HOW WELL IS THE PATIENT SELF-DETERMINATION ACT WORKING - AN EARLY ASSESSMENT

OBJECTIVES: To assess the association between implementation of the Pa tient Self-Determination Act (PSDA) and (1) the use of formal, written advance directives, (2) the use of informal advance care arrangements , and (3) discussions between patients and their physicians and proxie s on advance care planning and end-of-life treatment preferences. DESI GN: A time-sequence study in which patients discharged from acute care hospitals 1 month before the implementation of the PSDA and 5 months after implementation of the PSDA were interviewed. SETTING: Two medica l school-affiliated, major teaching hospitals with more than 500 beds and 3 nonteaching community hospitals with fewer than 400 beds in east ern Massachusetts. PATIENTS: A total of 579 adult patients were interv iewed: 258 patients discharged before the implementation of the PSDA ( pre-PSDA) and 321 patients discharged 5 months after implementation of the PSDA (post-PSDA). MEASUREMENTS: Patients were asked about their f ormal, written or informal advance care planning arrangements, about t he frequency of inquiries and information provided on advance care pla nning by the hospitals, and about their discussions of advance care pl anning and end-of-life treatment preferences with physicians and their proxies. RESULTS: In the pre-PSDA cohort, 60.9% of the patients had s ome kind of advance care planning, whereas in the post-PSDA cohort, 72 .6% did (p = 0.01). However, there was not a significant increase in t he proportion of patients who had advance care planning ''In a written document'' (19.8% of the pre-PSDA cohort compared with 25.5% of the p ost-PSDA cohort, p = 0.11). The increase in written advance care plann ing was concentrated in the community, nonteaching hospitals (10.7% pr e-PSDA versus 23.7% post-PSDA). Overall, 41.4% of patients recalled in quiries or information about advance care planning during their hospit alization. Implementation of the PSDA was not associated with a signif icant change in the proportion of patients who discussed advance care planning or end-of-life issues with their physicians (13.6% pre-PSDA v ersus 17.1% post-PSDA, p = 0.25). However, there was an increase in th e proportion of patients with poorer health who spoke with their physi cians (15.4% pre-PSDA versus 24.8% post-PSDA). Implementation of the P SDA was associated with an increase in the proportion of patients who had general discussions with proxies about end-of-life issues (61.8% p re-PSDA versus 73.0% post-PSDA, p = 0.024). However, 33.6% of pre-PSDA and 33.2% of post-PSDA patients had detailed discussions with their p roxy about specific interventions such as mechanical ventilation or ar tificial nutrition. Patients with formal proxies had detailed discussi ons significantly more frequently than other patients (50.0% versus 26 .8%, p <0.0001). CONCLUSIONS: The PSDA was associated with significant effects on general advance care planning issues, increasing the propo rtion of patients who had (1) some kind of advance care arrangements a nd (2) general discussions of end-of-life issues with their proxies. H owever, the PSDA did not appear associated with significant increases (1) in the use of formal, written advance care documents, (2) in the f requency of discussions between patients and their physicians on advan ce care documents or end-of-life issues, or (3) in the frequency of di scussions about specific treatment preferences between patients and th eir proxies.