physicians changed their preferences with time. The probability that physicians were in the same cluster at follow-up as at baseline was 0.41 for "most aggressive," 0.50 for "intermediate care," and 0.80 for "least aggressive." Physicians without advance directives were more likely to transition to the most aggressive cluster than to the least aggressive cluster during the 3-year follow-up (odds ratio, 1.96; 95% confidence interval, 1.11-3.45). Age at baseline and decline in physical and mental health were not associated with transitions between 1999 and 2002.

Conclusion  Periodic reassessment of preferences is most critical for patients who desire aggressive end-of-life care or who do not have advance directives.

Author Affiliations: Department of Family Medicine and Community Health (Drs Wittink and Gallo) and Center for Clinical Epidemiology and Biostatistics (Dr Morales), University of Pennsylvania School of Medicine, Philadelphia; and Department of Medicine, School of Medicine, and Departments of Epidemiology and Health Policy and Management, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland (Ms Meoni and Drs Ford, Wang, and Klag).

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