NEW YORK, Mar 14 (Reuters Health) -- Advance directives -- written
indications about how patients wish to be treated in the event of
life-threatening illness -- reduce the cost of healthcare in nursing homes
without affecting patients' quality of life, researchers report.
According to the results of the study, when nursing homes encouraged
residents to fill out advance directives, there were fewer hospitalizations and
lower associated healthcare costs.
The authors note that the use of the advance directives did not lower
patient satisfaction or increase mortality.
In the study, Dr. D. William Molloy of McMaster University in Ontario,
Canada, and colleagues instituted the "Let Me Decide" advance directive program
at three nursing homes. This included educating nursing home staff, residents
and family members, and offering residents -- or next-of-kin of mentally
incompetent residents -- an advance directive with a range of choices regarding
treatment in the event of life-threatening illness or cardiac arrest.
Ninety competent residents and family members of 305 incompetent residents
completed an advance directive.
At an 18-month follow-up, Molloy's group found no difference in satisfaction
of the residents between nursing homes that took part in the program and those
that had not. Nursing homes in the program reported fewer hospitalizations per
resident than other homes, and lower healthcare costs. Both types of homes
reported similar rates of death.
"Implementation of a program to increase use of advance directives reduces
healthcare services utilization without affecting satisfaction or mortality,"
the authors conclude in the March 15th issue of The Journal of the American
Medical Association.
"The results may have implications for training of nursing home personnel,"
Molloy and colleagues suggest, because "it is likely that the systematic
application of advance directives will increase the need for effective
palliative care in nursing homes." They note that "the workers in many nursing
homes are not educated about advance directives, and the homes are not equipped
to provide symptom relief and palliative care to residents at the end of life."
Dr. Joan Teno of Brown University in Providence, Rhode Island, writes in an
accompanying editorial that these results are "ethically defensible only if that
result reflects the informed preferences of (nursing home patients)... and if
the decision not to hospitalize did not reduce the quality of end-of-life care."
But the editorialist notes that the study did not collect adequate
information to answer either of these questions. "Future studies," Teno
suggests, "should examine whether medical care was consistent with the written
preferences contained in the advance directive."
Teno notes that "nursing homes will play an increasingly important role in
care of the dying," and adds that "additional research... that focuses on
improving the quality of end-of-life care for patients in nursing homes is
urgently needed."
