Advance Directives and the Cost of Terminal Hospitalization

Weeks, William B.

doi:10.1001/archinte.1994.00420180085010

Cited by 47 publications

(28 citation statements)

References 9 publications

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Section: Discussionmentioning

confidence: 99%

“…L ife-sustaining treatment decisions made for unconscious patients in the absence of advance directives are often assumed, first, to be discordant with individuals' prior preferences, 1 and second, to result in more treatments at the end of life than patients would have wanted. [2][3][4][5] Actual data on life-sustaining treatment practices have not been available to challenge or support either of these assumptions.Surrogate decisions about eventual end-of-life care often differ from patients' own stated preferences, 6,7 which is indirect evidence that the first assumption is valid. A more definitive assessment could be obtained by directly measuring the concordance between actual treatment practices and individuals' own advance preferences for care.…”

mentioning

confidence: 99%

“…[2][3][4][5] Actual data on life-sustaining treatment practices have not been available to challenge or support either of these assumptions.…”

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confidence: 99%

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Comparing utilization of life-sustaining treatments with patient and public preferences

Alpert

Emanuel

1998

J Gen Intern Med

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OBJECTIVE:The movement for advance planning of endof-life care was motivated in part by the assumption that medical intervention for terminally ill patients varies from what these patients would prefer. We examined the validity of this assumption by comparing actual life-sustaining treatment practices for patients in critical illness scenarios and surveyed patients' advance care preferences. MEASUREMENTS AND MAIN RESULTS:We selected at random and reviewed 7,400 inpatient medical records from a single urban teaching hospital during the period just prior to the Patient Self-Determination Act. Records of 198 patients with conditions that matched advance directive scenarios were examined, and practices to withhold or withdraw seven life-sustaining treatments were documented. Practices were compared with surveyed preferences of 102 members of the general public and 495 outpatients who were followed by the same physicians as the 198 patients. Concordance of practices and preferences for the 19 surveyed outpatients who eventually fell into one of the scenarios was also evaluated. One hundred sixty-seven inpatient cases met review criteria for the scenario coma with a small chance of recovery . Hospital patients received medical interventions that were not consistently greater or less than the preferences of the surveyed outpatients or members of the general public. Resuscitation, the most frequently withheld treatment (94% of cases), was withheld more often than surveyed preferences to decline it (56% of outpatients, p Ͻ .001). Four treatments-mechanical breathing, artificial nutrition, major surgery, and hemodialysis-were utilized comparably to surveyed outpatients' preferences (range p ‫؍‬ .704-.055). Antibiotics and artificial hydration were withheld (9% and 6%, respectively) less often than surveyed outpatient's prior preferences to decline them (48% and 52%, respectively, p Ͻ .001 for each). Conversely, treatments given to the 19 surveyed patients who subsequently developed one of the illness scenarios were often incongruent with the patients' prior preferences. Again, in some cases more interventions were provided (26 of 63 declined treatments were given), and in some cases less (10 of 21 desired treatments were withheld). CONCLUSIONS:This study does not support the assumption that, collectively, patients' advance care preferences are less interventionist than actual practices for patients in corresponding scenarios. Nevertheless, these results do support the assumption that life-sustaining treatment decisions do not conform well to individual patients' specific preferences. Progress in end-of-life care should focus on shared decision making at the patient-proxy-physician level rather than on overall life-sustaining treatments utilization. L ife-sustaining treatment decisions made for unconscious patients in the absence of advance directives are often assumed, first, to be discordant with individuals' prior preferences, 1 and second, to result in more treatments at the end of life than patients would have wanted....

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Comparing utilization of life-sustaining treatments with patient and public preferences

Alpert

Emanuel

1998

J Gen Intern Med

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“…State with laws enhancing incentives for compliance with Patient SelfDetermination Act (PSDA,1990) Weeks et al, 1994 Record of an AD completed prior to a terminal hospital admission in retrospectively reviewed medical records Chambers et al, 1994 Record of an AD entered into patient notes within 48 hours of terminal hospital admission in retrospectively reviewed medical records…”

Section: Kessler and Mcclellan 2004mentioning

confidence: 99%

“…Several studies attempt to distinguish ACP from the documenting of medical decision-making in the last weeks and days of life, with two studies specifying that ADs should have been initiated prior to the index hospital admission Tan and Jatoi, 2011). Weeks et al (1994) also gather data about when these ADs were first established, finding it to be a median of eight months prior to hospital admission. similarly require that end of life discussions with a physician should have occurred prior to study enrolment, with participants enrolled onto the study an average of 6 months prior to death.…”

Section: Kessler and Mcclellan 2004mentioning

confidence: 99%

The economic evidence for advance care planning: Systematic review of evidence

2015

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Advance directives completion and hospital out‐of‐pocket expenditures

Zhu

Enguídanos

2022

Journal of Hospital Medicine

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Introduction: Health care costs remain high at the end of life. It is not known if there is a relationship between advance directive (AD) completion and hospital out-ofpocket costs. This analysis investigated whether AD completion was associated with lower hospital out-of-pocket costs at end of life.Methods: We used Health and Retirement Study participants who died between 2000 and 2014 (N = 9228) to examine the association between AD completion status and hospital out-of-pocket spending in the last 2 years of life through the use of a two-part model controlling for socioeconomic status, death-related characteristics and health insurance coverage.Results: About 44% of decedents had completed ADs. Having an AD was significantly associated with $673 lower hospital out-of-pocket costs, with a higher magnitude of savings among younger decedents. Decedents who completed ADs 3 months or less before death had higher out-of-pocket costs ($1854 on average) than those who completed ADs more than 3 months before death ($1176 on average).Conclusions: AD completion was significantly associated with lower hospital out-ofpocket costs, with greater out-of-pocket savings among younger decedents. Early AD completers experienced lower costs than decedents who completed ADs closer to death.

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Advance Directives and the Cost of Terminal Hospitalization

Cited by 47 publications

References 9 publications

Comparing utilization of life-sustaining treatments with patient and public preferences

Comparing utilization of life-sustaining treatments with patient and public preferences

The economic evidence for advance care planning: Systematic review of evidence

Advance directives completion and hospital out‐of‐pocket expenditures

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