02/02/12

Advance directives specifying that patients don’t want aggressive treatment at the end of life limit interventions and their costs only in regions where aggressive end-of-life care is common, according to a report in JAMA.

In contrast, in areas of the United States where end-of-life treatment is not aggressive, such treatment-limiting documents have little effect on the use of these interventions or on health care costs, said Lauren Hersch Nicholas, Ph.D., of the University of Michigan, Ann Arbor, and her associates.

These results suggest that “the clinical effect of advance directives is critically dependent on the context in which a patient receives care,” they noted.

Dr. Nicholas and her colleagues assessed end-of-life care for 3,302 Medicare beneficiaries who died between 1998 and 2007, at a mean age of 83 years. They calculated health care spending during the last 6 months of life across all care settings, including skilled nursing. The researchers selected patients who had lived in specific geographic regions that were characterized by low, medium, or high end-of-life health care expenditures.

Overall, 70% of the beneficiaries were hospitalized at least once during their final 6 months of life, 41% died in a hospital, and 61% had a living will or durable power of attorney.

For the study population as a whole, health care spending did not vary according to whether or not a patient had an advance directive.

“When patients in high-spending areas had advance directives limiting treatment, they averaged significantly lower end-of-life Medicare spending, were less likely to have an in-hospital death, and had significantly greater odds of hospice use than [did] decedents without advance directives in these regions,” Dr. Nicholas and her associates said (JAMA 2011;306:1447-53).

In contrast, advance directives had no effect on end-of-life care or on end-of-life expenses among patients in medium- or low-spending regions.

“One interpretation of these data is that advance directives are most effective when one prefers treatment that is different from local norms. Thus, in high-intensity regions, more-limited treatment requires an explicit statement,” the investigators noted.

“We urgently need studies to examine the extent to which greater advance directive use in high-intensity regions would result in treatment that is more concordant with patient preferences and to understand the patient, physician, and health system characteristics that lead to higher rates of use,” they added.

Dr. William Smucker, CMD, medical director at Altenheim Nursing Home in Strongsville, Ohio, commented, “For patients who wish to exert an autonomous choice about how much treatment they receive at the end of life, advance directives that include information about limiting treatment seem to be able to help their loved ones and treating practitioners to limit the duration of intensive care interventions, enroll in hospice, and transfer care out of the hospital. This is a great benefit for patients and families regardless of whether health care expenditures are decreased. What remains is to determine the best way for an individual to characterize and record their goals, values, and preferences. Most current advance directives do not contain adequate information or direction to help guide decisions. One advance directive that can include guidance for limiting treatment is the POLST form, and I have found that to be a useful tool for framing treatment choices.”

In an editorial, Dr. Douglas B. White and Dr. Robert M. Arnold commented, “A more potent approach to improving end-of-life care may come through innovative strategies to change medical norms.”

Dr. White is in the department of critical care medicine at the University of Pittsburgh and Dr. Arnold the university’s section on palliative care and medical ethics.


Mary Ann Moon is a freelance writer based in Clarksburg, Md.

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