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Am J Respir Crit Care Med. 2017 Oct 15;196(8):958-963. doi: 10.1164/rccm.201701-0165CP.

Accounting for Patient Preferences Regarding Life-Sustaining Treatment in Evaluations of Medical Effectiveness and Quality.

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1 Division of Pulmonary and Critical Care Medicine, the Pulmonary Center, and.
2 Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.
3 Section of Decision Sciences, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
4 Department of Health Care Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.
5 Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial VA Hospital, Bedford, Massachusetts; and.
6 Division of Cardiovascular Medicine and Center for Health Outcomes and Policy, University of Michigan Medical School, Ann Arbor, Michigan.


The importance of understanding patient preferences for life-sustaining treatment is well described for individual clinical decisions; however, its role in evaluations of healthcare outcomes and quality has received little attention. Decisions to limit life-sustaining therapies are strongly associated with high risks for death in ways that are unaccounted for by routine measures of illness severity. However, this essential information is generally unavailable to researchers, with the potential for spurious inferences. This may lead to "confounding by unmeasured patient preferences" (a type of confounding by indication) and has implications for assessments of treatment effectiveness and healthcare quality, especially in acute and critical care settings in which risk for death and adverse events are high. Through a collection of case studies, we explore the effect of unmeasured patient resuscitation preferences on issues critical for researchers and research consumers to understand. We then propose strategies to more consistently elicit, record, and harmonize documentation of patient preferences that can be used to attenuate confounding by unmeasured patient preferences and provide novel opportunities to improve the patient centeredness of medical care for serious illness.


end-of-life care; epidemiologic biases; quality of healthcare

[Available on 2018-10-15]
[Indexed for MEDLINE]

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