Death panelists unite! Advance directives restrain high-billing MDs

Oct 11, 2011

In 2006, Medicare (we) spent 25% of our dollars on treatment for people in their last year of life. The debate rages, waged with euphemism in public and painful, conflicting emotions in private: how can we let Grandma go peacefully and with dignity, without feeling too guilty or ending up in front of a Senate subcommittee?

Nicholas et al used survey responses and linked Medicare data from 3,302 participants in the Health and Retirement Study who had recently died, in order to shine additional light on the effects of having an advance directive on end-of-life care. Here's what they found:

Mean age at death was 83 years old.
61% had a living will or a durable power of attorney.
39% had completed a treatment-limiting advance directive.
70% were hospitalized at least once in the last 6 months of life.
41% died in a hospital.

Those 39% with treatment-limiting advance directives did get less medical treatment at the end of life:

34% vs. 39% received life-sustaining treatment (mechanical ventilation, tracheostomy, PEG tube, hemodialysis, et al.)
37% vs 43% died in-hospital.
40% vs. 26% used hospice services.

Interestingly, overall median Medicare spending in the last 6 months of life did not vary according to whether someone had a treatment-limiting advance directive. (This was all linked to the Dartmouth Atlas, which describes the enormous geographic variability in treatment intensity and Medicare expenditures at the end of life.) Advance directives did change Medicare spending, depending on where beneficiaries lived:

People from low-spending regions were more likely to have advance directives. People who were white, affluent, and well-educated were also more likely to have advance directives.
But in these low-intensity & spending regions, advance directives didn't reduce end-of-life Medicare spending. (Editorial note: That's probably because these areas are already characterized by a culture of restraint by physicians and reasonable expectations by patients with a high degree of forethought and planning around end-of-life).
However, in high-spending regions, having an advance directive was associated with about a $6,000 lower spending in the last 6 months of life, or $33K vs. $39K.

Editorial translation: In areas with a culture of high-billing physicians, or fight-to-the-end-at-any-cost families, there needs to be an advance directive as a writ of cease-and-desist to call off the interventionalists. And that barely makes a dent, bringing costs down to $36K per patient, compared to the low-spending regions that spent only $21K per patient in the last 6 months of life (with or without a directive present), due to pre-existing culture and practice differences.

Nicholas LH et al. Regional Variation in the Association Between Advance Directives and End-of-Life Medicare Expenditures. JAMA 2011;306(13):1447-1453.