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Being involved or just beinginformed: Communicationpreferences of seriously ill, olderadultsStephen C. Hines a , Alvin H. Moss b & Laurie Badzek ca Assistant professor in the Communication StudiesDepartment , West Virginia University ,b Professor of medicine and the Director of the Center forHealth Ethics and Law at the Robert C. Byrd Health SciencesCenter , West Virginia University ,c Assistant professor of Nursing , West Virginia University ,Published online: 21 May 2009.

To cite this article: Stephen C. Hines , Alvin H. Moss & Laurie Badzek (1997) Being involved orjust being informed: Communication preferences of seriously ill, older adults, CommunicationQuarterly, 45:3, 268-281, DOI: 10.1080/01463379709370065

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Being Involved or Just Being Informed:Communication Preferences ofSeriously Ill, Older Adults

Stephen C. Hines, Alvin H. Moss and Laurie Badzek

Communication competence may play an important role in interactions betweenhealth care providers and patients. Because exactly what constitutes effective andappropriate communication in conversations with seriously ill, older adults is notclear, it is difficult to know haw such conversations can be improved. In this studywe conducted face-to-face interviews with 142 randomly selected, older dialysispatients to determine if they believed it was appropriate to inform them of theirmedical condition, discuss treatment alternatives, and involve them in medicaldecision making. Results confirmed the expectation that most such individualsbelieve it is appropriate to be informed about their condition and options, but do notbelieve it is appropriate to involve them in medical decision making. Respondentswho were older, less educated, and who had diminished cognitive capacity perceivedinvolvement as particularly inappropriate. Results suggest that many seriously ill,older adults may have communication beliefs about medical decision making whichcreate conflict between physicians' obligation to communicate effectively and theirneed to communicate in a manner patients deem to be appropriate.

KEY CONCEPTS communication competence, medical decision making,patient involvement, aging

Stephen C. Hines (Ph.D. Purdue University, 1993) is an assistant professor inthe Communication Studies Department at West Virginia University. AlvinH. Moss (M.D. University of Pennsylvania, 1975) is a professor of medicineand the Director of the Center for Health Ethics and Law at the Robert C. ByrdHealth Sciences Center of West Virginia University. Laurie Badzek (J.D. WestVirginia University, 1990; M.S.N DePaul University, 1993) is an assistantprofessor of Nursing at West Virginia University. An earlier version of thispaper was presented at the Eastern Communication Association's 1997annual meeting in Baltimore, MD. Research reported in this essay was fundedby a grant from the National Kidney Foundation of Western Pennsylvania.While the authors gratefully acknowledge this support, positions taken in thepaper do not necessarily reflect the views of the sponsoring organization.

Effective communication between patients and health care providers is widelyrecognized as being directly related to many important outcomes. Studieshave shown that more effective communication produces greater patient

Communication Quarterly, Vol. 45,No 3, Summer 1997, Pages 268-281

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satisfaction (see Kreps & Thornton, 1992; Stewart & Roter, 1989 for reviews), greatercompliance with treatment recommendations (C/Hair, 1986; CXHair, CXHair,Southward & Krayer, 1987), and a better understanding of self-care practices neededto preserve or restore good health (Badzek, Moss, & Hines, 1996; Kaplan, Greenfield,& Ware, 1989). From the health provider's perspective, more effective communicationis associated with a reduced chance of costly malpractice suits (Hickson, Clayton,Githens, & Sloan, 1992; Levinson, Roter, Mullooly, Dull, & Frankel, 1997; Vincent,Young, & Phillips, 1994) and more satisfying relations with patients and their families(Buckman, 1992). Bioeth-icists and others also have pointed to the importance ofeffective communication in achieving outcomes valued by both patients and thehealth care system, including collaborative decision making and upholding thedoctrine of informed consent (Beauchamp & Childress, 1994; Katz, 1984; President'sCommission, 1982).

But despite considerable evidence that effective communication between patientsand health care providers is essential to positive outcomes, much research indicatesthat this ideal is only infrequently achieved. Studies conducted in a variety of medicalcontexts document the unfortunate prevalence of poor communication by doctors andother health care providers (see Kreps & Thornton, 1992; Roter, Hall, & Katz, 1988; andThompson, 1994 for reviews).

