Advance Directives and End-of-Life Spending

End-of-life care can be very expensive, accounting for as much as one-fourth of Medicare spending.  There is substantial geographic variation in this care, which may reflect provider practice patterns more than patient preferences.  One method for a patient to attempt to ensure that end-of-life care is consistent with the patient’s values and preferences is to use an advance directive.  Research published in the Journal of the American Medical Association examined the relationship between advance directives and end-of-life care, given the geographic variation in spending.   (JAMA Article)  Using Medicare beneficiaries who were part of the Health & Retirement survey, advance directive use and health care expenditures near the end of life were studied for over 3300 beneficiaries who died between 1998 and 2007.

Of these decedents, 61% had some type of living will and 39% had a written, treatment-limiting advance directive.  Overall, median spending in the last 6 months of life did not vary by advance directive status, but on an unadjusted basis those with such directives had lower rates of life-sustaining treatment, lower rates of in-hospital death, and higher rates of hospice use.  Those with such directives were more likely to be white, affluent and well-educated.  There was substantial unadjusted variation in the level of end-of-life spending in various hospital referral regions; from a median $8787 in the lowest quartile to a median $15744 in the highest quartile.  Residents in low spending regions were more likely to have advance directives.  In high spending areas, people with advance directives were more likely to have lower spending than those without, but in low and medium spending areas, there was no such association.

Overall, the results suggest that first, there is great variation in end-of-life spending that may have little to do with actual patient needs or desires.  The direction of causation, if any, in regard to advance directives would seem to be that in a high-spending area, an advance directive can help limit excessive care.  Where a geographic area already appears to have less of such care and spending, an advance directive has less effect.  Advance directives appeared to increase the likelihood that a beneficiary would not die in the hospital and would receive palliative and hospice care, which other research has shown is associated with a better quality of life in the last few weeks leading up to death and is preferred by most patients.  The research is one more very good reason to ensure that every patient has a conversation with a medical profession about their end-of-life care and creates a written directive which embodies their preferences.