Why advance directives get ignored

Patients' ZIP codes could determine end-of-life care

Even though many older Americans have advance directives dictating the type of end-of-life care they desire, research suggests that such patient preferences are often ignored

When advance directives can be dangerous

A recent study which tracked more than 6,000 people over age 60 who died between 2000 and 2010 found that 72% of study participants had advance directives by the end of the study, up from 47% at the beginning.  However, the study found that having advance directives rarely influenced whether people were hospitalized and whether they died in hospital settings.

Why are directives so often ignored

Researchers found that whether medical professionals adhered to patients' advance directives depended on where patients live and how "aggressively" physicians practiced in the area, writes Paula Span for the New York Times' "The New Old Age."

Susan Tolle, director of the Center for Ethics in Health Care at Oregon Health and Science University said, "I don't want to demean advance directives," but when it comes to patients' end-of-life preferences, "It's your ZIP code."

The ABCDEs of advance care planning

Charlie Sabatino—chair of the American Bar Association Commission on Law and Aging—argues that it is not just physicians who insist on keeping patients alive; it's also disorganization of patient records.

For instance, directives are often kept in safes and drawers and do not follow the patient to the hospital in the case of an emergency. In addition, patients who are most likely to use their advance directives are likely to have multiple doctors and specialists, some of whom might not have a copy of the directive. Sabatino says, "People with complex medical conditions have a physician for every organ [and] these things aren't getting where they're supposed to be."

Other reasons directives are ignored include:

  • Patients failing to have meaningful conversations with their families about their decision;
  • Patients choosing ineffective proxies;
  • Family members disagreeing about best treatment options; and
  • Clerical errors.

What hospitals can do

In 2009, Oregon created an electronic registry of the Physician Orders for Life Sustaining Treatment (POLST), a program the state pioneered nearly 20 years ago.

In a new study of 58,000 Oregon residents who died in 2010 and 2011, researchers found that using POLST resulted in patients' wishes being more frequently respected.

For instance, just 6% of patients who selected "comfort measures only" died in a hospital, while 44% of those who selected "full treatment" died in the hospital.

Span notes that 41 other states have POLST registries, but the databases are not nearly as advanced. Span advocates for "push[ing] our states to pull in place full coverage and establish state registries," calling POLST "our best bet" for ensuring that advance directives are followed (Span, "The New Old Age," New York Times, 6/24).

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