Because many recognize that effective communication between patients andhealth care providers is both critical and uncommon, efforts to improve thecommunicative practices of doctors have been made. Many of these efforts haveutilized communicative competence as a standard against which doctors'communicative efforts can be evaluated. While the concept of communicativecompetence has been discussed extensively during the past twenty years (Bochner &Kelly, 1974; CKeefe & Delia, 1982; Rubin, 1990; Spitzberg, 1986), this discussion hasfailed to result in consensus concerning exactly what competence consists of and howit should be measured (see Cegala, McGee, & McNeilis, 1996; Rubin, 1990; andSpitzberg & Cupach, 1984, for reviews). Recently, Cegala and associates (Cegala et al.,1996; Cegala, McNeilis, & McGee, 1995, Cegala & Waldron, 1992) have argued that thedefinition of communication competence as "effective and appropriate" behaviormust be adapted to fit particular communication situations. Because communicationis rule-governed behavior, and because different rules are utilized in differentcontexts, in different cultures and subcultures, and by different individuals, efforts todevelop uniformly applicable dimensions of communicative competence areunfeasible, if not actually counterproductive (Cegala et al., 1996; Cegala, et al., 1995).

The analysis that suggests that communicative competence is an importantconstruct in health settings provides good reason to explore what constitutes effectiveand appropriate communication between doctors and their patients. Despite effortsby Cegala and others (Kasch, 1984; Kreps & Query, 1990; Morse & Piland, 1981) toexplore communication competence in health contexts, much research is still needed,particularly research that examines the effectiveness and appropriateness of com-munication behaviors directed toward patient populations who may differ fromAmerican middle-class norms.

Recently bioethicists and medical researchers have questioned the appropriate-ness of prescriptive rules for how doctors should communicate with patients fromdifferent cultures. Several studies have shown that discussions of medical contin-gencies, disclosure of bad news, and efforts to involve the patient as an active partici-

Being Involved or Just Being Informed 269

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pant may violate cultural norms in many other cultures (see Blackhall, Murphy, Frank,Michel, & Azen, 1995; Carrese & Rhodes, 1995; Jecker, Carrese, & Pearlman, 1995).Other research has raised questions concerning whether older patients in the UnitedStates also may have expectations for how doctors should communicate with themthat differ from the set of expectations that are widely-viewed as appropriate. Forexample, Ende, Kazis, Ash, and Moskowitz (1989) found that older patients want a lessactive role in decision making than younger patients. Cole and Holstein (1996) argueconvincingly that communication with older adults requires adapting to expectationsthey possess that are not shared by younger persons.

Research such as this suggests the need to more closely examine what constitutescommunicative competence for doctors in their conversations with older patients.Substantial evidence exists to show that the medical establishment is ageist and treatsolder patients inappropriately (see Hummert, 1994; Ryan & Butler, 1996). However,it may be equally stereotypical to assume without supporting evidence that older andyounger patients share the same set of communication expectations. Thus, the purposeof this study was to examine the expectations of older, chronically ill patients todetermine whether these patients employ different standards for evaluating thecommunicative competence of their doctors. Specifically, we wanted to learn whetherthese patients viewed efforts to inform them and involve them in collaborativedecision making as appropriate.

Communicative Competence in Exchanges between Doctors and Chronically HI OlderPatients

Because communicative competence involves the use of behaviors that areeffective and considered appropriate by patients, the objectives of doctor-patientexchanges must be understood before levels of competence may be assessed. Whilerelational concerns are important, most researchers maintain that the primaryobjective in these conversations is information exchange (see Cegala, et al., 1996).More specifically, doctors are ethically and legally obligated to involve patients in thedecision making process and obtain informed consent before treating them(Beauchamp & Childress, 1994; Hines, Badzek, & Moss, 1997; Katz, 1984; President'sCommission, 1982).

