Can Prospect Theory Explain Uncertainty in Decision Making among Older Adults?
Background: Researchers have found that older adults’ decisions regarding the care they desire at the end of life change over time and these changes impact the nature of the care they receive, particularly hospice and palliative care. Many descriptive studies have been undertaken, but few explore the underlying process leading to different decisions. Likewise, many frameworks have been developed to support patients in making “better” decisions. Prospect theory is one framework that specifically aims to explicate decision-making processes and has been gaining increased use in healthcare decision making, including end-of-life decisions.
Methods: We used grounded theory methods to explore the perspectives of older adults who are near the end of their lives and are in the midst of making significant healthcare. Using situational analysis, we sought to understand participants’ experiences within the context of their perceptions of health and prognosis. Participants were recruited through community-based geriatric clinics and were interviewed in their homes. Interviews were analyzed using constant comparative analysis and negative cases were sought to challenge emerging themes.
Results: Twenty participants were recruited. Thirteen participants were men and seven were women, ranging in age from 67 to 97. Seventeen were White and three were non-White. Four participants were married or in domestic partnerships.
Despite their limited prognosis, participants saw end-of-life decisions as future decisions that would be made in a context they could not know a priori. An over arching theme of decision making in the context of ambiguity emerged that reflected the uncertainty and ambivalence participants felt with regards to these decisions. Participants used different approaches to balance competing goals of maximizing length of life and quality of life. Valuing choices against competing goals is a behavior not explained by prospect theory, and we propose an extended model that can illustrate the unique nature of end-of-life decisions.
Implications: Being aware of how patients balance competing goals will enable providers to support patients’ decision making in a way that takes all priorities in account. Though prospect theory shows promise with many types of healthcare decisions, the contextual environment of decisions at the end of life is not easily captured in it and argues for a new model that can be used in both research and clinical practice. We propose a model that we hope will stimulate the dialog in both research and clinical practice.