EFFECTS OF OFFERING ADVANCE DIRECTIVES ON MEDICAL TREATMENTS AND COSTS

Objective: To examine the effects of advance directives on medical treatments and on patient satisfaction and well-being and to determine whether the enhancement of patient autonomy through advance directives provides a more ethically feasible approach to cost control than does the imposition of limits through rationing. Design: Randomized, controlled trial. Setting: University and Veterans Affairs medical center. Patients: Two hundred and four patients with life-threatening illnesses, 100 of whom died after enrollment in the study. Intervention: Patients randomly assigned to the experimental group were offered the California Durable Power of Attorney (a typical proxy-instruction directive), and patients assigned to the control group were not offered the advance directive. Hospital admissions were monitored to assure that a summary of the document was present in the active medical record at each hospitalization. Measurements: Cognitive function, patient satisfaction, pyschological well-being, health locus of control, sense of coherence, health-related quality of life, receipt of medical treatments, and medical treatment charges. Results: No significant differences were found between advance-directive and control groups regarding psychosocial variables, health outcome variables, and medical treatments or charges. Patients offered an advance directive had an average hospital stay of 40.8 days (95% Cl, 32.2 to 49.4 days), compared with an average of 33.1 days (95% Cl, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of $19 502 (95% Cl, $13 030 to $25 974) for medical treatments in the last month of life compared with $19 700 (95% Cl, $13 704 to $25 696) for controls. Conclusions: Despite claims that public demand for longer life accounts for rising medical costs, most surveys suggest that patients are calling for less, not more, of the expensive, high-technology treatment often used in terminal phases of illness. Executing the California Durable Power of Attorney for Health Care and having a summary copy placed in the patient's medical record had no significant positive or negative effect on a patient's well-being, health status, medical treatments, or medical treatment charges.