If collaborative decision making represents an overall goal in medical exchanges,specific communicative actions may be identified that are necessary in order to accom-plish this goal. These include making the patient aware of their medical condition,disclosing potential benefits and side effects associated with the medical procedure inquestion and its alternatives (including nontreatment) so that the patient understandsall of his/her options, and allowing the patient to voluntarily select or refuse therecommended medical treatment (Beauchamp & Childress, 1994; Katz, 1984;President's Commission, 1982).

But while disclosure of medical condition, benefits and risks of alternatives, andinvolvement of the patient are all components of communicative effectiveness,doctors frequently fail to accomplish one or more of these tasks when relating witholder patients (Hines et al., 1997; Katz, 1984; Kodish & Post, 1995; Lo, McCleod, &Saika, 1986; SUPPORT, 1995). While this failure may be attributable to inappropriatestereotyping of elderly patients (Baltes & Wahl, 1996; Hummert, 1994; Ryan & Butler,1996) or to structural constraints that limit time with patients (Blumenthal, 1993), itis also possible that messages designed to accomplish these objectives may be viewed

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as inappropriate by the patients themselves. Determining the extent to which olderpatients viewed doctors' efforts to generate messages needed for collaborativedecision making as appropriate has clear implications for how communicativecompetence is defined in this context and for subsequent efforts to increase thecompetence levels of physicians. Because understanding one's medical condition andtreatment options is foundational to determining what treatment choices should bemade, patients must know this information. However, among chronically ill olderpatients, it is possible that this information might also be quite discouraging andunwanted (see Buckman, 1992). Prior research indicates that older patients have somereservations about this type of information, but that they normally want to beinformed of their medical status (Emmanuel, Danis, Pearlman, & Singer, 1995; High,1991), particularly if the information is presented in an acceptable manner andcontext. This led us to predict that:

HI : Chronically ill older patients will believe that doctors shoulddisclose information about their medical condition andtreatment options.

While involvement of patients in medical decision making is considered theethical norm, a growing body of evidence indicates that this type of active involvementis not wanted by at least some older adults (Emmanuel, Danis, Pearlman, & Singer,1995; Ende, 1989; High, 1991; Kjellstrand, 1992). Many of the same older patients whoreported a desire to be informed about their condition and treatment options alsoindicated that they wanted to leave decisions about how they should be treated up tomedical practitioners. Moreover, an intriguing study by Strull, Lo, and Charles (1984)found that doctors tend to underestimate patients' desire for information but tooverestimate patients' desire for involvement in the decision making process This ledus to predict that

H2: Chronically ill older patients will believe that it is lessappropriate to be actively involved in decisions about theirtreatment than it is to receive information about theircondition and treatment options.

While prior research provides a basis for each of these hypotheses, there is noevidence concerning relations between perceptions of what constitutes appropriatebehavior and other characteristics of older patients that are of theoretical and clinicalinterest For example, practitioners would benefit from more precise profiles ofpatients likely to want to play an active role in their diagnosis and treatmentMoreover, communication theorists interested in developing better explanations forwhy important health communication behavior is viewed by patients as appropriateor inappropriate would profit from more information concerning differences in howthese behaviors are perceived, particularly among populations such as older adultswho have received comparatively less attention thus far. To obtain this type ofinformation we asked the following question:

RQ1: Are there relationships between desire for medicalinformation and involvement in medical decisions and

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factors such as physical and mental condition, age, educationlevel, sex, and marital status?

To answer this question and test the hypotheses which preceded it, we conductedthe following study.

METHODSPopulation

The population was defined as all hemodialysis patients age 65 or older receivingtreatment at dialysis units within three mid-Eastern states. Because older dialysispatients have one or more chronic medical conditions which have resulted inextensive experience communicating with nurses and doctors, this population wasideal for our study's purposes. Better understanding what constitutes communicativecompetence for these patients can allow for stronger generalizations aboutcommunicative competence to other groups of individuals who also are older andchronically ill. Moreover, because almost one half of U.S. dialysis patients are at least65 years old and because the federal government will spend well over three billiondollars to pay for these patients' dialysis treatments (Nissenson, 1993; NationalInstitutes of Health, 1994), our target population is of considerable social andeconomic importance as well.

