Treatment during the last year of life accounts for as much as one-quarter of Medicare spending, but whether advanced directives affect end-of-life spending or alter the course of treatment is unclear. Nicholas and colleagues used data from the Health and Retirement Study that were linked to Medicare claims to evaluate the relationship between advanced directives and the cost and aggressiveness of end-of-life care in U.S. regions with high, medium, and low end-of-life expenditures.

Of 3,302 decedents included in the survey, 61% had a living will or designated durable power of attorney, and 39% had completed a written treatment-limiting advanced directive.

In high-spending regions, having a treatment-limiting advanced directive was associated with lower end-of-life expenditures, but not in low- and medium-spending regions. Treatment-limiting advanced directives were also associated with lower rates of in-hospital death in high- and medium-spending regions but not in low-spending regions. In high- and medium-spending regions, patients with advanced directives were more likely to receive hospice care than those without a directive.

The authors suggest that having an advanced directive may be especially important for patients living in high-spending regions where aggressive end-of-life care is the norm.-KR

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