Mandating advance directives
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- Eltorai, A.E.M. & Besdine, R.W. Aging Clin Exp Res (2014) 26: 315. doi:10.1007/s40520-013-0167-x
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As the population ages, end-of-life care (EOLC) costs become an increasingly pressing subject. Advance directives (ADs) are legal documents that allow individuals to convey their decisions about EOLC. Although ADs have been shown to reduce EOLC costs, most people do not have ADs. To address this issue, we propose that Congress instruct the Centers for Medicare and Medicaid Services to collect ADs from Medicare beneficiaries. Because ADs can improve care and reduce unnecessary spending, this solution would likely be attractive to a broad coalition of support from providers, insurers, and the public.
KeywordsAdvance directivesEnd-of-life carePolicy
Advance directives (ADs) are legal documents that allow individuals to convey their decisions about end-of-life care (EOLC). ADs are completed ahead of time, when individuals are capable of choosing for themselves. ADs increase an individual’s autonomy. ADs allow for clear communication of an individual’s wishes to family, friends, and health care professionals. ADs can address the use of dialysis, ventilators, resuscitation, organ or tissue donation, tube feeding and any other health care intervention specified as desired or not desired. Per the 1990 Supreme Court ruling Cruzan v. Director, Missouri Department of Health, all individuals are free to choose as much or as little care as they want. An individual can delegate a durable power of attorney for health care decision-making to a trusted person to make health care decisions if the individual becomes unable to do so. Individuals can modify their ADs at any time. ADs can help insure that people get only the care they want, and avoid getting less or more care than they desire. Thinking about EOLC early is essential for optimal, non-futile, cost-effective, compassionate care.
As the population ages, EOLC costs become an increasingly pressing subject. There are approximately 76 million “Baby Boomers”—those born in the US between 1946 and 1964 . The Baby Boomers began turning 65 years old in 2011. By 2030, Americans age 65 and over are projected to constitute 19 % of the population, including 8.7 million individuals over 85 . Moreover, increased longevity due to healthier lifestyles (we hope) and medical advances—e.g., treatment of cardiac disease and reduced smoking rates—will also contribute to increasing numbers of elderly people .
Health care is expected to consume 19.5 % of the GDP by 2017 , and 32 % by 2030, or $16 trillion . EOLC accounts for a large portion of total US health care spending. EOLC often consumes expensive services, such as hospital and ICU stays, hospice, outpatient care, physician care, home health, and skilled nursing facility care . Five percent of the population is responsible for 49 % of the overall US medical spending . Health care costs in the last year of life constitute 22 % of all US medical expenditures . Per capita health expenditures for people older than 75 are five times higher than those age 25–34 . There is widespread agreement that EOLC conversations between patients and their physicians about patient wishes often result in ADs that limit intensive interventions and reduce EOLC costs .
EOLC accounts for 25–30 % of total Medicare spending . As Medicare becomes the primary insurer for an increasing number of individuals, the cost to the federal government will increase. Medicare enrollment is expected to increase by 1.6 million annually, leading to a total of nearly 81 million beneficiaries by 2030 . The aging of the population is expected to account for 52 % of the growth in spending on federal health programs over the next 25 years, and that growth has been repeatedly described as unsustainable .
Chronic disease becomes increasingly common with age. Approximately 80 % of American seniors have at least one chronic condition, and most have more than one . Patients with chronic conditions, and especially multiple ones, account for 84 % of US health care spending . The number of chronic conditions is directly related to the number of avoidable hospital admissions . Long-term care spending for older Americans will reach $346.1 billion by 2040 . EOLC costs are substantially increased by futile care . Most people do not want futile care, and ADs are one important tool to reduce futility and thus health care costs.
ADs have been shown to reduce EOLC costs [10, 19]. However, most people do not have ADs, and even when patients have executed one, it often is not available when needed [20–22]. Most people do not think of EOLC until it is too late. Without ADs, providers and family members have difficulty knowing when to stop treatment, and frequently wait until their loved one is very close to dying. In addition, most physicians whose patients actually have ADs are not aware that the document exists [21, 23].
Why do so few people have ADs? Few people oppose the use of ADs. Ninety-three percent of patients express the wish to have ADs . Approximately 84 % of the public supports laws that would allow terminal patients to choose whether or not to be kept alive .
The most commonly cited barrier to AD completion is lack of physician initiative . Patients expect AD counseling from health care workers; however, there is little incentive for health care workers to do so. Only 12 % of patients with ADs have received counseling from their primary care providers . The Patient Self-Determination Act of 1990 only requires hospitals to ask patients if they have an AD. Getting patients to complete ADs requires a system change.
We propose that Congress instruct the Centers for Medicare and Medicaid Services (CMS) to collect ADs from Medicare beneficiaries. CMS standards typically are subsequently adopted by private health insurance companies, including those for reimbursement, diagnosis-related groups, and coverage (e.g., lung volume reduction surgery for severe emphysema). The position statement of the American Geriatrics Society is that “national and state policies should encourage patients and those that care for them to engage in advance care planning discussions” . Because ADs can improve care and reduce unnecessary spending, this solution likely would be attractive to a broad coalition of support from providers, insurers, and the public.
As implementation of the Affordable Care Act progresses and the number of Medicare beneficiaries grows, encouraging and facilitating ADs becomes particularly timely. When individuals first enroll in Medicare, and, after subsequent broad adoption by the private sector, insurers can simply process completion of ADs. The completed ADs can be securely filed and accessed by health care providers in times of need. Moreover, providers nationwide will be able to access the ADs, which will optimize EOLC care for everyone. Having the insurance industry collect the documents and federal storage will create a secure, national AD repository. The proposed solution will help lower national health care costs and ensure that more patients receive the care they actually want.
Financial support provided by Rhode Island Public Health Institute and Arnold P. Gold Foundation.
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.