Effects of Offering Advance Directives on Medical Treatments and Costs
▪ Objective: To examine the effects of advance directives on medical treatments and on patient satisfaction and well-being and to determine whether the enhancement of patient autonomy through advance directives provides a more ethically feasible approach to cost control than does the imposition of limits through rationing.
▪ Design: Randomized, controlled trial.
▪ Setting: University and Veterans Affairs medical center.
▪ Patients: Two hundred and four patients with life-threatening illnesses, 100 of whom died after enrollment in the study.
▪ Intervention: Patients randomly assigned to the experimental group were offered the California Durable Power of Attorney (a typical proxy-instruction directive), and patients assigned to the control group were not offered the advance directive. Hospital admissions were monitored to assure that a summary of the document was present in the active medical record at each hospitalization.
▪ Measurements: Cognitive function, patient satisfaction, pyschological well-being, health locus of control, sense of coherence, health-related quality of life, receipt of medical treatments, and medical treatment charges.
▪ Results: No significant differences were found between advance-directive and control groups regarding psychosocial variables, health outcome variables, and medical treatments or charges. Patients offered an advance directive had an average hospital stay of 40.8 days (95% CI, 32.2 to 49.4 days), compared with an average of 33.1 days (95% CI, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of $19 502 (95% CI, $13 030 to $25 974) for medical treatments in the last month of life compared with $19 700 (95% CI, $13 704 to $25 696) for controls.
▪ Conclusions: Despite claims that public demand for longer life accounts for rising medical costs, most surveys suggest that patients are calling for less, not more, of the expensive, high-technology treatment often used in terminal phases of illness. Executing the California Durable Power of Attorney for Health Care and having a summary copy placed in the patient's medical record had no significant positive or negative effect on a patient's well-being, health status, medical treatments, or medical treatment charges.
Schneiderman Land Arras J. Counseling patients to counsel physicians on future care in the event of patient incompetence. Ann Intern Med. 1985;102:693-8. LinkGoogle Scholar
- 2. Omnibus Reconciliation Act 1990. Title IV. Section 4206. Congressional Record, October 26, 1990:12638. Google Scholar
Callahan D. What Kind of Life: The Limits of Medical Progress, New York: Simon and Schuster; 1990:80. Google Scholar
Taylor H. Withholding and withdrawal of life support from the critically ill. N Engl J Med. 1990;322:1891-2. CrossrefMedlineGoogle Scholar
Schneiderman L, Pearlman R, Kaplan R, Anderson J, and Rosenberg E. Relationship of general advance directive instructions to specific life-sustaining treatment preferences in patients with serious illness. Arch Intern Med. [In press.] Google Scholar
Shmerling R, Bedell S, Lilienfeld A, and Delbanco T. Discussing cardiopulmonary resuscitation: a study of elderly outpatients. J Gen Intern Med. 1988;3:317-21. CrossrefMedlineGoogle Scholar
Everhart Mand Pearlman R. Stability of patient preferences regarding life-sustaining treatments. Chest. 1990;97:159-64. CrossrefMedlineGoogle Scholar
Danis M, Southerland L, Garrett J, Smith J, Hielema F, and Pickard C. A prospective study of advance directives for life-sustaining care. N Engl J Med. 1991;324:882-8. CrossrefMedlineGoogle Scholar
Emanuel L, Barry M, Stoeckle J, Ettelson L, and Emanuel E. Advance directives for medical care—a case for greater use. N Engl J Med. 1991;324:889-95. CrossrefMedlineGoogle Scholar
Danis M, Patrick D, Southerland L, and Green M. Patients' and families' preferences for medical intensive care. JAMA. 1988;260:797-802. CrossrefMedlineGoogle Scholar
Buchanan Aand Brock D. Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge: Cambridge University Press; 1989. Google Scholar
- 12. Current Opinions of the Council on Ethical and Judicial Affairs of the American Medical Association. Chicago: American Medical Association; 1989:2.20, 2.21. Google Scholar
