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