SampleSample design. We used a modified three-stage cluster design to sample 142

hemodialysis patients. Stage one consisted of identifying 23 hemodialysis units withinan 80- mile radius of Morgantown, WV. This area included northern and north-centralWest Virginia, western Maryland, and southwestern Pennsylvania, including thePittsburgh area. All but two of the 19 unit directors we contacted allowed us to conductinterviews in their units, hi stage two we randomly selected the dates and timesinterviewers would visit all 17 consenting units, hi each unit we conducted interviewson at least two of the three scheduled dialysis shifts and on either one or two randomlyselected days. The third stage of our cluster sample involved selecting from among theeligible patients receiving dialysis on each shift While a majority of the patients overage 64 on each shift were interviewed, our sample did not include any patients who inthe judgment of the unit nurses or the interviewer were too seriously ill to engage inoral communication.

Sample demographics. Of the 157 patients we approached, 142 (90%) agreed toparticipate. Of these, half (51%) were male, 87% were white, and 12% were black. Themean age was 74 and mean level of education was 11th grade. Participants hadreceived dialysis for an average time of 35 months and reported experiencing anaverage of four other serious medical problems. The samples of men and women werenot significantly different with respect to race, education, or age. However, only 42%of the women were married, as opposed to 73% of the men (chi square [1] = 13.99, p <.001, N = 138).

Interviewing ProceduresWe trained and supervised two interviewers who conducted face-to-face, 45-

minute interviews with patients who were receiving a hemodialysis treatment Afterobtaining informed consent and promising to keep all responses confidential, the

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interviewers asked participants a series of questions concerning their understandingsof communicative competence, demographic and psychographic information, andother variables not directly relevant to this essay. Most patients appeared toappreciate the opportunity to discuss their experiences; only seven indicated thatanswering the questions made them somewhat or very uncomfortable.

QuestionnaireDevelopment. We conducted in-depth, open-ended interviews of 16 older dialysis

patients to better understand the life experiences of our target population. Followingthese interviews we constructed and pretested two preliminary versions of thequestionnaire. These steps led to the final questionnaire, which included the followingmeasures relevant to the present study.

Measures of desire for information about medical condition and treatment options. Sixquestions were used to determine whether participants wanted doctors to revealinformation about their medical condition and treatment options. Patients were askedto indicate their level of agreement with the statements, "It is okay for doctors to lie ifthe lies will make the patient feel better" (statement one), "If a doctor thinks a patientis dying of an untreatable disease, s/he should tell this to the patient as soon aspossible" (statement two), "doctors should try to convince dialysis patients that theyare doing well even if they are really doing poorly" (statement three), "Doctors shouldtell dialysis patients about all of their options instead of just the option they think isbest" (statement four), "If a doctor isn't sure what s/he should do, s/he should tell thisto the patient even if it may make the patient worried" (statement five), and "Ifinformation is likely to make a patient discouraged, the doctor should not give theinformation to the patient" (statement six). For each measure, response categoriesranged from strongly agree (coded one) to strongly disagree (coded five). However,because distributions of responses were very bimodal, responses were recoded aseither endorsing a response consistent with patient participation (coded 1; i.e. agreeingwith statements two, four, and five or disagreeing with statements one, three, and six)or as not endorsing a response consistent with patient participation (coded 0; i.e. notagreeing with statements two, four, and five or not disagreeing with statements one,three, and six). The reliability for the combined measure (Cronbach's alpha = .39) waslower than expected, probably due to the exploratory nature of the research, the use ofa limited number of dichotomous measures, and the use of a sample whose levels ofcognitive impairment were unexpectedly high. Because reliability of the combinedmeasure was low, tests of our hypotheses were conducted on individual measures aswell as the combined scale. Moreover, because low reliabilities reduce the size ofobserved relationships with other variables (Cohen & Cohen, 1983, pp. 67-70), the neteffect of the low reliability was to make the confirmation of our hypotheses moredifficult.

