Are advance directives associated with better hospice care?
OBJECTIVE
To describe individuals with advance directives at the time of hospice enrollment and to determine whether they have patterns of care and outcomes that are different from those of individuals without advance directives.


METHODS
Electronic health record-based retrospective cohort study with propensity score-adjusted analysis.


METHODS
Three hospice programs in the United States.


METHODS
Individuals admitted to hospice between January 1, 2008, and May 15, 2012 (N = 49,370).


METHODS
Timing of hospice enrollment before death, rates of voluntary withdrawal from hospice, and site of death.


RESULTS
Most participants (35,968, 73%) had advance directives at the time of hospice enrollment. These participants were enrolled in hospice longer (median 29 vs 15 days) and had longer survival times before death (adjusted hazard ratio = 0.62; 95% confidence interval (CI) 0.58-0.66; P < .001). They were less likely to die within the first week after hospice enrollment (24.3% vs 33.2%; adjusted odds ratio (aOR) = 0.83, 95% CI = 0.78-0.88; P < .001). Participants with advance directives were less likely to leave hospice voluntarily (2.2% vs 3.4%; aOR = 0.82, 95% CI = 0.74-0.90; P = .003) and more likely to die at home or in a nursing home than in an inpatient unit (15.3% vs 25.8%; aOR = 0.82, 95% CI = 0.77-0.87; P < .001).


CONCLUSIONS
Participants with advance directives were enrolled in hospice for a longer period of time before death than those without and were more likely to die in the setting of their choice.
Physician Services, Suncoast Hospice, Clearwater, Florida.
Kevin
K
Ache
Joan
J
Harrold
Pamela
P
Harris
Meredith
M
Dougherty
David
D
Casarett
D016223:Advance Directives; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D005260:Female; D017051:Hospice Care / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011787:Quality of Health Care; D012189:Retrospective Studies
advance directive; hospice