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Nursing home advance directives reduce use of health care services without affecting satisfaction or mortality

Advance directives, so-called living wills, enable individuals to decide what life-saving treatments they wish (or do not wish) to receive if their life is endangered, so that these wishes can be carried out if the patient is unable to voice these wishes at that time. Systematic implementation of an advance directive program in nursing homes apparently saves health care resources that would otherwise be spent on care not wanted by nursing home patients, concludes a study supported by the Agency for Healthcare Research and Quality (HS07878). The study found that such a program reduced hospitalizations and health care costs.

D. William Molloy, M.R.C.P., F.R.C.P.C., of McMaster University, and colleagues matched six Ontario nursing homes with a total of 1,292 residents into three pairs. They randomized one home in each pair to receive the Let Me Decide advance directive program and the other home in each pair to continue with their usual policies concerning advance directives. The Let Me Decide program provided a range of choices for levels of care for a serious illness, resuscitation, and nutritional support. It also included education programs for nursing home staff that included videotapes and in-service training, use of a health care facilitator, the requirement that physicians review and sign each directive, and steps to ensure that the directive was prominently placed in the medical record and transferred with patients who moved to an acute care hospital.

Homes that implemented the advance directive program reduced the rate of hospitalizations (0.27 hospitalizations per program patient versus 0.48 per control patient) and health care costs (saving about $1,200 per patient [Editor's Note: This study was conducted in Canada, but the savings are reported in U.S. dollars]). In addition, satisfaction with care was not significantly different in program and control nursing homes, and mortality rates were similar (24 vs. 28 percent).

The study did not collect evidence on the impact of the advance directive program on relief of patients' symptoms or patient quality of life.

See "Systematic implementation of an advance directive program in nursing homes," by Dr. Molloy, Gordon H. Guyatt, F.R.C.P.C., Rosalie Russo, and others, in the March 15, 2000 Journal of the American Medical Association 283(11), pp. 1437-1444.

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