Measures of desire for patient involvement. To assess the level of involvement thatrespondents believe is appropriate, patients were asked to indicate their agreementwith six statements, all of which were coded using the procedures described above.Patients indicated if they agreed with statements that, "When dealing with issues ofstarting and stopping dialysis, doctors should tell patients what is best for them to do,""Doctors don't need the opinions of dialysis patients when they decide how to treatthem," "Good patients do what their doctor tells them to do and don't ask lots ofquestions about their doctor's orders," "When doctors have to ask their patients lots

Being Involved or Just Being Informed 273

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of questions, it's usually because they don't know what they are doing," "If a patientfeels like stopping dialysis, if s the doctor's job to convince them to stay on dialysis,"and "Even if you disagree with something the doctor tells you, if s not your job to arguewith the doctor or find out why he told it to you." Again, initial responses were recodedas either endorsing a response consistent with patient participation (coded 1; i.e.disagreeing with each of the six statements) or as not endorsing a response consistentwith patient participation (coded 0; i.e. not disagreeing with each of these statements).Internal consistency reliability for this measure was .50.

Measures of patient characteristics. Participants were asked to report their sex, theyear in which they were born, which was recoded to produce a measure of age, theirmarital status (coded as married or not currently married), and the number of years offormal education they had completed. In addition, patients completed the MiniMental Status Exam (MMSE), a 30-item measure of cognitive functioning withestablished reliability and validity (Folstein, Anthony, Parhad, Duffy, & Gruenberg,1985; Folstein, M., Folstein, S., & McHugh, 1975; Launer, Dinkgreve, Jonker, Hooijer, &Lindeboom, 1993). They also responded to the 10-item Activities of Daily Living (ADL)measure, an established measure of physical mobility (Julius, et al., 1989). Internalconsistency reliabilities, as assessed using Cronbach's alpha, was .82 for the MMSE and.83 for the ADL.

Data AnalysisHypothesis one predicted that a majority of respondents would agree with each of

the statements regarding a desire for information about their medical condition. Thiswas tested using a series of chi-square tests to determine if the number of respondentswho agreed with each statement was significantly greater than 50% of the respond-ents. The second prediction was tested using a paired t-test to determine if agreementwith the six statements about involvement in medical decision making wassignificantly lower than the level of agreement with the six statements dealing withbeing informed.

Our research question was answered using Pearson's correlations to explorerelationships between desire for information and involvement in medical decisionmaking and the variables of age, education, cognitive capacity, and physical statusand independent t-tests to determine if sex and marital status were related toinformation and involvement preferences. All tests used the .05 significance level andwere two-tailed.

RESULTSHypothesis one. We predicted in hypothesis one that a majority of older dialysis

patients would want information from their doctors about their current medicalcondition and treatment options. As expected, significantly more respondents agreedthan disagreed with each of the statements indicating a desire for medical information(all chi squares > 4.29, p's < .04). As Table 1 reveals, approximately 75% of the patientsendorsed positions on each of the six statements that indicated a desire to be informedabout their condition and treatment options. The percentages who took positions insupport of informing patients ranged from a high of 94% (who agreed that patientsshould be told about all treatment options), to a low of 63% (who believed doctorsshould provide information even if it discouraged patients).

On a scale ranging from zero (all responses opposed informing patients about their

274 Hines, Moss and Badzek

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condition or options) to six (all responses supported informing patients), the mean scorewas 4.52 (SD=1.23, N=134). Seventy-seven members (57% ) of our sample had a score offive or six on this combined measure. While the percentage of participants who believedthat informing patients about their condition may be somewhat lower than would

TABLE 1

Patient beliefs about the appropriateness of being informed about condition and options

Type of communicative behavior Agree Don't agree

1) Doctors shouldn' t lie about the patient's

condition to make them feel better 104 (76%) 32 (24%)2) Doctors should tell patients as soon as

possible if they are dying of untreatable disease 100(74%) 36(26%)3) Doctor's shouldn't try to convince patients who

are doing poorly that they are doing well 103(76%) 33(24%)4) Doctors should tell patients about all options,

not just the one they think is best 129(94%) 8 (6%)5) If the doctor isn't sure what to do, s/he should tell

the patient even if it creates worry 94(69%) 42(31%)6) If information is likely to create discouragement,

the doctor should give it to the patient anyway 86(63%) 51(37%)Statements one, three, and six are reworded here so that agreement with each statement reflects a desirefor information about the patient's medical condition.

probably be found in the general population, these results are fully consistent with theprediction we made in hypothesis one.

