THE PATIENT SELF-DETERMINATION ACT AND ADVANCE DIRECTIVE COMPLETION IN NURSING-HOMES

Objectives: To assess the prevalence of advance directives among nursi ng home residents before and after passage of the Patient Self-Determi nation Act (PSDA) and to identify factors associated with advance dire ctive completion. Design: Prestudy and poststudy of nursing home admis sions using medical record reviews and a companion cross-sectional sur vey of alert and oriented residents. Setting: Six nursing homes in Con necticut. Participants: Residents (N = 635) from 6 randomly chosen nur sing homes in the greater Hartford and greater New Haven areas. Main O utcome Measures: The existence of a documented advance directive, the timing of advance directive completion, and reported reasons for compl etion and noncompletion. Results: The prevalence of advance directives documentation in nursing home medical records has increased significa ntly since the implementation of the PSDA (4.7% [14/300] before vs 34. 7% [104/300] after PSDA; odds ratio, 10.84; P<.001). The increase in d ocumented advance directives was significant after controlling for soc iodemographic and health status factors (odds ratio, 11.5; P<.001). Re sidents admitted to the nursing homes from hospitals (vs from their ho me or other source), residents with more education, and residents payi ng privately for nursing home care (vs using Medicare or Medicaid bene fits) were more likely to have documented advance directives. Younger residents (aged (75 years) were less likely than older residents to ha ve completed a directive. Among the 35 interviewed residents, the most common reason for completing an advance directive was experience with a prolonged death of a friend or family member. Only 1 of the intervi ewed residents reported that the information provided under the PSDA a t the time of admission was an important factor in choosing to complet e an advance directive. Conclusions: Nearly 35% of the residents in th e post-PSDA cohort had an advance directive documented in the medical record. Most residents with advance directives had completed them more than 6 months before the nursing home admission. The major effect of the PSDA for nursing homes has been to enhance the documentation of ex isting advance directives. Little evidence exists that providing advan ce directive information at the time of nursing home admission has enh anced the completion of an advance directive after admission.