Decision-control preferences in patients with advanced cancer

Abstract

8069 Background: Many argue that when patients with advanced cancer face medical decisions, the chief value that clinicians must respect is patient autonomy, and when patients cannot speak for themselves, decisions should be based on substituted judgments about patients' autonomous wishes. Others have suggested that the decision making process is more complex. Methods: We interviewed 130 patients with a ≥ 50% 2-year expected mortality (47 with advanced gastrointestinal or lung cancer, 52 with Class III-IV heart failure, and 31 with amyotrophic lateral sclerosis) at 2 teaching hospitals using a modified Decision Control Preferences Scale. We assessed the extent to which patients would involve others in medical decisions along 3 dimensions: patient-physician, patient-family, and physician-family, considering their present state and a hypothetical unconscious state. Results: A plurality of all patients (44%), presuming they were conscious, wanted to share decision making with their families. However, compared with the others, cancer patients were more likely to prefer decision making independent of their family (64% vs. 42%, P = .01). Overall, presuming they were conscious, most patients (52%) wanted to share decision making with their physicians. However, compared with others, patients with cancer preferred decision making independent of their physicians (43% vs. 29%, P = .07). Comparing decision control preferences for the unconscious with the conscious state, patients were significantly more likely to prefer that their physicians should decide based on the patient's best interest rather than on their autonomous preferences (P < .001). For the hypothetical unconscious state, few patients (19%) weigh the physician's views more than their families'. A plurality (48% overall, 53% cancer) prefer equal family/physician input. Conclusions: A plurality of patients preferred shared decision-making; a minority preferred autonomous decision-making. However, when capable, patients with cancer were more likely than others to prefer autonomous decision making. The pattern of preferences for the hypothetical unconscious state is more complicated than might be predicted by the autonomy model. No significant financial relationships to disclose.