Advance directives specifying that patients don’t want aggressive treatment at the end of life only limit interventions and their costs in regions in which aggressive end-of-life care is common, according to a report in the Oct. 5 issue of JAMA.
In contrast, in areas of the United States where end-of-life treatment is not aggressive, such treatment-limiting documents have little effect on the use of these interventions or on health care costs, said Lauren Hersch Nicholas, Ph.D., of the University of Michigan, Ann Arbor, and her associates.
These results suggest that "the clinical effect of advance directives is critically dependent on the context in which a patient receives care," they noted.
Dr. Nicholas and her colleagues assessed end-of-life care for 3,302 Medicare beneficiaries who died between 1998 and 2007, at a mean age of 83 years. They calculated health care spending during the last 6 months of life across all care settings, including inpatient, outpatient, hospice, home health, and skilled nursing settings. The researchers selected patients who had lived in specific geographic regions across the country that were characterized by low, medium, or high end-of-life health care expenditures.
Overall, 70% of the beneficiaries were hospitalized at least once during their final 6 months of life, 41% died in a hospital, and 61% had an advanced directive (a living will or durable power of attorney).
"The clinical effect of advance directives is critically dependent on the context in which a patient receives care."
For the study population as a whole, health care spending did not vary according to whether or not a patient had an advance directive.
When the data were broken down by the usual type of end-of-life care (and costs) in each region, advance directives were associated with less-aggressive care (and lower costs) only in regions where more-aggressive care (and higher costs) were the norm.
"When patients in high-spending areas had advance directives limiting treatment, they averaged significantly lower end-of-life Medicare spending, were less likely to have an in-hospital death, and had significantly greater odds of hospice use than [did] decedents without advance directives in these regions," Dr. Nicholas and her associates wrote (JAMA 2011;306:1447-53).
In contrast, advance directives had no effect on end-of-life care or on end-of-life expenses among patients in medium- or low-spending regions.
"One interpretation of these data is that advance directives are most effective when one prefers treatment that is different from local norms. Thus, in high-intensity regions, more-limited treatment requires an explicit statement," the investigators noted.
"We urgently need studies to examine the extent to which greater advance directive use in high-intensity regions would result in treatment that is more concordant with patient preferences and to understand the patient, physician, and health system characteristics that lead to higher rates of use," they added.
This study was supported by the National Institutes of Health and the Michigan Institute for Clinical and Health Research. The authors reported that they had no relevant financial conflicts of interest.