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The stability of care preferences following acute illness: a mixed methods prospective cohort study of frail older people

Etkind, Simon; Lovell, Natasha; Bone, Anna; Guo, Ping; Nicholson, Caroline; Murtagh, F. E.M.; Higginson, Irene J


Simon Etkind

Natasha Lovell

Anna Bone

Ping Guo

Caroline Nicholson

Irene J Higginson


Background: Patient preferences are integral to person-centred care, but preference stability is poorly understood in older people, who may experience fluctuant illness trajectories with episodes of acute illness. We aimed to describe, and explore influences on the stability of care preferences in frail older people following recent acute illness.
Methods: Mixed-methods prospective cohort study with dominant qualitative component, parallel data collection and six-month follow up. Study population: age ≥65, Rockwood Clinical Frailty score ≥5, recent acute illness requiring acute assessment/hospitalisation. Participants rated the importance of six preferences (to extend life, improve quality of life, remain independent, be comfortable, support ‘those close to me’, and stay out of hospital) at baseline, 12 and 24 weeks using a 0-4 scale, and ranked the most important. A maximum-variation sub-sample additionally contributed serial in-depth qualitative interviews. We described preference stability using frequencies and proportions, and undertook thematic analysis to explore influences on preference stability.
Results:90/192 (45%) of potential participants consented. 82/90 (91%) answered the baseline questionnaire; median age 84, 63% female. 17 undertook qualitative interviews. Most participants consistently rated five of the six preferences as important (range 68 – 89%). ‘Extend life’ was rated important by fewer participants (32 – 43%). Importance ratings were stable in 61–86% of cases. The preference ranked most important was unstable in 82% of participants. Preference stability was supported by five influences: the presence of family support; both positive or negative care experiences; preferences being concordant with underlying values; where there was slowness of recovery from illness; and when preferences linked to long term goals. Preference change was related to changes in health awareness, or life event; if preferences were specific to a particular context, or multiple concurrent preferences existed, these were more liable to change.
Conclusions:Preferences were largely stable following acute illness. Stability was reinforced by care experiences and the presence of family support. Where preferences were unstable, this usually related to changing health awareness. Consideration of these influences during preference elicitation or advance care planning will support delivery of responsive care to meet preferences. Obtaining longer-term data across diverse ethnic groups is needed in future research.


Etkind, S., Lovell, N., Bone, A., Guo, P., Nicholson, C., Murtagh, F. E., & Higginson, I. J. (2020). The stability of care preferences following acute illness: a mixed methods prospective cohort study of frail older people. BMC Geriatrics, 20(1),

Journal Article Type Article
Acceptance Date Aug 19, 2020
Publication Date Sep 29, 2020
Deposit Date Aug 24, 2020
Publicly Available Date Aug 25, 2020
Journal BMC Geriatrics
Print ISSN 1471-2318
Electronic ISSN 1471-2318
Publisher Springer Verlag
Peer Reviewed Peer Reviewed
Volume 20
Issue 1
Article Number 370
Keywords Patient preference; Frail elderly; Aged; Patient-centered care; Palliative care; Cohort studies
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