Does facilitated Advance Care Planning reduce the costs of care near the end of life? Systematic review and ethical considerations

Abstract

Background:While there is increasing evidence that Advance Care Planning has the potential to strengthen patient autonomy and improve quality of care near the end of life, it remains unclear whether it could also reduce net costs of care.Aim:This study aims to describe the cost implications of Advance Care Planning programmes and discusses ethical conflicts arising in this context.Design:We conducted a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.Data sources:We systematically searched the databases PubMed, NHS EED, EURONHEED, Cochrane Library and EconLit. We included empirical studies (no limitation to study type) that investigated the cost implications of Advance Care Planning programmes involving professionally facilitated end-of-life discussions.Results and discussion:Seven studies met our inclusion criteria. Four of them used a randomised controlled design, one used a before-after design and two were observational studies. Six studies found reductions in costs of care ranging from USD1041 to USD64,827 per patient, depending on the study period and the cost measurement. One study detected no differences in costs. Studies varied considerably regarding the Advance Care Planning intervention, patient selection and costs measured which may explain some of the variations in findings.Normative appraisal:Looking at the impact of Advance Care Planning on costs raises delicate ethical issues. Given the increasing pressure to reduce expenditures, there may be concerns that cost considerations could unduly influence the sensitive communication process, thus jeopardising patient autonomy. Safeguards are proposed to reduce these risks.Conclusion:The limited data indicate net cost savings may be realised with Advance Care Planning. Methodologically robust trials with clearly defined Advance Care Planning interventions are needed to make the costs and returns of Advance Care Planning transparent.

Measuring Advance Care Planning: Optimizing the Advance Care Planning Engagement Survey

“…1 Increasing attention has been paid to ACP over the past several years by healthcare systems, insurers, and researchers, because ACP can improve patient and family satisfaction, increase alignment of medical care with patients’ values, and reduce costs. 2–4 With the proliferation of new ACP initiatives, tools, and reimbursement models for ACP, measuring the success of an ACP program has become increasingly important. Traditionally, successful ACP has been measured only by the completion of an advance directive.…”

Palliative care for people with COPD: effective but underused

“…There is evidence that advance care planning improves end of life care and patient and family satisfaction and reduces stress, anxiety and depression in surviving relatives [22], as well as reducing the costs of care [23]. It is important that the details of advance directives are regularly reviewed with patients to ensure that their instructions reflect their current wishes.…”

What are the ethical questions raised by the integration of intensive care into advance care planning?

“…To date, economic studies in this area have mainly focused on healthcare establishments caring for patients with dementia and/or highly dependent patients at the endof-life (37). Importantly, ethical considerations must remain to the forefront during discussions of management options in patients at the end-of-life, and economic conditions must not be allowed to influence patient autonomy (38).…”