Advance Directives Help Assure End-of-Life Wishes Are Honored
WEDNESDAY March 31, 2010 -- When people prepare advance directives, such as a living will or a durable power of attorney for health care, most will receive the type of medical care that they've requested as they near the end of their lives, a new study suggests.
The study also found that 30 percent of people required another person to make decisions for them at the end of life. This highlights the need to prepare some kind of advance directive and to discuss end-of-life care wishes with your loved ones before you get sick, the study authors said.
"We conducted an observational study of elderly across the United States, and probably the single most interesting finding was that 29.8 percent needed some form of medical decision-making on their behalf before they died," said the study's lead author, Dr. Maria J. Silveira, a clinician/scientist at the Veterans Affairs Center for Clinical Management Research and an assistant professor of internal medicine at the University of Michigan.
In the group that needed someone to make decisions for them, nearly 70 percent had completed an advance directive, according to results of the study, published in the April 1 issue of the New England Journal of Medicine.
Another study in the same issue of the journal also underscored the need for advance planning for end-of-life care. It found that during the last year of life, fewer than one in five people has no disability that interferes with daily living activities. Over the 10-year study period, nearly 50 percent of the study's older adult participants, who had been healthy and had no disabilities at the start of the study, had a progressive or persistently severe disability. The researchers said these disabilities didn't follow a common pattern and would be difficult to predict ahead of time.
Advance directives are documents that list your end-of-life care wishes (a living will) or who you would like to make those decisions for you if you are incapacitated (durable power of attorney for health care).
Silveira said that whenever someone enters a hospital or care facility, he or she is given the opportunity to complete an advance directive, which is one reason why so many elderly people may have these documents.
The problem, however, is that many people will designate a health-care proxy or prepare a living will and then tuck the document away without discussing it.
"People need to have conversations with the person they've appointed, not just put the document in a locked safe deposit box," said the author of an accompanying editorial in the same issue of the journal, Dr. Muriel R. Gillick, a clinical professor in the department of population medicine at Harvard Pilgrim Health Care Institute and Harvard Medical School in Boston.
Silveira's study included 3,746 people over 60 years old who died between 2000 and 2006. The vast majority of people with living wills -- 92.7 percent -- wanted only limited care at the end of their lives. Slightly more than 96 percent said they'd prefer comfort care. Only 1.9 percent requested all care possible.
The researchers found that 83.2 percent of those who requested limited care and 97.1 percent who asked for comfort care received the care they requested.
"People should be reassured [that] if they complete advance directives, they get what they want most of the time," Silveira said.
Gillick said she recommends designating a health-care proxy to make decisions for you, and to have a non-legal letter expressing your more specific wishes for medical care. She said the problem with many living wills is that they're too generic.
In her editorial, Gillick said, "The ongoing challenge is to transform advance care planning from the act of signing a form to a process that begins by clarifying the patient's current health status, moves to elicitation of the goals of care, and then designates a proxy to work with clinicians and interpreting and implementing these goals."
She suggests a better way to begin these discussions might be to show people short videos of potential medical scenarios so they have a better understanding of the procedures.
Posted: March 2010
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