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Research ArticleOriginal Research

Older Adults’ Preferences for Discussing Long-Term Life Expectancy: Results From a National Survey

Nancy L. Schoenborn, Ellen M. Janssen, Cynthia Boyd, John F.P. Bridges, Antonio C. Wolff, Qian-Li Xue and Craig E. Pollack
The Annals of Family Medicine November 2018, 16 (6) 530-537; DOI: https://doi.org/10.1370/afm.2309
Nancy L. Schoenborn
1The Johns Hopkins University School of Medicine, Baltimore, Maryland
MD, MHS
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  • For correspondence: nancyli@jhmi.edu
Ellen M. Janssen
2The Johns Hopkins University School of Public Health, Baltimore, Maryland
3ICON Plc, Gaithersburg, Maryland
PhD
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Cynthia Boyd
1The Johns Hopkins University School of Medicine, Baltimore, Maryland
MD, MPH
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John F.P. Bridges
2The Johns Hopkins University School of Public Health, Baltimore, Maryland
4Ohio State University, Department of Biomedical Informatics, Columbus, Ohio
PhD
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Antonio C. Wolff
1The Johns Hopkins University School of Medicine, Baltimore, Maryland
MD
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Qian-Li Xue
1The Johns Hopkins University School of Medicine, Baltimore, Maryland
2The Johns Hopkins University School of Public Health, Baltimore, Maryland
PhD
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Craig E. Pollack
1The Johns Hopkins University School of Medicine, Baltimore, Maryland
MD,MHS
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    Figure 1

    Preferences for discussing life expectancy at various time points.

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    Table 1

    Participant Characteristics

    CharacteristicAll (N = 878)Preference for Discussing Life Expectancy
    Wanted to Discussa
    (n = 363)
    Did Not Want to Discussa
    (n = 515)
    P Value
    Age, mean (SD), y73.4 (6.1)73.5 (6.1)73.3 (6.2).70
    Female sex, No. (%)462 (55.1)177 (51.9)285 (57.4).20
    Race, No. (%)
     White575 (77.2)261 (80.9)314 (74.7).15
     African American214 (8.7)68 (6.3)146 (10.4)
     Other89 (14.1)34 (12.8)55 (14.9)
    Educational level, No. (%)
     <High school61 (14.4)13 (9.6)48 (17.7)<.001
     High school268 (33.2)80 (26.2)188 (37.9)
     <4-year college243 (24.2)104 (25.9)139 (23.0)
     College graduate or postgraduate degrees306 (28.3)166 (38.2)140 (21.5)
    Health literacy,b,36 mean (SD)13.1 (2.1)13.2 (2.2)13.0 (2.0).33
    Numeracy,c,37 mean (SD)13.8 (3.5)14.4 (3.4)13.4 (3.6)<.001
    Predicted life expectancy,31 No. (%)
     >10 years631 (68.9)262 (69.7)369 (68.4).76
     <10 years197 (31.1)81 (30.3)116 (31.6)
    Self-perceived life expectancy, No. (%)
     ≥10 years762 (83.4)322 (84.7)440 (82.5).54
     <10 years110 (16.6)41 (15.3)69 (17.5)
    Belief that life expectancy can be predicted,21 No. (%)
     Disagree446 (47.3)155 (39.5)291 (52.6)<.001
     Neutral308 (38.6)132 (39.1)176 (38.2)
     Agree122 (14.2)74 (21.4)48 (9.2)
    Has had life-threatening illness,32 No. (%)252 (29.3)120 (33.4)132 (26.5).09
    Has discussed life expectancy of a loved one,32 No. (%)240 (24.8)156 (40.7)84 (14.0)<.001
    Complete trust in doctor,35 No. (%)
     Disagree81 (8.6)26 (7.0)55 (9.7).53
     Neutral231 (27.6)98 (27.6)133 (27.6)
     Agree565 (63.8)238 (65.4)327 (62.7)
    Preferred decision-making role, 33 No. (%)
     Make own decisions533 (62.5)220 (62.0)313 (62.9).83
     Shared or leave to doctor337 (37.5)141 (38.0)196 (37.1)
    Religion is important,34 No. (%)633 (70.8)242 (65.5)391 (74.5).02
    • ↵a Responses to the hypothetical scenario. See Methods for description.

    • b Possible range 3 to 15; higher scores indicate better health literacy.

    • c Possible range 3 to 18; higher scores indicate better numeracy.

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    Table 2

    Factors Associated With Preferring to Discuss Life Expectancy

    CharacteristicUnadjusted Odds Ratio (95% CI)P ValueAdjusted Odds Ratio (95% CI)aP Value
    Age, per year1.01 (0.98-1.03).62––
    Female sex0.80 (0.61-1.05).11––
    Race.05.55
     WhiteRefRef
     Black0.56 (0.33-0.93)0.80 (0.45-1.43)
     Other0.79 (0.53-1.17)0.82 (0.53-1.28)
    Education<.001.004
     <High schoolRefRef
     High school1.27 (0.80-2.01)1.09 (0.66-1.82)
     Some college2.06 (1.28-3.33)1.66 (0.96-2.85)
     >College3.26 (2.05-5.19)2.18 (1.25-3.80)
    Health literacy,36 per point1.05 (0.98-1.12).15––
    (scale 3-15)
    Numeracy,37 per point (scale 3-18)1.09 (1.05-1.14)<.0011.04 (0.99-1.09).11
    Predicted 10-year mortalityb,310.81 (0.46-1.43).47––
    Self-perceived 10-year mortalityb1.08 (0.62-1.87).78––
    Doctors can accurately predict<.001<.001
    life expectancy21
     DisagreeRefRef
     Neutral1.36 (1.01-1.83)1.59 (1.14-2.21)
     Agree3.10 (2.05-4.69)3.06 (1.93-4.86)
    Has had life-threatening illness321.39 (1.04-1.86).031.50 (1.07-2.09).02
    Has discussed life expectancy4.22 (3.05-5.85)<.0013.98 (2.82-5.62)<.001
    of a loved one32
    Complete trust in doctor35.36
     DisagreeRef––
     Neutral1.38 (0.80-2.37)––
     Agree1.44 (0.87-2.39)––
    Prefers shared decision making or leaving decision to doctor (vs making own decisions)331.04 (0.79-1.37).79––
    Religion is important340.65 (0.48-0.87).0040.69 (0.49-0.97).03

    Note: Preference expressed in the hypothetical patient scenario. See Methods for description.

