One of the things we’re trying to accomplish with this blog is to provide insight into the many factors that influence health status and outcomes. These include health behaviors, the social, economic, and physical environments and, of course, healthcare. This week we’re focusing on the quality and cost of healthcare at the end of life, and thinking specifically about how advance directives apply to population health. To shed some light on the topic, we interviewed the University of Michigan’s Dr. Maria Silveira about her April 1, 2010 New England Journal of Medicine article (subscription required) on Advance Directives and Outcomes of Surrogate Decision Making Before Death.
What are advance directives?
Advance directives usually document patients’ wishes for life-sustaining treatment in a living will, as well as their choice of a proxy decision-maker in a durable power of attorney for health care. Advance directives are sanctioned in all 50 states and can be completed for free without the aid of an attorney.
What was the motivation for doing this research?
My experience in palliative care didn't jibe with the growing belief, reinforced during the recent “death panel” debate, that advance directives are not necessary or useful.
What were the main findings of your study, and how did they differ from previous work?
A 1994 study indicated that only 21% of all seriously ill hospitalized patients had an advance directive. Our research shows that currently almost 60% of elderly have one.
Prior to our study, no one knew how many elderly adults might need others to make complex medical decisions on their behalf at the end of life. 30% of older adults need someone else to make decisions (i.e., they had lost decision-making capacity) about whether aggressive, limited, or comfort care should be provided at the end of life. Subjects who had living wills were more likely to want limited care (93%) or comfort care (96%) than all care possible (2%). We also found that among people who had prepared living wills and had also expressed a preference for or against all care possible, there was a strong agreement between their stated preference and the care they received.
Fisher and colleagues at Dartmouth assert that end of life expenditures are one category of spending that increase costs without increases in outcomes or quality of care. Is it possible that advance directives could save resources by respecting patient preferences about care?
Absolutely – there’s no worse way to waste money as a health system than on care that is unwanted. Still, I'm not sure that the advance directives are as important as the conversations that take place about future care. Certainly I believe that when physicians (especially primary care physicians) have these conversations, patients are less likely to be hospitalized and to receive unwanted care. That should translate into cost savings for the system, but most importantly, it prevents undue suffering upon patients and his/her families.
What are the policy implications of your study?
Our results suggest that helping patients prepare for a time when they cannot speak for themselves is important and worthwhile—policymakers and insurers should consider reimbursing physicians appropriately for this effort. Currently, advance care planning is an activity that goes unreimbursed for most physicians.
About a year ago, Representative Earl Blumenhauer (Oregon) proposed enhancing Medicare and Medicaid coverage of advanced illness management services and requiring physicians to provide Medicare beneficiaries with information on advance directives. The proposed legislation never made it out of committee (due to the controversy surrounding "death panels"). However, the Patient Protection and Affordable Care Act (PPACA) actually does contain a couple of small but relevant end of life provisions, including a 3-year demonstration project that will explore cost and quality implications of combining curative treatment and hospice care. Representative Blumenhauer is spearheading another effort to revive legislation that would allow for reimbursement of physician time to help patients plan for the future.
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