THE ILLUSION OF END-OF-LIFE RESOURCE SAVINGS WITH ADVANCE DIRECTIVES

OBJECTIVE: Would increasing the documentation of advance directives (A Ds) lead to a reduction in resource utilization? We examined this ques tion by conducting three secondary analyses: (1) we tested for a chang e in resource use among those who died in the hospital at a time befor e and after an intervention that increased the documentation of ADs in the medical record; (2) we replicated analyses of published studies t hat reported an association of chart documentation of ADs and hospital resource use; and (3) we examined whether a potential explanation of the observed association is biased documentation of ADs among patients who have completed an AD. DESIGN: Replication of analysis of previous published studies using data from a prospective cohort study and bloc k-randomized controlled trial. SETTING: Five teaching hospitals in the United States. PATIENTS: A total of 9105 seriously ill patients were enrolled in the Study to Understand Prognoses and Preferences for Outc omes and Risks of Treatments (SUPPORT), including 4301 patients in the 2 years (1989-91) before the Patient Self-Determination Act (PSDA) an d 4804 in the 2 years (1992-94) after the PSDA implementation, with 26 52 patients receiving the intervention and 2152 serving as controls. I NTERVENTIONS: The SUPPORT intervention provided a nurse to facilitate communication among patients, surrogates, and physicians about prefere nces for and outcomes of treatments. Documenting existing advance dire ctives was also one of this nurse's tasks. The Patient Self-Determinat ion Act required that health care institutions inquire about and docum ent existing advance directives at the time of hospital admission. MEA SUREMENT: Hospital resource use was derived from the Therapeutic Inten sity Scoring System and hospital length of stay, converted into 1994 d ollars. RESULTS: Chart documentation of existing advance directives at the time of study admission increased with both the PSDA and the SUPP ORT intervention. We found that intervention patients were more likely to have pre-existing ADs documented. Despite this increase, there was no corresponding change in hospital resource use for those who died d uring the enrollment hospitalization. Replication of analyses from pub lished studies using data from the block randomized controlled trial f ound that ADs documented by the third day of serious illness were asso ciated with a 23% reduction in hospital resource use among control pat ients ($21,284 with ADs documented compared with $26,127 without, 95% CI 1-48% reduction). However, this association was not observed among intervention patients, who had more pre-existing ADs documented in the medical record. Intervention patients with early documentation of ADs showed a trend toward greater cost ($28,017 compared with $24,178 amo ng those without AD documentation, 95% CI 0-25% increase). The rate of documentation and characteristics of those with documentation differe d between control and intervention patients. Intervention patients wer e more likely (as reported by patient or surrogate interview) to have ADs documented in the medical record by the third day (55% vs 32%, P < .001). In contrast to intervention patients, control patients who wer e older, less wealthy, less educated, more likely to prefer to forgo C PR, and more likely to want life-sustaining treatment limited had thei r ADs documented. These associations were not found among intervention patients when comparison was made between those with and those withou t an AD documented in the medical record. CONCLUSION: Increasing the d ocumentation of pre-existing ADs was not associated with a reduction i n hospital resource use. ADs documented without further intervention b y the third day of a serious illness were associated with decreased ho spital resource use. However, we did not find this association with an intervention that increased AD documentation. One potential explanati on of these findings is that classification of those with an AD was ba sed on chart documentation among a biased cohort of patients. Our resu lts cast doubt on whether policy interventions that only increase AD d ocumentation will reduce hospital resource use for dying patients.