Hypothesis two. Our second hypothesis predicted that seriously ill older patientswould have less interest in being involved in making decisions than they had in beinginformed about their condition. This expectation also was confirmed. As shown inTable 2, the percentages of patients who endorsed positions supporting patientinvolvement in medical decision making were considerably lower than than thosereported above. Only 9% of patients felt it was inappropriate for doctors to tell patientswho needed to make decisions about starting or stopping dialysis what was best forthem to do, despite the fact that determining what is "best" for individual patientsalmost always involves patient's personal value judgments. Moreover, only 16% feltthat it was inappropriate for doctors to convince a patient to change a decision theyhad made to stop dialysis.

On a scale ranging from zero (all responses opposed involving patients in medicaldecision making) to six (all responses supported patient involvement), the mean scorewas just 3.02 (SD = 1.35, N = 135). Only thirteen members (9%) of our sample had ascore of five or six on this combined measure. A paired t-test revealed that the averagescore on the combined measure of desire for information was significantly higher thanthe average desire for involvement score (r (133) = 9.38, f < .001). And because thecorrelation of these two combined measures was not statistically significant (r = .15, p> .09, N = 134), patients' desire for information about their medical condition does notappear to be related to their desire to be actively involved in the medical decision

Being Involved or Just Being Informed 275

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12(9%)

100(74%)

92(68%)

93(68%)

21(16%)

125(91%)

36(26%)

44(32%)

43(32%)

114(84%)

TABLE 2Patient beliefs about the appropriateness of being involved in medical decision making

Type of communicative behavior Disagree Don't disagree

1) When dealing with issues of starting and stopping dialysisdoctors should tell patients what is best for them to do

2) Doctors don't need the opinions of patients indeciding how to treat them

3) Good patients do what they are told to do anddon't ask lots of questions about their doctor's orders

4) When doctors have to ask lots of questions, it'susually because they don't know what they are doing

5) If a patient feels like stopping dialysis, it's thedoctor's job to convince them to stay on dialysis

6) Even if you disagree with something the doctor tells you,it's not your job to argue with him/her or try to find outwhys/he told it to you 89(66%) 46(34%)

Disagreement with each statement reflects a desire for patients to be actively involved in the process ofmedical decision making.

making process. Collectively, this information provides strong support for hypothesistwo.

Research qties turn. Our research question sought to determine if patient characteristicswere associated with their perceptions of whether it was appropriate for doctors toinform patients about their medical condition and treatment options and to involvepatients in medical decision making. As table three reveals, several characteristics weresignificantly associated with patient beliefs about whether they should be involved inmaking medical decisions. Patients who were older, had less formal education, and whohad lower levels of cognitive capacity, as measured by the MMSE, were less likely tobelieve that they should be actively involved in the medical decision making process.

TABLE 3Relations between patient characteristics and desire for medical information and involvement

( 1 ) Information about condition and options(2) Invol vement in medical decision making(3) Participant's age(4) Participant's education level(5) Mini Mental Status Exam score(6) Activities of Daily Living score

(1)

1.00

(2)

.151.00

' (?)

-.16-.24**1.00

(4)

.12

.35**-.121.00

(5)

.21*

.29**-.17.24**

1.00

(6)

-.01.08

-.10-.0236**1.00

*p_<.05 * * E < . 0 1

Higher scores represent a desire for more information, for more involvement, greater cognitive capacity,and greater physical ability.

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Together these three variables explained almost 20% of thef variance in the measure ofinvolvement beliefs (F (3,128) = 9.95, p < .0001; R2 = .19).

Cognitive capacity was the only patient characteristic with a statisticallysignificant association with preferences about being informed about medicalcondition and treatment options, but this association was relatively small (r = .21,p < .02). Neither marital status or sex were associated with beliefs about either beinginformed or being involved in decision making.

