McMaster study findings support the use of advance directives


[img_inline align=”right” src=”” caption=”Willie Molloy”]When older people and their families make choices regarding long term care they use fewer health care resources and seem to have no worse outcomes than when health care professionals make choices for them.

That's the major finding of a McMaster University study to be published March 15 in the Journal of the American Medical Association (JAMA). The Geriatric Research Group at McMaster studied results of a randomized controlled trial in six nursing homes in Ontario.

The study showed that when competent residents and families of incompetent residents made health care decisions for themselves or for their loved ones, these residents had fewer hospitalized days than when health care professionals made the decisions (2.61 days versus 5.86 days). Over a period of 18 months, people in the control homes had significantly more days in hospital, 3,551, compared to 1,378 in the Let Me Decide (LMD) group. LMD intervention homes reported 143 hospitalizations compared to 290 in the control homes.

The average hospital cost per resident for intervention homes was $1,772 and $3,869 for residents in control homes. Total health care costs were significantly lower for residents in the intervention homes ($3,490 versus $5,239) compared to the control residents.

“We believe that this study challenges us to look at how we are delivering health care to this population,” says Willie Molloy, professor of medicine at McMaster University and the principal investigator of the study. “We need to empower people to take control of their own health care and make decisions for themselves.”

The three pairs of nursing homes were randomized to receive the LMD advance directive program or to use regular advance directives such as “do not resuscitate.”

The objectives of the project were to examine the impact of using the LMD directive on the satisfaction with health care received, and with health care utilization and cost.

Advance directives are documents that people fill out to say what they would want in terms of treatment in the event that they become incompetent. LMD is a comprehensive advance directive that allows people to spell out the care they would want for life threatening illness, cardiac arrest and in the event that they can not swallow or feed themselves.

They can make choices depending on whether they are in a reversible condition with an acceptable quality of life, or in an irreversible condition with an unacceptable quality of life. The personal statement allows individuals to define for themselves what they would consider an irreversible condition.

There were 1,292 residents in the six nursing homes. In three of the LMD intervention homes, residents filled out the LMD directive and made explicit choices about their health care. They nominated proxies that would speak for them if a time came when they could not make treatment decisions. In the LMD homes, 70 per cent completed directives (63 per cent LMD and 7 per cent other directives).

In the control homes, there was no systematic implementation and they used regular directives, which were not as comprehensive. The most popular directive in the control homes was a “do not resuscitate” order. In the control homes, 57 per cent of residents had some treatment instructions.

There was a slight increase in satisfaction with health care received in the LMD homes after the program was implemented and no change in satisfaction in the control homes. However, people in the LMD homes had significantly less health care use and there were fewer deaths (28 per cent versus 24 per cent) in the LMD homes.

“The Let Me Decide directive increases patients' autonomy, takes family off the hook and allows health care workers to give people what they want. Otherwise, health care professionals feel obliged to “do everything to prolong life” when, in fact, they may be prolonging the dying process”, says Molloy.

“This is not what the vast majority of us would want. When one considers that there are five million people in nursing homes in the U.S. and 55,000 in Ontario alone, one starts to realize the impact of these findings. These numbers will triple in the next 30 to 50 years. We are going bankrupt in health care providing resources to people who don't want them, and we have just shown that they don't benefit from them.”

Molloy and Rosalie Russo, senior research co-ordinator, are currently writing a book on advance directives entitled Let Me Pass Gently – A Guide to Completing The “Let Me Decide” Advance Directive, to be released this month.