Are Advance Directives Associated with Better Hospice Care?

OBJECTIVES: To describe individuals with advance directives at the time of hospice enrollment and to determine whether they have patterns of care and outcomes that are different from those of individuals without advance directives. DESIGN: Electronic health record-based retrospective cohort study with propensity score-adjusted analysis. SETTING: Three hospice programs in the United States. PARTICIPANTS: Individuals admitted to hospice between January 1, 2008, and May 15, 2012 (N = 49,370). MEASUREMENTS: Timing of hospice enrollment before death, rates of voluntary withdrawal from hospice, and site of death. RESULTS: Most participants (35,968, 73%) had advance directives at the time of hospice enrollment. These participants were enrolled in hospice longer (median 29 vs 15 days) and had longer survival times before death (adjusted hazard ratio = 0.62; 95% confidence interval (CI) 0.58-0.66; P < .001). They were less likely to die within the first week after hospice enrollment (24.3% vs 33.2%; adjusted odds ratio (aOR) = 0.83, 95% CI = 0.78-0.88; P < .001). Participants with advance directives were less likely to leave hospice voluntarily (2.2% vs 3.4%; aOR = 0.82, 95% CI = 0.74-0.90; P = .003) and more likely to die at home or in a nursing home than in an inpatient unit (15.3% vs 25.8%; aOR = 0.82, 95% CI = 0.77-0.87; P < .001). CONCLUSION: Participants with advance directives were enrolled in hospice for a longer period of time before death than those without and were more likely to die in the setting of their choice.