A study published today finds that record numbers of people are completing advance directives to navigate end-of-life medical care. The research, published in Journal of the American Geriatrics Society, looked at data from the Health and Retirement Study, a nationally-representative sample of older Americans that is conducted by the U-M Institute for Social Research on behalf of the National Institute of Aging.
After looking at data of more than 6,000 individuals, the study found that more people are completing advance directives: from 47% in 2000 up to 72% in 2010.
An advanced directive is “anything you prepare in advance of your death,” according to lead study author Dr. Maria J. Silveira. There are two kinds: living wills (LW) and a surrogate designation form or “durable power of attorney for health care” (DPAHC). A living will covers your wishes in regards to life sustaining treatment like CPR. Questions on a living will might ask range from if you want your organs donated to how aggressive you want your care to be if you ended up in a vegetative state. A DPAHC form appoints someone to make medical decisions on your behalf if you are unable to make them.
To examine trends in use of these documents, Dr. Silveira and colleagues looked the data of people who died in the study population between 2000-2010 and asked how many of those people had a living will or a health care proxy. Other research has suggested that more people might have these documents now versus a few years ago but no one had examined whether these increases were part of an increasing trend.
The 25% increase that they found is good news, according to Dr. Silveira: “it’s great because we know that these documents ensure that people get care that is consistent with what they want. Aggressiveness of care tends to match what patients want if they have an advance directive- which is good.”
While the study did not address why advance directives are more prevalent, Dr. Silveira speculates that there are multiple factors driving the trend: “I think they’ve become more familiar with the elderly population, she said. “This is the baby boomer population and I believe they are more inclined to take control over their lives- it’s a cultural shift related to the aging of the baby boomer population. Also as people live longer they see more of their friends live and die in the hospital so they have more of the personal experience of what can happen if you end up in the hospital without properly preparing for it.”
While the use of living wills and the use of DPAHC (surrogate designation) forms both increased overall- DPAHCs were more popular and were more common than living wills in every year over the past ten years. Additionally, the rate of completion for DPAHC’s
Dr. Silveira thinks that trend is appropriate: “the single most important thing is to appoint a health care proxy and have a conversation so that they have a general sense of what kinds of things are most important to you. The living will can only cover so much. The proxy is more flexible and important.”
Not only is it more flexible, it also may be a more gentle way to start thinking about end of life care. Instead of diving right into questions of CPR and specific guides for end of life care, designating a healthcare proxy is more a matter of identifying who you trust to make decisions on your behalf. “I think that the easiest question is to think about who in your life you would trust to make a decision if something happened and you couldn’t make decisions for yourself,” says Dr. Silveira, “that’ not a difficult thing to think through- most people can think about that off the top of their heads. A little harder to is to go that person and ask them to accept that responsibility and ask if you can talk a little about the things that matter to you.”
Appointing a proxy is especially important for certain people, especially those who have nontraditional family relationships- for example if you are in a committed relationship with someone but you are not legally married. If there is an emergency they will turn to your family. “The default is usually spouse, then children then parents. But if those defaults are not consistent with your preference– you absolutely should have one of these forms completed,” says Dr. Silveira.
Hayley Goldbach, MD
2013-2014 Stanford-NBC News Global Health and Media Fellow