What Difference Do Advance Directives Make?
The results were surprising: The advance directives only saved money in areas where Medicare’s end-of-life costs are high. Think Florida and New York. In areas where Medicare’s costs are already low — say, Minnesota — there was no change in spending….
The big difference, in fact, was that patients with end-of-life directives in high-costs areas were more likely to die outside of the hospital than patients who didn’t have end-of-life directives. That suggests the end-of-life directives do not prevent emergency measures at the end of life. If a patient is about to die, doctors try and save them. But in a non-emergency context, when doctors have time to talk with the patient’s family about treatment options, they do prevent certain types of life-prolonging treatment.
Ezra Klein post. Study here [gated, but with abstract].
My impression is that, for reasons of ethics and potential legal liability, hospitals mostly do what they do regardless of advanced directives.
You can anticipate what might occur, but the providers must deal with what actually does occur at end of life, and the professional standards and requirements they must meet then cannot, in many cases, be anticipated.
It’s hard to imagine that DNRs and advanced directives don’t save money. But, by the time a DNR comes into play, most of the money has already been spent on care that has any value.
I’m getting the impression that advance directives don’t make much difference.
From what I can gather, more hospitals are trying to get more patients to use them. DNR’s reduce risk-adjusted mortality measures, which will likely feed into Medicare reimbursements in the near future. Hospitals are scared of being labeled as killing machines and are taking measures to make their in-hospital deaths look better. This includes shuffling end-of-life patients to hospice or palliative care before the patient codes in the ER.