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Using Prospect Theory to Understand End-of-Life Decisions

Department of Health Policy, Jefferson Medical College, Philadelphia, PA

To the Editor:

In his discussion of prospect theory and patient preferences for cancer care, Weinfurt¹ provides important examples of how preferences may change for patients with grave prognoses. Weinfurt points out that a patient with a reduced life expectancy will place a greater value on the incremental benefits expected to be gained from a risky treatment. As the patient's financial reference point will presumably not have changed, the patients will be more likely to select the risky treatment.

Although this rationale can be applied to the case in which the upside of treatment is added health benefits and the downside is cost, the same result does not occur if the downside is a poorer health outcome, which may be the case in many situations. For instance, assume a patient is asked to choose between an aggressive and a conservative regimen, with the former providing a possible gain in life expectancy at the cost of a possible decrease in quality of life. At the theoretical point where these outcomes balance, a patient who has adjusted her reference point will be more likely to select the conservative treatment, as a loss will carry greater weight than a gain. However, a patient who has not adjusted her reference point will select the aggressive regimen, as the reduced loss from a gain in life expectancy will outweigh the increased loss from reduced quality of life.

Assuming that patients have adjusted their reference points, they should be more likely to choose aggressive treatments if they consider costs to be the downside, and more likely to choose conservative treatments if health risks are the downside. As Kim² points out, costs associated with treatments are rarely addressed. Furthermore, patients are typically more interested in the health benefits and risks of treatment than the cost. Thus, it would seem as though patients with poor prognoses would have greater knowledge of the health risks than the financial risks, and would tend to favor conservative treatments.

Yet, empirical evidence shows that patients are more likely than controls and providers to select aggressive treatments at the end of life.^3,4 As I have described here, this outcome cannot be explained by an adjusted reference point. Prospect theory also teaches that decisions may be affected by the manner in which outcomes are framed, with losses having greater weight than benefits. Perhaps patients faced with an end-of-life situation consider outcomes differently than controls (eg, patients frame the trade-off as a loss of life expectancy for a gain in quality of life, while controls see a gain in life expectancy, for a loss in quality of life). Patients may be subject to other psychological biases such as perceptions that choosing an aggressive regimen is fighting the illness, while a conservative regimen is giving up. Given the emotional, clinical, and financial ramifications of these decisions, a better understanding of the behavioral psychology of these patients and the influence of providers is needed.

AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

REFERENCES

1. Weinfurt KP: Value of high-cost cancer care: A behavioral science perspective. J Clin Oncol 25:223-227, 2007[Abstract/Free Full Text]

2. Kim P: Cost of cancer care: The patient perspective. J Clin Oncol 25:228-232, 2007[Abstract/Free Full Text]

3. Slevin ML, Stubbs L, Plant HJ, et al: Attitudes to chemotherapy: Comparing views of patients with cancer with those of doctors, nurses, and general public. BMJ 300:1458-1460, 1990[Abstract/Free Full Text]

4. Bremnes RM, Andersen K, Wist EA: Cancer patients, doctors and nurses vary in their willingness to undertake cancer chemotherapy. Eur J Cancer 31A:1917-1918, 1995[CrossRef]

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