Orentlicher D. Advance medical directives. JAMA. 1990;263:2365-7. CrossrefMedlineGoogle Scholar
- 14. American Academy of Neurology. Resolution on legislation regarding durable power of attorney for health care. Minneapolis: American Academy of Neurology; 1989. Google Scholar
- 15. The Hastings Center. Guidelines on the termination of life-sustaining treatment and the care of the dying. Bloomington: Indiana University Press; 1987. Google Scholar
- 16. California Code. 1987 Supplement. 1985. Article 5, Sections 2430-2444. Google Scholar
Zelen M. A new design for randomized clinical trials. N Engl J Med. 1979;300:1242-5. CrossrefMedlineGoogle Scholar
Folstein M, Folstein S, and McHugh P. Mini-Mental State: a practical method from grading the cognitive state of patients for the clinician. J Psych Res. 1979;12:189-98. CrossrefGoogle Scholar
DiMatteo Mand Hays R. The significance of patients' physician contact: a study of patient satisfaction in a family practice center. J Community Health. 1980;6:18-34. CrossrefMedlineGoogle Scholar
Wan Tand Liveratos B. Validating a general well-being index by clinical measures of health. Gerontologist. 1977;17:129-30. Google Scholar
Fazio A. A concurrent validational study of the NCHS General Weil-Being Schedule. Vital Health Statistics, Series 2, 1977. Google Scholar
Wallston K, Wallston B, and DeVellis R. Development of the multidimensional health locus of control scales. Health Education Monographs. 1976;16:160-70. Google Scholar
Antonovsky A. Health, Stress and Coping: New Perspectives on Mental and Physical Well-Being. San Francisco: Jossey-Bass; 1981. Google Scholar
Kaplan Rand Anderson J. The general health policy modes: an integrated approach. In: Spilker B, ed. Quality of Life Assessments in Clinical Trials. New York: Raven, 1990:131-49. Google Scholar
Kaplan Rand Anderson J. A general health policy model: update and applications. Health Serv Res. 1988;23:203-35. MedlineGoogle Scholar
Kaplan R, Bush J, and Berry C. Health status: types of validity for an index of well-being. Health Serv Res. 1976;11:478-507. MedlineGoogle Scholar
Anderson J, Bush J, and Berry C. Classifying function for health outcome and QOL evaluation: self versus interviewer modes. Med Care. 1986;24:454-69. CrossrefMedlineGoogle Scholar
Kaplan R, Anderson J, Wu A, Mathews W, Kozin F, and Orenstein D. The quality of well-being scale: applications in AIDS, cystic fibrosis, and arthritis. Med Care. 1989;27(Suppl 3):S27-S43. CrossrefMedlineGoogle Scholar
Kaplan R. Quality of Life Assessment. In: Karoly P, ed. Measurement Strategies in Health Psychology. New York: Wiley; 1985:115-46. Google Scholar
Langer R, Wark R, Schneiderman L, Kaplan R, Anderson J, and Chen M. A research-oriented medical cost accounting system. Int J Biomed Comput. 1991;28:161-7. CrossrefMedlineGoogle Scholar
Scitovsky A. The high cost of dying: what do the data show? Milbank Memorial Fund Quarterly/Health and Society. 1984;62:591609. Google Scholar
Lubitz Jand Prihoda R. The use and costs of Medicare services in the last two years of life. Health Care Financ Rev. 1984;5:117-31. MedlineGoogle Scholar
Bedell Sand Delbanco K. Choices about cardiopulmonary resuscitation in the hospital: when do physicians talk with patients? N Engl J Med. 1984;310:1089-93. CrossrefMedlineGoogle Scholar
Uhlmann R, Pearlman R, and Cain K. Understanding of elderly patients' resuscitation preferences by physicians and nurses. West J Med. 1989;150:705-7. MedlineGoogle Scholar
Uhlmann R, Pearlman R, and Cain K. Physicians' and spouses' predictions of elderly patients' resuscitation preferences. J Gerontol. 1988;43:M115-21. CrossrefGoogle Scholar
Seckler A, Meier D, Mulvihill M, and Paris B. Substituted judgment: how accurate are proxy predictions? Ann Intern Med. 1991;115:92-8. LinkGoogle Scholar
Emanuel Land Emanuel E. The medical directive: a new comprehensive advance care document. JAMA. 1989;261:3288-93. CrossrefMedlineGoogle Scholar
Brett A. Limitations of listing specific medical interventions in advance directives. JAMA. 1991;266:825-8. CrossrefMedlineGoogle Scholar
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Lawrence J. Schneiderman,
From the University of California, San Diego, California. For current author addresses, see end of text.