Hospice use not rising with end-of-life planning


A record 72 percent of elderly people had created advance directives in 2010 to guide their end-of-life care. That’s up from 47 percent in 2000, according to research from the University of Michigan (UM) and the Veterans Affairs Ann Arbor Healthcare System.

“Given the aging population, there’s been a great push to encourage more people to complete advance directives with the idea that this may increase hospice care and reduce hospitalization for patients during the last six months of life,” said the study’s lead author, palliative care specialist Maria Silveira, MD.

However, the study—which was published in the Journal of the American Geriatrics Society—found that hospitalization rates and deaths in hospitals remained the same.

“We found that while there’s an upward trend in creating these documents, it didn’t have much bearing at all on hospitalization rates over the decade,” Dr. Silveira said.

About the study

Data came from the UM’s Health and Retirement Study, a long-term research project involving more than 26,000 U.S. adults over age 50. The study collects information about a variety of topics, including health insurance, physical health and health care expenditures.

The sample for the study on advance directives included 6,122 people age 60 and older who died between 2000 and 2010, the most recent data available for the biennial study.

Based on responses to surveys completed by proxies (such as family or friends of the deceased), researchers learned that 6,005 people in the sample had prepared one or both of the following documents to guide their end-of-life care:

  • A living will. This is a legal document that spells out what kind of medical treatment you want near the end of life.
  • A durable power of attorney for health care. Also a legal document, this lets you name the person you want (a proxy) making medical decisions for you if you can’t make them yourself.

According to background information in the study, conventional wisdom has held that advance directives would result in spending less money on unwanted, aggressive treatment at the end of life and that people would be less likely to die in hospitals.

However, of the sample group for this study:

  • 38 percent died in the hospital
  • 27 percent died in their homes
  • 23 percent died in long-term care facilities
  • 8 percent died in hospice facilities

The findings suggest that several things are going on, said Dr. Silveira. One is that a piece of paper cannot control the likelihood of a person being hospitalized before death. A more direct and detailed conversation with family members or proxies may be needed for that to happen.

However, a second finding is that the increase in advance directives suggests that people are less timid about broaching the subject with loved ones, she said.

The take-home message
People with advance directives are more likely to have their wishes for treatment respected, according to the study’s authors. But the documents may not be enough in some cases.

“It may be that conversations in which individuals are given the choice not to be hospitalized and are provided with the appropriate support to safely and comfortably stay home are much more likely to affect hospitalization rates than advance directives are,” the study concluded.

The National Institutes of Health’s new NIHSeniorHealth site offers information about preparing for end-of-life treatment, as well as definitions of different types of care and legal directives.


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