Ad­vance di­rec­tives en­ter equa­tion

Ad­vance di­rec­tives have value, but some in in­dus­try cite draw­backs, too

Modern Healthcare - - Front Page - Jen­nifer Lubell

Richard Raskin, vice pres­i­dent of med­i­cal af­fairs at Ge­n­e­sis Health­Care Corp. in An­dover, Mass., is all in fa­vor of ad­vance di­rec­tives. As the over­seer of a large chain of nurs­ing fa­cil­i­ties that treats peo­ple in short-term rehabilitation or those dis­charged from the hos­pi­tal that need more in­sti­tu­tional care, Raskin makes sure that ev­ery pa­tient signs a writ­ten edict for end-of-life care.

In his view, ad­vance di­rec­tives are crit­i­cal for long-term-care pa­tients, the el­derly and the chron­i­cally ill. “De­ci­sions on end-of-life care are very im­por­tant—they’re very fo­cused on mak­ing sure ev­ery­one has an ad­vance di­rec­tive in place to iden­tify what the pa­tient’s needs will be.”

Not only that, they save money be­cause “they help pre­vent un­nec­es­sary fu­tile treat­ments at the end of life as part of a well-de­lin­eated care plan,” he says. They also help to avoid hos­pi­tal­iza­tions. They keep pa­tients in nurs­ing fa­cil­i­ties, “which is good for our rev­enue,” and they save money be­cause peo­ple in these in­stances of­ten ask for less ag­gres­sive care, which means fewer lab­o­ra­tory tests, X-rays and med­i­ca­tions.

For any is­sues not ad­dressed in an ad­vance di­rec­tive, it’s im­por­tant to have a “health­care proxy,” some­one who knows what the pa­tient’s wishes are, he says.

Oth­ers in the in­dus­try say these sit­u­a­tions aren’t that cut-and-dried. Even if an ad­vance di­rec­tive is writ­ten, and a trusted friend or fam­ily mem­ber has been cho­sen to ad­min­is­ter a pa­tient’s wishes, things can go askew.

An ad­vance health­care di­rec­tive, also known as a liv­ing will, per­sonal di­rec­tive, ad­vance di­rec­tive or ad­vance de­ci­sion, are in­struc­tions given by in­di­vid­u­als spec­i­fy­ing what ac­tions should be taken in the event they are no longer able to make de­ci­sions be­cause of ill­ness or in­ca­pac­ity, and ap­points a per­son to make such de­ci­sions on their be­half.

They have been in ex­is­tence for a long time—a fed­eral law passed in 1990 for­mal­ized these di­rec­tives in all 50 states, which have since in­creased their vis­i­bil­ity.

Ad­vance di­rec­tives are a well-mean­ing as­sump­tion, but mak­ing de­ci­sions about endof-life care is of­ten a tricky propo­si­tion, says Peter Ditto, pro­fes­sor and chair­man of psy­chol­ogy and so­cial be­hav­ior at the Uni­ver­sity of Cal­i­for­nia at Irvine. He has con­ducted stud­ies on the ef­fec­tive­ness of these doc­u­ments.

The di­rec­tive en­ables peo­ple to record what type of care they want when they are young, healthy and cog­nizant, but the ad­vance di­rec­tive also as­sumes that peo­ple will know what they want in the fu­ture, he says. In his view, it’s un­rea­son­able to make younger peo­ple do this, be­cause peo­ple’s wishes change over time, in­clud­ing de­ci­sions on med­i­cal wishes.

“If they’re not feel­ing very well, peo­ple tend to want less treat­ment, if they’re feel­ing healthy, they want more treat­ments,” Ditto says. There’s al­ways that as­sump­tion the ad­vance di­rec­tive has com­mu­ni­cated the per­son’s wishes ef­fec­tively, but in prac­tice this is dif­fi­cult to carry out, he says. “They’re a great idea, but they’re not a panacea.”

On av­er­age, about 50 mil­lion adults in the United States have an ad­vance di­rec­tive, “but there’s no good data that ev­i­dences the num­bers have climbed,” says Nathan Kot­tkamp, a part­ner at the McGuireWoods law firm in Rich­mond, Va., who has made a ca­reer of pro­mot­ing ad­vance di­rec­tives. A 2008 HHS re­port to Congress es­ti­mated that only 18% to 36% of Amer­i­cans had com­pleted an ad­vance di­rec­tive.

Kot­tkamp, who has been spear­head­ing Na­tional Health­care De­ci­sions Day, an an­nual push since 2008 to get peo­ple to write up ad­vance di­rec­tives, says he be­lieves he has made head­way in flash­ing a spot­light on the is­sue.

This year’s event alone in­spired more than 3,850 peo­ple to ex­e­cute an ad­vance di­rec­tive, a 3% in­crease over 2009, he says. In ad­di­tion, 347,854 mem­bers of the pub­lic were con­firmed to have re­ceived ad­vance di­rec­tive in­for­ma­tion as part of the event, a 350% in­crease over 2009. And nearly 600,000 fa­cil­ity staff mem­bers or or­ga­ni­za­tional staff mem­bers re­ceived in­for­ma­tion about the event, he says.

All of this is progress, but even Kot­tkamp con­cedes that a pam­phlet won’t be enough to drive in­ter­est among providers—or pa­tients. Poor com­pen­sa­tion to physi­cians is one of the rea­sons why con­ver­sa­tions about ad­vance di­rec­tives aren’t tak­ing place, but the is­sue has been tainted in the wake of the re­cent health re­form de­bates, Kot­tkamp says.

It was a pro­vi­sion in the health re­form bill to com­pen­sate physi­cians for hav­ing con­ver­sa­tions with pa­tients about ad­vance di­rec­tives that spurred the fre­netic “death pan­els” ar­gu­ment that doc­tors would push pa­tients to say they didn’t want to be on ma­chines, in an ef­fort to save money, he says.

That pro­vi­sion was even­tu­ally stripped out of the bill, which is un­for­tu­nate, be­cause it made sense, Kot­tkamp says. In his view, the is­sue was more about pa­tients avoid­ing un­nec­es­sary tests and treat­ment as op­posed to sav­ing money “by pulling the plug.”

Ditto agrees. “It’s too bad that didn’t take ef­fect, be­cause that’s what the sys­tem needs, to pay doc­tors to con­sult pa­tients on end-oflife care.” Ad­vance di­rec­tives are about writ­ing some­thing down, but a lot of times doc­tors don’t do the things they need to do for fear of not hon­or­ing some­one’s wishes or

About 50 mil­lion adults in the United States have an ad­vance di­rec­tive.

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