Understanding decision-making by older adults about the refusal or acceptance of life-prolonging treatment (LPT) is important for medical professionals and their families. In recent years, the tendency to refuse LPT has spread widely through societies worldwide, and as a result, LPT tends to be refused by older adults, their families, and medical professionals1,2). Previous studies have revealed that older adults at the end-of-life (EOL) stage can have a feeling of having lived a complete life, and are therefore tired of living. In addition, they wish to keep their dignity, minimize the burden they believe they put on their families, and avoid feelings isolation3-6). These studies suggest that these are the reasons why older adults tend to reject LPT.
On the other hand, since refusal of LPT makes death certain, we must be extremely cautious about whether the decisions made by older adults are truly voluntary. Previous studies have shown that economic status is a social determinant when older adults make LPT decisions at the EOL stage; they are more likely to accept treatment if it is low-cost7). Additionally, social inequality can result in feelings of social resentment and “denial of death”; such feelings can enhance preference for LPT8). In addition, low income and low subjective economic status are associated with lower rates of LPT among older adults9,10).
The above-mentioned reasons and social determinants, such as economic status regarding LPT, may be mutually associated. However, previous studies have not adequately defined these associations due to three limitations. First, the reasons why older adults refuse LPT were determined using the subjects’ answers to items prepared by researchers in advance1,4,5); thus, even if the subjects have more diverse reasons than the researchers expect, such reasons cannot be measured properly. Second, although a few studies have explored such reasons using qualitative methods, the subjects in these studies were comprised of individuals with certain characteristics, such as having cancer or being a resident of a nursing home11,12); as a result, the generalizability of such studies is considered to be narrow. Third, it has been reported that gender and economic status are determinants of LPT decision-making, but the extent of their influence on the decision-making is unknown13,14). Therefore, we hypothesized that surveying reasons for refusal of LPT using open-ended questions in the general older adult population is necessary.
The purpose of the present study was to investigate the reasons for refusal of LPT according to gender and subjective economic status in the general older adult population by content analysis. We posit the following two hypotheses after taking into consideration the results of the above-mentioned previous studies: first, decision-making on LPT can vary depending on gender and subjective economic status. Second, individuals in difficult economic situations frequently use terms that are strongly related to their economic situation, while those without financial distress frequently use terms that are closely related to reasons other than economic circumstances.