Advance Directives Are Usually Followed

Most People With Living Wills or Health Care Proxies Have Their Treatment Wishes Honored

From the WebMD Archives

March 31, 2010 -- Advance directives, which describe the medical care you want to have if you're incapacitated, are honored most of the time, a study shows.

''If you take time out to put together a living will or durable power of attorney for health care, most often you get your wishes," says study researcher Maria J. Silveira, MD, MPH, a clinician scientist at the Ann Arbor VA Medical Center and an assistant professor of medicine, University of Michigan School of Medicine, Ann Arbor.

The study is published in The New England Journal of Medicine.

The results of her new study, Silveira concludes, support the continued use of advance directives.

There are two types of advance directives: a living will or a medical power of attorney, also known as a health care proxy. A living will informs your doctor and your family about the type of treatment you'd want to receive if you are unable to make your own medical decisions. A medical power of attorney assigns a person -- called a health care proxy -- to make the decisions for you.

Advance directives became more common after the passage of the Patient Self-Determination Act in the U.S. 20 years ago, but debate about the usefulness of the documents has been ongoing for several years, Silveira tells WebMD.

During the recent health care reform debate, a proposal to pay back health care providers for advance directives planning discussions through Medicare sparked controversy, raising concern that these advance directives would result in denial of necessary care, Silveira says.

Honoring Advance Directives

Silveira and her colleagues used data from the Health and Retirement study, a nationally representative group of U.S. adults age 51 and older, taken every two years.

They looked just at people 60 and older who had died between 2000 and 2006, asking a family member or other informed person to answer questions about circumstances and decisions after the participant's death, usually within 24 months of the death.

Among the 3,746 people 60 and above who died, 42.5% had to make treatment choices and 70.3% of those did not have the ability to decide for themselves.

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One surprise: 67.6% of those who lacked decision-making ability had advance directives -- either a living will, health care proxy, or both.

So were their wishes followed?

''What we found was, the agreement depended on what the patient wanted," Silveira tells WebMD. "Almost everyone who wanted comfort care got it." If they asked for limited care -- not the most aggressive but beyond comfort care -- 83.2% got it, she found.

Only half of the 10 people who requested ''all care possible,'' the most aggressive approach, got it. But Silveira says that was sometimes because ''all care possible'' couldn't be given.

One example: A person with very low blood pressure who wanted dialysis if needed would not be given it, she says, as the dialysis would lower their pressure more and perhaps hasten death.

The health care proxy wish was nearly always carried out, she found. ''Thirty percent of the [3,746] older adults needed surrogate decisions," she says. "When they appointed a durable power of attorney for health care, 92% of the time they got the decision maker they chose.''

Silveira's bottom line? "No one is claiming these things are perfect,'' she says of advance directives. "But they are better than nothing. They are meant to make a difficult situation a little bit less so for the family. Without them, what else do we have?"

Advance Directives: Second Opinion

Not everyone agrees entirely with the study's conclusions. Muriel Gillick, MD, a clinical professor of population medicine at Harvard Medical School and a practicing physician, wrote an editorial to accompany the study. She finds a health care proxy helpful but criticizes the living will as ''mostly useless.''

Part of the problem, she says, is that the documents spell out preferences for specific interventions, but that a patient can't really make informed choices until he or she knows the pros and cons of the treatments, and that a patient's preference may change once the condition is real, not theoretical.

The study method could have affected the results. "The study relies on the memories of friends or family members, an average of a year after the person's death. One has to question the accuracy in terms of the details of those memories," Gillick tells WebMD.

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Both the passage of time and the usually heightened emotions at a time of crisis could have affected the memories, she says.

Finding a health care surrogate in advance, however, is a good idea, Gillick says. "Talking to a health care proxy is helpful."

The new study results, she says, demonstrate that talking about the goals of medical care at a time of crisis or end of life seems to becoming more acceptable to Americans.

Advance care planning should include a conversation with your health care provider, she says. It should include a process of clarifying the patient's current health status, talking about goals, and then designating a health care proxy to work with the doctor in interpreting and carrying out the goals when needed.

One program that uses this approach, she says, is called the Physician Orders for Life-Sustaining Treatment, adopted in a dozen states and being introduced in others.

WebMD Health News Reviewed by Laura J. Martin, MD on March 31, 2010

Sources

SOURCES:

Maria J. Silveira, MD, MPH, clinician scientist, VA Ann Arbor Healthcare System; assistant professor of medicine, University of Michigan School of Medicine, Ann Arbor.

Muriel Gillick, MD, clinical professor of population medicine, Harvard Medical School; physician, Harvard Vanguard Medical Associates, Boston.

Silveira, M. The New England Journal of Medicine, April 1, 2010; vol 362: pp 1211-1218.

Gillick, M. The New England Journal of Medicine, April 1, 2010; vol 362: pp 1239-1240.

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