Relationship of Advance Directives to Hospital Charges in a Medicare Population

OBJECTIVE: There is a growing demand both for respect for patient autonomy regarding the use of sophisticated technology and for consideration of health care expenditures at the end of life. The major objective of this study was to assess the relationship between the documentation of a discussion of advance directives and hospital charges for Medicare patients during the last hospitalization of the patient's life. DESIGN: Multivariate analysis of a retrospective cohort. SETTING: Large (700+ beds), private university, tertiary care hospital. PATIENTS: All 474 patients who had Medicare listed as their primary insurer and who died in the hospital between January 1 and June 30 in 1990, 1991, or 1992. MAIN OUTCOME MEASURE: Total inpatient charges. RESULTS: The mean inpatient charge for the 342 patients without documentation of a discussion of advance directives was more than three times that of the 132 patients with such documentation (95. 305 vs 30, 478). This relationship remained statistically significant after controlling for severity of disease, use of an intensive care unit, and number of procedures. Demographics, length of stay, admitting service, admitting diagnosis, and previous admission to the study hospital did not contribute to the predictive model. CONCLUSIONS: During discussions of advance directives, patients often opt to limit the extent of care they desire in certain situations. Although the most appropriate setting for developing advance directives is not clear, the results of this study imply that an enormous cost savings to society may be realized if such discussions take place, while, at the same time, autonomous patient choice will be respected.