Communicating End-of-Life Wishes Pays Off Where Aggressive Treatment Is the Norm

A new study finds that when medical personnel know what kind of care a patient wants at the end of life, Medicare can be spared significant sums and the patient is more likely to die at home rather than in a hospital, at least in certain areas.

The study, published in the October 5, 2011, issue of the Journal of the American Medical Association, found that in regions of the U.S. that tend to spend the most on end-of-life care, patients who have "advance directives" cost Medicare about $5,600 less per person.  (Advance directives allow patients to communicate their end-of-life wishes if they are unable to do so themselves.)  These patients' quality of life also appeared to be better; they were more likely to receive hospice care and to be at home when they died.

But the differences in spending and care did not hold up in regions of the country with low- to average end-of-life expenditures.  The researchers speculated that in these areas, less aggressive care at the end of life is already the norm and more in line with what many patients want.  In high-spending regions, by contrast, an advance directive may embolden caregivers to go against the local norm of aggressive treatment and prolonged hospital care.   In 2006, treatment during the last year of life accounted for more than one-quarter of Medicare expenditures.  

Advance directives typically include a "living will" that gives instructions regarding treatment if the individual becomes terminally ill or is in a persistent vegetative state.  It may contain directions to refuse or remove life support in the event the individual is in a coma or a vegetative state, or it may provide instructions to use all efforts to keep the person alive, no matter the circumstances.  Most participants in the study who had advance directives specified that they wanted to limit treatment.

"[The study] absolutely highlights some of the reasons why you should both talk to family, friends and physicians about the type of care you might want to receive, should you be unable to make your own decisions," said Lauren Hersch Nicholas, the study's lead author and a health economist at the University of Michigan.

Second Study: Aggressive Treatment Doesn't Prolong Life

A related study just published in the medical journal The Lancet has found that nearly one of every three Medicare beneficiaries had an operation in their last year of life. 

Operations were more likely in regions with a greater availability of hospital beds and higher levels of Medicare spending.  But the higher rates of surgery didn't necessarily pay off.  The regions where doctors were more likely to operate had higher patient death rates.

"This level of surgical intensity doesn't seem to be having much in the way of benefit for the population," Dr. Ashish Jha, the study's author and an associate professor of health policy at the Harvard School of Public Health, told ABC News. "Our sense is that there are probably lots of unnecessary procedures that go on at end of life."

Each state has its own laws on advance directives.  Caring Connections, a site run by the National Hospice and Palliative Care Organization, offers state-by-state information on advance directives

Advance medical directives are an integral part of the estate planning services provided by elder law attorneys. 

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