Lawrence J. Schneiderman, MD; Richard Kronick, PhD; Robert M. Kaplan, PhD; John P. Anderson, PhD; Robert D. Langer, MD, MPH
▪ 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% CI, 32.2 to 49.4 days), compared with an average of 33.1 days (95% CI, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of $19 502 (95% CI, $13 030 to $25 974) for medical treatments in the last month of life compared with $19 700 (95% CI, $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.
Schneiderman LJ, Kronick R, Kaplan RM, Anderson JP, Langer RD. Effects of Offering Advance Directives on Medical Treatments and Costs. Ann Intern Med. 1992;117:599–606. doi: 10.7326/0003-4819-117-7-599
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Published: Ann Intern Med. 1992;117(7):599-606.
End-of-Life Care, Hospital Medicine.
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