Advance Directives and Outcomes of Surrogate Decision Making before Death

Published - Written by Karen Buckley

Many patients require decisions about their health care at the end of life when they no longer have the capacity to make decisions.  Advance directives (living wills and health care proxies) are designed to protect a patients’ autonomy if they become seriously ill and unable to make medical decisions, but it is unclear how helpful advance directives are in ensuring that patients receive care consistent with their wishes.

Silveira et al. examined the association between preferences for care documented in advance directives and the health care they received at the end of life, using data from surveys of proxies of 3,746 adults 60 years of age or older who died between 2000 and 2006. More than one quarter of the patients required decision making at the end of life, but lacked decision-making capacity.  They found that patients who had prepared advance directives received care that was strongly associated with their preferences.

“This study illustrates what a common issue this is,” says Mary Beth Hamel, deputy editor at NEJM.  “Many people lose the ability to make decisions for themselves at the end of their life, yet decisions about their care need to be made.”

There has been much debate about the usefulness of advance directives, and controversy over how they might be used.

In an accompanying editorial, Dr. Muriel Gillick cautions, “The selection of medical interventions for an imagined future health state is problematic, since preferences change in the face of real rather than theoretical conditions.”

The challenge going forward is to incorporate advance care planning in a way that will benefit the many patients whose physicians and proxies will be faced with difficult choices about their health care.

The authors conclude, “Advance directives are important tools for providing care in keeping with patients’ wishes. For more patients to avail themselves of these valuable instruments, the health care system should ensure that providers have the time, space, and reimbursement to conduct the time-consuming discussions necessary to plan appropriately for the end of life.”

Do you recommend advance directives in your practice?  Have you found that advance directives help or hinder decision making at the end of life? Do time constraints or reimbursement policies affect advance care planning?