Advance Directives Are Usually Followed

Advance directives, which describe the medical care you
want to have if you're incapacitated, are honored most of the time, a study
shows.

''If you take time out to put together a living will or durable power of
attorney for health care, most often you get your wishes," says study
researcher Maria J. Silveira, MD, MPH, a  clinician scientist at the Ann
Arbor VA Medical Center and an assistant professor of medicine, University of
Michigan School of Medicine, Ann Arbor.

The study is published in The New England Journal of Medicine.

The results of her new study, Silveira concludes, support the continued use
of advance directives.

There are two types of advance directives: a living will or a medical power
of attorney, also known as a health care proxy. A living will informs your
doctor and your family about the type of treatment you'd want to receive if you
are unable to make your own medical decisions. A medical power of attorney
assigns a person -- called a health care proxy -- to make the decisions for
you.

Advance directives became more common after the passage of the Patient
Self-Determination Act in the U.S. 20 years ago, but debate about the
usefulness of the documents has been ongoing for several years, Silveira tells
WebMD.

During the recent health care reform debate, a proposal to pay back health
care providers for advance directives planning discussions through Medicare sparked controversy, raising concern that
these advance directives would result in denial of necessary care, Silveira
says.

Honoring Advance Directives

Silveira and her colleagues used data from the Health and Retirement study,
a nationally representative group of U.S. adults age 51 and older, taken every
two years.

They looked just at people 60 and older who had died between 2000 and 2006,
asking a family member or other informed person to answer questions about
circumstances and decisions after the participant's death, usually within 24
months of the death.

Among the 3,746 people 60 and above who died, 42.5% had to make treatment
choices and 70.3% of those did not have the ability to decide for
themselves.

One surprise: 67.6% of those who lacked decision-making ability had advance
directives -- either a living will, health care proxy, or both.

So were their wishes followed?

''What we found was, the agreement depended on what the patient wanted,"
Silveira tells WebMD.  "Almost everyone who wanted comfort care got it."
If they asked for limited care -- not the most aggressive but beyond comfort
care -- 83.2% got it, she found.

Only half of the 10 people who requested ''all care possible,'' the most
aggressive approach, got it. But Silveira says that was sometimes because ''all
care possible'' couldn't be given.

One example: A person with very low
blood pressure who wanted dialysis if needed would not be given it, she
says, as the dialysis would lower their pressure more and perhaps hasten
death.

The health care proxy wish was nearly always carried out, she found.
''Thirty percent of the [3,746] older adults needed surrogate decisions," she
says. "When they appointed a durable power of attorney for health care, 92% of
the time they got the decision maker they chose.''

Silveira's bottom line? "No one is claiming these things are perfect,'' she
says of advance directives. "But they are better than nothing. They are meant
to make a difficult situation a little bit less so for the family. Without
them, what else do we have?"

Advance Directives: Second Opinion

Not everyone agrees entirely with the study's conclusions. Muriel Gillick,
MD, a clinical professor of population medicine at Harvard Medical School and a
practicing physician, wrote an editorial to accompany the study. She finds a
health care proxy helpful but criticizes the living will as ''mostly
useless.''

Part of the problm, she says, is that the documents spell out preferences
for specific interventions, but that a patient can't really make informed
choices until he or she knows the pros and cons of the treatments, and that a
patient's preference may change once the condition is real, not
theoretical.

The study method could have affected the results. "The study relies on the
memories of friends or family members, an average of a year after the person's
death. One has to question the accuracy in terms of the details of those
memories," Gillick tells WebMD.

Both the passage of time and the usually heightened emotions at a time of
crisis could have affected the memories, she says.

Finding a health care surrogate in advance, however, is a good idea, Gillick
says. "Talking to a health care proxy is helpful."

The new study results, she says, demonstrate that talking about the goals of
medical care at a time of crisis or end of life seems to becoming more
acceptable to Americans.

Advance care planning should include a conversation with your health care
provider, she says. It should include a process of clarifying the patient's
current health status, talking about goals, and then designating a health care
proxy to work with the doctor in interpreting and carrying out the goals when
needed.

One program that uses this approach, she says, is called the Physician
Orders for Life-Sustaining Treatment, adopted in a dozen states and being
introduced in others.

By Kathleen Doheny
Reviewed by Laura Martin
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