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Advance Directives Might Curb Cost of End-of-Life Care

By Serena Gordon
HealthDay Reporter

TUESDAY, Oct. 4 (HealthDay News) -- Depending on where you live, having an advance directive may raise the odds that you'll receive hospice services and reduce the overall cost of your end-of-life care, a new study indicates.

An advance directive, sometimes called a living will, is a legal document that expresses your wishes for the type of care you would like to receive should you become unable to make such decisions yourself.

"The most important finding from our study is the evidence that advance directives can be very important in shaping the care that's provided to patients," said study author Lauren Hersch Nicholas, a health economist at the Institute for Social Research at the University of Michigan, in Ann Arbor.

The findings are published in the Oct. 5 issue of the Journal of the American Medical Association.

End-of-life care is often a controversial subject, and when policymakers are looking for ways to control Medicare costs, such care typically comes up in the discussion. That's not surprising, because end-of-life care accounted for more than one-quarter of Medicare spending last year, according to background information in the study. One concern is that this spending may be largely earmarked for aggressive care that's not necessarily what the patient might have wanted.

And, that's where advance directives can be useful. They allow patients to document their wishes, whether they want all life-sustaining measures to be taken or if they'd prefer to avoid such procedures.

The study authors noted that there's also a wide variation in the amount spent on end-of-life care, depending on the area you live in the United States. For example, according to 2003-2007 data from the Dartmouth Atlas of Health Care, regions such as the more densely populated areas of the Northeast, Texas and California spend much more on caring for people in their last 2 years of life than do areas such as the rural Midwest.

So, the Michigan researchers wanted to see what effect advance directives might have on end-of-life treatments and costs by region.

Their study included information on more than 3,300 Medicare beneficiaries from the Health and Retirement Study. The data was gathered prospectively between 1998 and 2007, and it was linked to Medicare claims information and the National Death Index.

The researchers found that in areas where end-of-life care costs were normally high, having an advance directive significantly lowered the cost of care. On average, end-of-life care spending was $5,585 less per person in the high-spending regions when someone had an advance directive.

Having an advance directive didn't change end-of-life care costs in regions that were already considered low- or medium-spending areas for end-of-life care.

"We found that for people in some parts of the country -- those who live in regions classified by more aggressive, expensive end-of-life care -- there was a very pronounced difference in outcomes for those who had a living will," said Hersch Nicholas. "They were much more likely to receive palliative care, much less likely to die in the hospital, and Medicare spending on these patients was about $5,000 lower than on patients who didn't have an advance directive."

As to why an advance directive didn't appear to change much about end-of-life care in lower-spending regions, Hersch Nicholas said these areas may have come up with ways to rein in more aggressive end-of-life care.

Another important finding, she said, was that having an advance directive didn't necessarily limit the initiation of aggressive treatments, but seemed to lead to their earlier withdrawal.

Hersch Nicholas said this finding was particularly important because some people make the argument that having an advance directive might limit all of the care you receive at the end of your life. But, this finding shows that while treatments are often started, for "patients with an advance directive, there's an earlier recognition of when treatments aren't working and when it's time to go to hospice."

"Advance directives do serve as a helpful tool, but they're not a perfect tool. What you say you want today might be different from what you want another day. But, an advance directive gives permission for family members to withhold care when there's no reason to think that more medical treatments might help, and to do what will make this person more comfortable," said Dr. Tia Powell, director of the Montefiore-Einstein Center for Bioethics, and director of the Einstein-Cardozo Masters of Science in Bioethics in New York City.

"There remains a disconnect between practice patterns regarding [end-of-life care] in different parts of the country. We still have a lot of distance to cover in terms of providing the level of sensitive, individualized care for the elderly and the ill in the U.S.," Powell said. "There can be benefits from advance directives, and also from providing appropriate care and not wasting money."

More information

Learn more about advance directives from the American Academy of Family Physicians.

SOURCES: Lauren Hersch Nicholas, Ph.D., health economist, Institute for Social Research, University of Michigan, Ann Arbor, Mich.; Tia Powell, M.D., director, Montefiore-Einstein Center for Bioethics, and director, Einstein-Cardozo Masters of Science in Bioethics, New York City; Oct. 5, 2011, Journal of the American Medical Association

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