The Patient Self-Determination Act and advance directive completion in nursing homes

Objectives: To assess the prevalence of advance directives among nursing home residents before and after passage of the Patient Self-Determination Act (PSDA) and to identify factors associated with advance directive completion. Design: Prestudy and poststudy of nursing home admissions using medical record reviews and a companion cross-sectional survey of alert and oriented residents. Setting: Six nursing homes in Connecticut. Participants: Residents (N = 635) from 6 randomly chosen nursing homes in the greater Hartford and greater New Haven areas. Main Outcome Measures: The existence of a documented advance directive, the timing of advance directive completion, and reported reasons for completion and noncompletion. Results: The prevalence of advance directives documentation in nursing home medical records has increased significantly since the implementation of the PSDA (4.7% [14/300] before vs 34.7% [104/300] after PSDA; odds ratio, 10.84; P<.001). The increase in documented advance directives was significant after controlling for sociodemographic and health status factors (odds ratio, 11.5; P<.001). Residents admitted to the nursing homes from hospitals (vs from their home or other source), residents with more education, and residents paying privately for nursing home care (vs using Medicare or Medicaid benefits) were more likely to have documented advance directives. Younger residents (aged (75 years) were less likely than older residents to have completed a directive. Among the 35 interviewed residents, the most common reason for completing an advance directive was experience with a prolonged death of a friend or family member. Only 1 of the interviewed residents reported that the information provided under the PSDA at the time of admission was an important factor in choosing to complete an advance directive. Conclusions: Nearly 35% of the residents in the post-PSDA cohort had an advance directive documented in the medical record. Most residents with advance directives had completed them more than 6 months before the nursing home admission. The major effect of the PSDA for nursing homes has been to enhance the documentation of existing advance directives. Little evidence exists that providing advance directive information at the time of nursing home admission has enhanced the completion of an advance directive after admission.