    • Ref = reference group.

    • ↵a Only variables having P ≤.05 in univariate analysis were included in multivariate analysis.

    • ↵b Analyzed as continuous variables with range of 0 to 1 in the regression model. For example, one person’s 10-year mortality risk may be 0.02 or 2%, and another person’s 10-year mortality risk may be 0.92 or 92%. Here, the odds ratio is per 1 unit of mortality risk, ie, comparing 100% mortality risk with 0%.

    • View popup
    Table 3

    Participants’ Reasons and Preferences Around Discussing Life Expectancy

    Reason/PreferenceWanted to Discuss Life Expectancya (n = 363)Did Not Want to Discuss Life Expectancya (n = 515)
    Reason for wanting to discuss life expectancyb–
     Help patient better plan life270 (72.3)
     Important to be honest and open151 (42.2)
     Other16 (4.6)
    Reason for not wanting to discuss life expectancyb–
     Doctors cannot predict life expectancy302 (56.7)
     May worry or depress patient272 (52.2)
     Other43 (9.7)
    Acceptable for the doctor to offer to discuss life expectancy?
     Yes, as long as I can say no344 (94.8)222 (40.1)
     No, the doctor should not have brought up the topic at all16 (5.2)291 (59.9)
    Want the doctor to discuss life expectancy with family or friends?
     Yes198 (57.9)65 (12.3)
     No164 (42.1)450 (87.7)
    If the doctor recommends stopping cancer screening due to limited life expectancy of the patient, should doctor then discuss life expectancy with the patient?
     Yes305 (84.5)114 (21.3)
     No58 (15.5)401 (78.7)
    How should the doctor describe life expectancy of about 5 years?
     In the range of a few years174 (49.2)255 (48.7)
     About a 50-50 chance to live another 5 years188 (50.8)252 (51.3)
    • ↵a Responses to the hypothetical scenario. See Methods for description.

    • ↵b Participants could choose more than 1 reason; therefore, percentages do not add up to 100%.

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    Supplemental Appendix

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    • Supplemental data: Appendix - PDF file
  • The Article in Brief

    Older Adults' Preferences for Discussing Long-Term Life Expectancy: Results From a National Survey

    Nancy Li Schoenborn , and colleagues

    Background Clinical practice guidelines recommend incorporating long-term life expectancy to inform a number of decisions in primary care. We aimed to examine older adults' preferences for discussing life expectancy in a national sample.

    What This Study Found A majority of older adults do not wish to discuss life expectancy when presented with a hypothetical scenario on the topic. In a survey of communication around life expectancy, 878 adults age 65 years and older received a description of a hypothetical patient with limited life expectancy who is not imminently dying. Participants were asked, as the hypothetical patient, if they would like to talk with the doctor about how long they might live, if it was acceptable for the doctor to offer such discussion, whether they would want the doctor to discuss life expectancy with family or friends, and when life expectancy should be discussed. Fifty-nine percent of participants (n = 515) did not want to discuss how long they might live in the presented scenario. Among these, 291 participants did not think that the doctor should offer discussion, and 450 participants did not want the doctor to discuss life expectancy with family or friends. As estimated life expectancy increased, fewer participants felt that it should be discussed. Fifty-six percent of participants (n = 478) only wanted to discuss life expectancy if it were less than two years. Factors associated with wanting to discuss life expectancy included higher educational levels, belief that doctors can predict life expectancy, and past experiences with either a life-threatening illness or with discussing life expectancy of a loved one. Reporting that religion is important was associated with lower odds of choosing to discuss life expectancy.

    Implications

    • Overall, this research--the first national study to examine these questions--found that long-term life expectancy can be an important factor in health care decisions for older adults, but whether, when, and how to communicate with patients about it is not clear.
    • The authors suggest that strategies to address this topic include assessing patient factors associated with willingness to discuss life expectancy and offering the discussion when closer to the patient's final year of life.
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The Annals of Family Medicine: 16 (6)
The Annals of Family Medicine: 16 (6)
Vol. 16, Issue 6
November/December 2018
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Older Adults’ Preferences for Discussing Long-Term Life Expectancy: Results From a National Survey
Nancy L. Schoenborn, Ellen M. Janssen, Cynthia Boyd, John F.P. Bridges, Antonio C. Wolff, Qian-Li Xue, Craig E. Pollack
The Annals of Family Medicine Nov 2018, 16 (6) 530-537; DOI: 10.1370/afm.2309

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Older Adults’ Preferences for Discussing Long-Term Life Expectancy: Results From a National Survey
Nancy L. Schoenborn, Ellen M. Janssen, Cynthia Boyd, John F.P. Bridges, Antonio C. Wolff, Qian-Li Xue, Craig E. Pollack
The Annals of Family Medicine Nov 2018, 16 (6) 530-537; DOI: 10.1370/afm.2309
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