title: Quality of Life and Cost of Care at the End of Life: The Role of Advance Directives.
abstract: BACKGROUND
  Advance directives (ADs) are expected to improve patients' end-of-life outcomes, but retrospective analyses, surrogate recall of patients' preferences, and selection bias have hampered efforts to determine ADs' effects on patient outcomes.
  
  
  OBJECTIVE
  The aim was to examine associations among ADs, quality of life, and estimated costs of care in the week before death.
  
  
  METHODS
  We used prospective data from interviews of 336 patients with advanced cancer and their caregivers and analyzed patient baseline interview and caregiver and provider post-mortem evaluation data from the Coping with Cancer study. Cost estimates were from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample and published Medicare payment rates and cost estimates. Outcomes were quality of life (range 0-10) and estimated costs of care received in the week before death. Because patient end-of-life care preferences influence both AD completion and care use, analyses were stratified by preferences regarding heroic end-of-life measures (everything possible to remain alive).
  
  
  RESULTS
  Most patients did not want heroic measures (76%). Do-not-resuscitate (DNR) orders were associated with higher quality of life (β = 0.75, standard error = 0.30, P = 0.01) across the entire sample. There were no statistically significant relationships between DNR orders and outcomes among patients when we stratified by patient preference or between living wills/durable powers of attorney and outcomes in any of the patient groups.
  
  
  CONCLUSIONS
  The associations between DNR orders and better quality of life in the week before death indicate that documenting preferences against resuscitation in medical orders may be beneficial to many patients.
authors.affiliation: James J. Peters Veterans Affairs Medical Center, Bronx, and Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Melissa M
authors.initials: MM
authors.lastname: Garrido
authors.affiliation: Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Tracy A
authors.initials: TA
authors.lastname: Balboni
authors.affiliation: Weill Cornell Medical College, New York, New York, USA.
authors.forename: Paul K
authors.initials: PK
authors.lastname: Maciejewski
authors.affiliation: Weill Cornell Medical College, New York, New York, USA.
authors.forename: Yuhua
authors.initials: Y
authors.lastname: Bao
authors.affiliation: Weill Cornell Medical College, New York, New York, USA. Electronic address: hgp2001@med.cornell.edu.
authors.forename: Holly G
authors.initials: HG
authors.lastname: Prigerson
mesh_terms: D016223:Advance Directives / Q000191:economics*; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D009369:Neoplasms / Q000191:economics* / Q000401:mortality*; D015995:Prevalence; D011788:Quality of Life; D016414:Resuscitation Orders; D012297:Right to Die; D012307:Risk Factors; D013727:Terminal Care / Q000191:economics* / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology
keywords: DNR; Quality of life; advance directives; costs of care; end-of-life care