by Liam Davenport
February 5, 2013
Advance care planning (ACP) for older adults results in improved quality of care at the end of life, with less in-hospital death and the increased use of hospice services, the results of a study indicate.
“There appears to be utility in each aspect of ACP that was studied-completing an AD [advance directive], assigning a DPOA [durable power of attorney], and having an ACP discussion with next of kin-albeit in somewhat different ways,” says Kara Bischoff (University of California at San Francisco, USA) and colleagues.
The team looked at data from 4394 Medicare beneficiaries enrolled in the cohort Health and Retirement Study who died between 1993 and 2007. Individuals were at least 50 years of age at enrollment and did not die before age 65 years.
Overall, 76% of participants engaged in ACP, with 2.8% having an AD only, 9.3% a DPOA only, 13.9% an ACP discussion only, 9.4% an AD and a DPOA, 5.9% an AD and an ACP discussion, 8.8% a DPOA and discussion, and 26.0% all three components.
The mean time from completion of an AD to death was 61 months, while the time to death after DPOA completion was 56 months. The use of ACP increased after 1993, with more than half of patients who died during or after 1997 engaging in ACP.
Patients who engaged in ACP were significantly less likely to die in the hospital, more likely to be admitted to a hospice, and less likely to have a hospice stay of no more than 3 days than those who did not engage in ACP.
Furthermore, having an AD alone was linked to a 69% reduced risk for hospital stays of more than 14 days in the last month of life, while having an AD or a DPOA was associated with an increase in hospice admission (67% and 40%, respectively) and a reduced likelihood of a hospice stay of 3 or fewer days (12% and 7% reduction, respectively).
The investigators conclude in the Journal of the American Geriatrics Society: “The finding that having an AD, a DPOA, and an ACP discussion is each associated with end-of-life care has implications for traditional practitioners, who have focused primarily on completing ADs, as well as for practitioners who see minority populations, where studies suggest a general preference for discussing ACP but reluctance to sign ACP documents.
“It may be that neither approach alone has the full effect of multimodal ACP.”