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QUESTION: Does systematic implementation of an advance directive programme in nursing homes affect patient and family satisfaction and reduce healthcare costs?
Design
Randomised {allocation concealed}*, blinded {residents}*, controlled trial with 18 months of follow up.
Setting
6 nursing homes in Ontario, Canada, each with >100 residents.
Patients
1292 nursing home residents.
Intervention
6 nursing homes were matched in pairs on key characteristics and randomised 1 home per pair to either an advance directive programme (3 intervention homes, 636 patients) or to continue with usual policies of advance directives (3 control homes, 656 patients). The intervention homes used an advance directive programme called Let Me Decide (LMD), which consisted of healthcare choices related to life threatening illness, cardiac arrest, and nutrition. The LMD advance directive programme involved educating hospital and nursing home staff, residents, and families about advance directives. Trained nurses classified residents as being mentally competent or incompetent. Competent residents and family members of incompetent residents had the choice of completing the LMD advance directive.
Main outcome measures
Resident and family self reported satisfaction with health care received and involvement in decision making, deaths, and healthcare services use. All costs were reported in Canadian dollars.
Main results
In the intervention homes, 527 of 636 residents (83%) agreed to participate, and 444 of these (70%) completed advance directives. In the control homes, 606 of 656 residents (92%) agreed to participate, and 374 of these (57%) completed advance directives. Per resident, intervention homes had lower mean number of admissions to hospital (0.27 v 0.48, p=0.001), fewer hospital days (2.61 v 5.86, p=0.01), lower hospital costs (CN$1772 v $3869, p=0.003), and lower total healthcare costs (CN$3490 v $5239, p=0.013) than control homes. No differences existed between residents from intervention and control homes for satisfaction with health care or rate of death.
Conclusion
Systematic implementation of an advance directive programme in nursing homes reduced healthcare services use and costs without affecting patient satisfaction or mortality.
Commentary
Molloy et al have made a commendable effort to determine the effects of systematically offering advance directives to competent nursing home residents and family members of incompetent residents. Healthcare providers in the nursing homes and hospitals were alerted to the advance directives. This study showed that the use of advance directives led to less use of hospitals (with the associated cost savings) without adverse outcomes on patient satisfaction or mortality.
Teno,1 of the investigators of the SUPPORT study, praises Molloy et al for their well conducted study and promising results.1 She points out, however, that the data presented are insufficient to conclude that the directives provided adequate palliation if the decision was not to admit to hospital. Other outcomes could have been considered, such as quality of life rather than patient satisfaction.
Although 90 of the directives were completed by patients (49% of those interested and deemed capable), families of patients who were “mentally incompetent” (78% of those interested) completed 305 directives. Choices by patients were similar to those made by their families. A previous study,2 however, has shown that patient utilities for poor health are greater than anticipated by their families and the value of advance directives completed by family members has been questioned.
Perhaps the most interesting finding is that, with a systematic educational effort, patients, their families, and providers can be made more aware of the many management options available, even when technology intensive interventions, other than cardiopulmonary resuscitation, are no longer desired. This can be done at no excessive cost.
Footnotes
Source of funding: Agency for Healthcare Research and Quality.
For correspondence: Dr D W Molloy, Geriatric Research Group, Hamilton Health Sciences Corporation, McMaster University, 711 Concession Street, Hamilton, ON L8V 1C3, Canada. Fax +1 905 575 5121. Abstract and commentary also appear in ACP Journal Club.
↵* Information provided by author.