RELATIONSHIP OF ADVANCE DIRECTIVES TO HOSPITAL CHARGES IN A MEDICARE POPULATION

Objective: There is a growing demand both for respect for patient auto nomy regarding the use of sophisticated technology and for considerati on of health care expenditures at the end of life. The major objective of this study was to assess the relationship between the documentatio n of a discussion of advance directives and hospital charges for Medic are patients during the last hospitalization of the patient's life. De sign: Multivariate analysis of a retrospective cohort. Setting: large (700 + beds), private university, tertiary care hospital. Patients: Al l 474 patients who had Medicare listed as their primary insurer and wh o died in the hospital between January 1 and June 30 in 1990, 1991, or 1992. Main Outcome Measure: Total inpatient charges. Results: The mea n inpatient charge for the 342 patients without documentation of a dis cussion of advance directives was more than three times that of the 13 2 patients with such documentation ($95 305 vs $30 478). This relation ship remained statistically significant after controlling for severity of disease, use of an intensive care unit, and number of procedures. Demographics, length of stay, admitting service, admitting diagnosis, and previous admission to the study hospital did not contribute to the predictive model. Conclusions: During discussions of advance directiv es, patients often opt to limit the extent of care they desire in cert ain situations. Although the most appropriate setting for developing a dvance directives is not clear, the results of this study imply that a n enormous cost savings to society may be realized if such discussions take place, while, at the same time, autonomous patient choice will b e respected.