title: Does facilitated Advance Care Planning reduce the costs of care near the end of life? Systematic review and ethical considerations.
abstract: BACKGROUND
  While there is increasing evidence that Advance Care Planning has the potential to strengthen patient autonomy and improve quality of care near the end of life, it remains unclear whether it could also reduce net costs of care.
  
  
  OBJECTIVE
  This study aims to describe the cost implications of Advance Care Planning programmes and discusses ethical conflicts arising in this context.
  
  
  METHODS
  We conducted a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.
  
  
  METHODS
  We systematically searched the databases PubMed, NHS EED, EURONHEED, Cochrane Library and EconLit. We included empirical studies (no limitation to study type) that investigated the cost implications of Advance Care Planning programmes involving professionally facilitated end-of-life discussions.
  
  
  CONCLUSIONS
  Seven studies met our inclusion criteria. Four of them used a randomised controlled design, one used a before-after design and two were observational studies. Six studies found reductions in costs of care ranging from USD1041 to USD64,827 per patient, depending on the study period and the cost measurement. One study detected no differences in costs. Studies varied considerably regarding the Advance Care Planning intervention, patient selection and costs measured which may explain some of the variations in findings.
  Looking at the impact of Advance Care Planning on costs raises delicate ethical issues. Given the increasing pressure to reduce expenditures, there may be concerns that cost considerations could unduly influence the sensitive communication process, thus jeopardising patient autonomy. Safeguards are proposed to reduce these risks.
  
  
  CONCLUSIONS
  The limited data indicate net cost savings may be realised with Advance Care Planning. Methodologically robust trials with clearly defined Advance Care Planning interventions are needed to make the costs and returns of Advance Care Planning transparent.
authors: Institute for Ethics, History and Theory of Medicine, Ludwig Maximilian University, Munich, Germany.
authors: Corinna
authors: C
authors: Klingler
authors: Institute of General Practice, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany.
authors: Jürgen
authors: J
authors: in der Schmitten
authors: Institute for Ethics, History and Theory of Medicine, Ludwig Maximilian University, Munich, Germany marckmann@lmu.de.
authors: Georg
authors: G
authors: Marckmann
mesh_terms: D032722:Advance Care Planning; D003363:Cost Control; D003362:Cost-Benefit Analysis; D017048:Health Care Costs; D006801:Humans; D013727:Terminal Care / Q000191:economics*
keywords: Advance care planning; advance directives; economics; ethics; healthcare costs; review