Brief communication: The relationship between having a living will and dying in place

Background: Living wills, a type of advance directive, are promoted as a way for patients to document preferences for life-sustaining treatments should they become incompetent. Previous research, however, has found that these documents do not guide decision making in the hospital. Objective: To test the hypothesis that people with living wills are less likely to die in a hospital than in their residence before death. Design: secondary analysis of data from a nationally representative longitudinal study. Setting: Publicly available data from the Asset and Health Dynamics Among the Oldest Old (AHEAD) study. Patients: People older than 70 years of age living in the community in 1993 who died between 1993 and 1995. Measurements: Self-report and proxy informant interviews conducted in 1993 and 1995. Results: Having a living will was associated with lower probability of dying in a hospital for nursing home residents and people living in the community. For people living in the community, the probability of in-hospital death decreased from 0.65 (95% CI, 0.58 to 0.71) to 0.52 (CI, 0.42 to 0.62). For people living in nursing homes, the probability of in-hospital death decreased from 0.35 (CI, 0.23 to 0.49) to 0.13 (CI, 0.07 to 0.22). Limitations: Retrospective survey data do not contain detailed clinical information on whether the living will was consulted. Conclusion: Living wills are associated with dying in place rather than in a hospital. This implies that previous research examining only people who died in a hospital suffers from selection bias. During advance care planning, physicians should discuss patients' preferences for location of death.