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Joel Tsevat, MD, MPH; Neal V. Dawson, MD; Albert W. Wu, MD, MPH; Joanne Lynn, MD, MA; Jane R. Soukup, MS; E. Francis Cook, ScD; Humberto Vidaillet, MD; Russell S. Phillips, MD; for the HELP Investigators

JAMA. 1998;279:371-375.

Context.— Health values (utilities or preferences for health states) are often incorporated into clinical decisions and health care policy when issues of quality vs length of life arise, but little is known about health values of the very old.

Objective.— To assess health values of older hospitalized patients, compare their values with those of their surrogate decision makers, investigate possible determinants of health values, and determine whether health values change over time.

Design.— A prospective, longitudinal, multicenter cohort study.

Setting.— Four academic medical centers.

Participants.— Four hundred fourteen hospitalized patients aged 80 years or older and their surrogate decision makers who were interviewed and understood the task.

Main Outcome Measures.— Time–trade-off utilities, reflecting preferences for current health relative to a shorter but healthy life.

Results.— On average, patients equated living 1 year in their current state of health with living 9.7 months in excellent health (mean [SD] utility, 0.81 [0.28]). Although only 126 patients (30.7%) rated their current quality of life as excellent or very good, 284 (68.6%) were willing to give up at most 1 month of 12 in exchange for excellent health (utility 0.92). At the other extreme, 25 (6.0%) were willing to live 2 weeks or less in excellent health rather than 1 year in their current state of health (utility 0.04). Patients were willing to trade significantly less time for a healthy life than their surrogates assumed they would (mean difference, 0.05; P=.007); 61 surrogates (20.3%) underestimated the patient's time–trade-off score by 0.25 (3 months of 12) or more. Patients willing to trade less time for better health were more likely to want resuscitation and other measures to extend life. Time–trade-off score correlated only modestly with quality-of-life rating (r=0.28) and inversely with depression score (r=-0.27), but there were few other clinical or demographic predictors of health values. When patients who survived were asked the time–trade-off question again at 1 year, they were willing to trade less time for better health than at baseline (mean difference, 0.04; P=.04).

Conclusion.— Very old hospitalized patients who could be interviewed were able, in most cases, to have their health values assessed using the time–trade-off technique. Most patients were unwilling to trade much time for excellent health, but preferences varied greatly. Because proxies and multivariable analyses cannot gauge health values of elderly hospitalized patients accurately, health values of the very old should be elicited directly from the patient.

From the Section of Outcomes Research, Division of General Internal Medicine, Department of Internal Medicine, and the Center for Clinical Effectiveness, Institute for Health Policy and Health Services Research, University of Cincinnati Medical Center, Cincinnati, Ohio (Dr Tsevat); Division of General Internal Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr Dawson); Health Services Research and Development Center, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Md (Dr Wu); Center to Improve Care of the Dying, George Washington University Medical Center, Washington, DC (Dr Lynn); Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School (Dr Phillips and Ms Soukup), and Section for Clinical Epidemiology, Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School (Dr Cook), Boston, Mass; and Department of Cardiology, Marshfield Clinic, Marshfield, Wis (Dr Vidaillet).

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