Friday, April 09, 2010

The Use of Health Powers of Attorney/Advance Directive for Decision Making Before Death

What type of heath care do the elderly receive when they near the end of their life? Are the wishes they described in a Living Will or Health Power of Attorney actually followed?

Information was gathered from a number of sources, including the Veterans Affairs Center for Clinical Management Research that concluded patients who signed the health care documents usually received the care that was associated with their preferences.  The following a summary of an article published Aril 10, 2010 in the New England Journal of Medicine[1].

 Background:  Recent discussions about health care reform have raised questions regarding the value of advance directives.

Method:  We used data from survey proxies in the Health and Retirement Study involving adults 60 years of age or older who had diedbetween 2000 and 2006 to determine the prevalence of the need for decision making and lost decision-making capacity and totest the association between preferences documented in advance directives and outcomes of surrogate decision making.

Results:  Of 3746 subjects, 42.5% required decision-making, of whom 70.3% lacked decision-making capacity and 67.6% of those subjects, in turn, had advance directives. Subjects who had living wills were more likely to want limited care (92.7%) or comfort care (96.2%) than all care possible (1.9%); 83.2% of subjects who requested limited care and 97.1% of subjects who requested comfort care received care consistent with their preferences.  Among the 10 subjects who requested all care possible, only 5 received it; however, subjects who requested all care possible were far more likely to receive aggressive care as compared with those who did not request it (adjusted odds ratio, 22.62;95% confidence interval [CI], 4.45 to 115.00). Subjects with living wills were less likely to receive all care possible (adjusted odds ratio, 0.33; 95% CI, 0.19 to 0.56) than were subjects without living wills.  Subjects who had assigned a durable power of attorney for health care were less likely to die in a hospital (adjusted odds ratio, 0.72; 95% CI, 0.55 to 0.93) or receive all care possible (adjusted odds ratio, 0.54; 95% CI, 0.34 to 0.86) than were subjects who had not assigned a durable power of attorney for health care.

Conclusions:   Between 2000 and 2006, many elderly Americans needed decision making near the end of life at a time when most lacked the capacity to make decisions. Patients who had prepared advance directives received care that was strongly associated with their preferences. These findings support the continued use of advance directives.

 [1]  Advance Directives and Outcomes of Surrogate Decision Making Before Death.  The New England Journal of Medicine, April 1, 2010.  Authors are Maria J. Silveira, M.D., M.P.H., Scott Y.H. Kim, M.D., Ph.D., and Kenneth M. Langa, M.D., Ph.D