Association between advance directives and quality of end-of-life care: a national study.
OBJECTIVE
To examine the role of advance directives (ADs) 10 years after the Patient Self-Determination Act.


METHODS
Mortality follow-back survey.


METHODS
People who died in a nursing home, hospital, or at home.


METHODS
Bereaved family member or other knowledgeable informant.


METHODS
Telephone interviewers that asked about the use of written ADs, use of life-sustaining treatment, and quality of care by asking whether staff provided desired symptom relief, treated the dying with respect, supported shared decision-making, coordinated care, and provided family with the needed information and emotional support.


RESULTS
Of the 1,587 people who died, 70.8% had an AD. Persons who died at home with hospice or in a nursing home were more likely to have an AD. In addition, those with an AD were less likely to have a feeding tube (17% vs 27%) or use a respirator in the last month of life (11.8% vs 22.0%). Bereaved family members who reported that the decedent did not have an AD were more likely to report concerns with physician communication (adjusted odds ratio (AOR)=1.4, 95% confidence interval (CI)=1.1-1.6) and with being informed about what to expect (AOR=1.2, 95% CI=1.0-1.3). No statistically significant differences were observed in other outcomes. Even in those with an AD, important quality concerns remained; one in four reported an unmet need in pain, one in two reported inadequate emotional support for the patient, and one in three stated inadequate family emotional support.


CONCLUSIONS
Bereaved family member report of completion of an AD was associated with greater use of hospice and fewer reported concerns with communication, yet important opportunities remain to improve the quality of end-of-life care.
Teno
Joan M
JM
Center for Gerontology and Health Care Research, Brown Medical School, Providence, Rhode Island, USA. Joan_Teno@brown.edu
Gruneir
Andrea
A
Schwartz
Zachary
Z
Nanda
Aman
A
Wetle
Terrie
T
D024362:Advance Directive Adherence; D016223:Advance Directives; D000368:Aged; D001601:Bereavement; D003258:Consumer Behavior / Q000706:statistics & numerical data*; D005260:Female; D006738:Hospices / Q000706:statistics & numerical data; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D009735:Nursing Homes; D011368:Professional-Family Relations; D011787:Quality of Health Care; D013727:Terminal Care / Q000379:methods* / Q000523:psychology / Q000592:standards; D014481:United States; D014600:Utilization Review