Participation of Very Old Adults in Health Care Decisions

Background. Some elderly people receive tests or interventions from which they have low likelihood of benefit or for which the goal is not aligned with their values. Engaging these patients in the decision process is one potential approach to improve the individualization of care. Yet some clinicians perceive and some survey data suggest that older adults prefer not to participate in the decision-making process. Those preferences, however, may be formed based on an experience in which factors, such as communication issues, were barriers to participation. Our goal was to shed light on the experience of very old adults in health care decision making from their own point of view to deepen our understanding of their potentially modifiable barriers to participation. Design and Methods. Semistructured interviews of participants aged 80 and older (n = 29, 59% women and 21% black) were analyzed using the constant comparative method in a grounded theory approach to describe decision making in clinic visits from the patient’s perspective. Results. The average age was 84 years (range, 80–93); each described an average of 6.4 decision episodes. Active participation was highly variable among subjects. Marked differences in participation across participants and by type of decision—surgery, medications, diagnostic procedures, routine testing for preventive care—highlighted barriers to greater participation. The most common potentially modifiable barriers were the perception that there were no options to consider, low patient activation, and communication issues. Conclusions. The experience of very old adults highlights potentially modifiable barriers to greater participation in decision making. To bring very old patients into the decision process, clinicians must modify interviewing skills and spend additional time eliciting their values, goals, and preferences.