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Medline ® Abstracts for References 9,13,24

of 'Advance care planning and advance directives'

Advance directives and outcomes of surrogate decision making before death.
Silveira MJ, Kim SY, Langa KM
N Engl J Med. 2010;362(13):1211.
BACKGROUND: Recent discussions about health care reform have raised questions regarding the value of advance directives.
METHODS: We used data from survey proxies in the Health and Retirement Study involving adults 60 years of age or older who had died between 2000 and 2006 to determine the prevalence of the need for decision making and lost decision-making capacity and to test 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.
Veterans Affairs Center for Clinical Management Research, and Division of General Medicine, University of Michigan, Ann Arbor, USA. mariajs@umich.edu
Association between advance directives and quality of end-of-life care: a national study.
Teno JM, Gruneir A, Schwartz Z, Nanda A, Wetle T
J Am Geriatr Soc. 2007;55(2):189.
OBJECTIVES: To examine the role of advance directives (ADs) 10 years after the Patient Self-Determination Act.
DESIGN: Mortality follow-back survey.
SETTING: People who died in a nursing home, hospital, or at home.
PARTICIPANTS: Bereaved family member or other knowledgeable informant.
MEASUREMENTS: Telephone interviewers that asked about the use of written ADs, use of life-sustaining treatment, and quality of care by asking whether staff provided desired symptom relief, treated the dying with respect, supported shared decision-making, coordinated care, and provided family with the needed information and emotional support.
RESULTS: Of the 1,587 people who died, 70.8% had an AD. Persons who died athome with hospice or in a nursing home were more likely to have an AD. In addition, those with an AD were less likely to have a feeding tube (17% vs 27%) or use a respirator in the last month of life (11.8% vs 22.0%). Bereaved family members who reported that the decedent did not have an AD were more likely to report concerns with physician communication (adjusted odds ratio (AOR)=1.4, 95% confidence interval (CI)=1.1-1.6) and with being informed about what to expect (AOR=1.2, 95% CI=1.0-1.3). No statistically significant differences were observed in other outcomes. Even in those with an AD, important quality concerns remained; one in four reported an unmet need in pain, one in two reported inadequate emotional support for the patient, and one in three stated inadequate family emotional support.
CONCLUSION: Bereaved family member report of completion of an AD was associated with greater use of hospice and fewer reported concerns with communication, yet important opportunities remain to improve the quality of end-of-life care.
Center for Gerontology and Health Care Research, Brown Medical School, Providence, Rhode Island, USA. Joan_Teno@brown.edu
Advance directive completion by elderly Americans: a decade of change.
Silveira MJ, Wiitala W, Piette J
J Am Geriatr Soc. 2014;62(4):706.
OBJECTIVES: To describe trends in advance directive (AD) completion from 2000 to 2010 and to explore the relationship between AD and hospitalization and hospital death at the end of life.
DESIGN: Retrospective cohort study.
SETTING: Health and Retirement Study (HRS).
PARTICIPANTS: HRS participants who died between 2000 and 2010 and were aged 60 and older at death (N = 6,122).
MEASUREMENTS: Trends over time in rates of AD completion, hospitalization before death, and death in hospital are described. The association between trends in AD completion and hospital death was then assessed by comparing nested, multivariable logistic regression models predicting the odds of hospital death over time with and without adjusting for AD status and sociodemographic characteristics. The complex sampling design was accounted for in all analyses.
RESULTS: The proportion of decedents with an AD increased from 47% in 2000 to 72% in 2010. At the same time, the proportion of decedents with at least one hospitalization in the last 2 years of life increased from 52% to 71%, and the proportion dying in the hospital decreased from 45% to 35%. After adjusting for confounding by sociodemographic characteristics, the trend in declining hospital death over the decade was negligibly associated with the greater use of ADs.
CONCLUSION: There has been a significant increase in rates of AD completion over the last decade, but this trend has had little effect upon hospitalization and hospital death, suggesting that AD completion is unlikely to stem hospitalization before death.
Center for Clinical Management Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, Michigan; Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.