How do Americans want to die? A factorial vignette survey of public attitudes about end-of-life medical decision-making

Public attitudes and values regarding medical decision-making in cases of catastrophic and terminal illness are notoriously hard to measure. In the summer of 1994, during the opening round of the national debate on health-care reform, we interviewed a representative sample of Virginians. Ten vignettes presented randomly assembled but plausible cases of terminal and catastrophic illness, varying along medical and social dimensions. Each vignette solicited me respondent's recommendation to continue or terminate expensive care with limited medical value. This randomized multivariate design minimizes maturation and question-order effects, efficiently samples the universe of potential vignettes, and allows analysis by vignette and respondent characteristics simultaneously. Major findings: Respondents exhibited a carefully graded sensitivity to what constituted appropriate and inappropriate medical treatments. Recommendations varied considerably according to medical prognosis and the presence of advance directives for health care. Other characteristics of vignettes and respondents had varying but lesser impacts on recommendations. (C) 1997 Academic Press.