DISCUSSIONResults from our study suggest the need to refine conceptions of communicative

competence when health care providers interact with seriously ill older patients. Priorresearch that has examined the expectations of healthier and younger individuals hasshown that a substantial majority of those individuals do want to be thoroughlyinformed about their medical condition and the options for treating it, and that theyalso want to be active participants in medical decision making. Our results suggest thatwhat constitutes communicative competence may differ in important ways whenhealth care providers converse with older, seriously ill individuals.

As predicted in hypothesis one, we did find that a majority of our sample of olderdialysis patients wanted to be informed about their condition and how it might betreated. However, for each of our six measures of this construct, roughly 25% of therespondents did not agree that it was appropriate for patients to be given informationthat is commonly regarded as essential to obtaining informed consent Moreover,roughly half of our sample failed to endorse the appropriateness of two or more of thesix communication behaviors related to informing patients. These results suggestconsiderable variance in how communicative competence is conceptualized amongolder individuals who are seriously ill and also suggests that many such persons mayexperience ambivalence concerning what they wish to be informed about

Results obtained in answer to our research question indicate that differences inperceptions of what information should be disclosed to patients are not stronglyrelated to a number of patient characteristics, including sex, marital status, age,education level, and level of cognitive and physical functioning. This result reinforcesthe claims made by others (Baltes & Wahl, 1996; Hummert, 1994; Ryan & Butler, 1996)that age-related stereotypes are not useful in determining the most appropriatecommunication strategies to use in conversation. Instead, the communicativepreferences of seriously ill older adults may most effectively be determined throughdirect conversations with them and members of their families.

The confirmation of hypothesis two provides further corroboration of earlierresearch (Srull, Lo, & Charles, 1984) which found that patients are more interested inbeing informed than they are in being involved in the process of medical decisionmaking. Our study found that seriously ill, older dialysis patients were substantiallyless interested in participating in decisions about their treatment than they were inbeing informed. The average sample member agreed with only half of the sixstatements about the appropriateness of patient involvement in decision making; only9% of the sample endorsed five or all six of these statements.

We found it interesting that age, educational level, and level of cognitivefunctioning accounted for 19% of the variance in patients' beliefs about theappropriateness of involving themselves in decision making, particularly because nosuch relationship was found for the desire to be informed. One interpretation of this

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result is that patients with diminished cognitive capacity, minimal formal schooling, andconsiderable age may perceive themselves as less capable of assuming an active role intheir medical treatment by asking questions or by making choices about their care. Whilefurther research is needed to explore this possibility, our study does imply thatit may beparticularly critical to determine how active a role very aged patients with little formalschooling and reduced cognitive capacity wish to play in the decision making process.

More generally, our findings suggest that communicative competence in interactionswith chronically ill, older adults cannot be defined by any absolute standard that fails toaccount for the communicative expectations which these individuals may hold. Becausemany older patients endorse communication behaviors that are viewed as inconsistentwith good decision making by most health professionals and other patients, efforts toassign blame for "poor" communication between these groups are more complex thansome might believe (Hines, Babrow, Badzek, & Moss, 1997). In fact, it appears thatcommunication behaviors that are commonly regarded as essential for effectivecommunication by health care providers and health communication researchers are alsoregarded by many chronically ill older patients as inappropriate.

More creative recommendations are needed to circumvent this potential dilemma.One possible solution might involve efforts to educate chronically ill older adults so thatthey understand the importance of their active participation in collaborative decisionmaking. A second alternative would be to train physicians to adapt their communicationbehavior to the preferences of older adults by asking questions such as, "How muchinformation would you like to receive about your medical condition?/' "How would youlike decisions about your treatment to be made?," and "Do you want the physicians tomake recommendations that you accept or refuse or do you want them to do what I thinkis best?" (see Buckman, 1992, p. 74; President's Commission, 1982, pp. 96-98). A finalalternative might involve redefining what constitutes effective communication withchronically ill older adults. While all such patients who want information andinvolvement in decision making should certainly be given that option, many olderpatients, if given the option, may prefer that decision making for them rely moreextensively on communication with their family or other designated decision makerssuch as a trusted friend. These alternatives might be most effective in avoiding medicalpaternalism while simultaneously respecting patient attitudes and values regardingcommunication.

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