Association Between Advance Directives and Quality of End‐of‐Life Care: A National Study

OBJECTIVES: To examine the role of advance directives (ADs) 10 years after the Patient Self‐Determination Act. DESIGN: Mortality follow‐back survey. SETTING: People who died in a nursing home, hospital, or at home. PARTICIPANTS: Bereaved family member or other knowledgeable informant. MEASUREMENTS: Telephone interviewers that asked about the use of written ADs, use of life‐sustaining treatment, and quality of care by asking whether staff provided desired symptom relief, treated the dying with respect, supported shared decision‐making, coordinated care, and provided family with the needed information and emotional support. RESULTS: Of the 1,587 people who died, 70.8% had an AD. Persons who died at home with hospice or in a nursing home were more likely to have an AD. In addition, those with an AD were less likely to have a feeding tube (17% vs 27%) or use a respirator in the last month of life (11.8% vs 22.0%). Bereaved family members who reported that the decedent did not have an AD were more likely to report concerns with physician communication (adjusted odds ratio (AOR)=1.4, 95% confidence interval (CI)=1.1–1.6) and with being informed about what to expect (AOR=1.2, 95% CI=1.0–1.3). No statistically significant differences were observed in other outcomes. Even in those with an AD, important quality concerns remained; one in four reported an unmet need in pain, one in two reported inadequate emotional support for the patient, and one in three stated inadequate family emotional support. CONCLUSION: Bereaved family member report of completion of an AD was associated with greater use of hospice and fewer reported concerns with communication, yet important opportunities remain to improve the quality of end‐of‐life care.