Key senators announced on August 13th that the end of life provision would be dropped from the health care reform bill. Senator Charles Grassley was quoted saying that the provision would be dropped because of fears that it would be misinterpreted or implemented incorrectly. The provision to include Medicare funding for advance directive (AD) discussions between practitioners and patients roused active and, at times vitriolic, discussions on radio talk shows and social networking sites. However, the concept of ADs is based on America’s core ethical principle of autonomy. While Nancy Cruzan and Terri Schiavo brought national attention to the issue for a brief time, recent data suggest while only ~30% of adults have completed an AD(1–3), 93% of adults would like to discuss ADs with their physician.(4) The reality is that these conversations are time consuming, incompatible with 20 minute appointments, and are not billable. The health care reform bill would have allowed physician compensation for an AD discussion every five years, provided guidelines, and suggested a mechanism to track the quality of these discussions. The bill states (page 430), that an AD consultation could take place more frequently if there were a significant change in the patient’s health status. Those opposed to the end of life provision interpret this to mean that discussing ADs with one’s physician will hasten death.
Between 2003 and 2005, we interviewed 464 patients at an index hospitalization and asked if anyone had discussed ADs with them. A concurrent chart review documented the presence or absence of completed ADs in the medical record (Do Not Resuscitate orders (the majority of which are written three days before death(5)), and other broader types of ADs (living will, Durable Power of Attorney, a form like Five Wishes)). To date, 123 (27%) of these patients have died. Using logistic regression, we found no association between having had an AD discussion or the presence of ADs in the medical record and death at one year or death over the complete follow up period after adjusting for age and disease severity (Table 1). While this study was not powered to detect small differences in mortality or risk of death, it does provide some data to inform the current national debate that favors honoring patient wishes to have AD discussions and confirming that there is no evidence that these discussions or completing an advance directive lead to harm.
Table 1.
No Significant Association between AD Discussions or ADs and Death and One Year or Death from 2003–2009
| Death at one year | Death 2003–2009 | |
|---|---|---|
| Odds ratio (95%CI) | ||
| Model of AD Discussions | (c= 0.81) | (c=0.82) |
| AD Discussions | 1.2 (0.69–2.24) | 1.6 (0.93–2.59) |
| Model of AD on chart | (c= 0.83) | (c=0.82) |
| AD on chart | 1.4 (0.61–3.03) | 1.1 (0.51–2.25) |
Contributor Information
SM Fischer, Division of Health Care Policy and Research, University of Colorado Denver.
SJ Min, Division of Health Care Policy and Research, University of Colorado Denver.
JS Kutner, Division of General Internal Medicine, University of Colorado Denver.
Reference List
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