Brief Communication: The Relationship between Having a Living Will and Dying in Place

20 July 2004 | Volume 141 Issue 2 | Pages 113-117

Background: Living wills, a type of advance directive, are promoted as a way for patients to document preferences for life-sustaining treatments should they become incompetent. Previous research, however, has found that these documents do not guide decision making in the hospital.

Objective: To test the hypothesis that people with living wills are less likely to die in a hospital than in their residence before death.

Design: Secondary analysis of data from a nationally representative longitudinal study.

Setting: Publicly available data from the Asset and Health Dynamics Among the Oldest Old (AHEAD) study.

Patients: People older than 70 years of age living in the community in 1993 who died between 1993 and 1995.

Measurements: Self-report and proxy informant interviews conducted in 1993 and 1995.

Results: Having a living will was associated with lower probability of dying in a hospital for nursing home residents and people living in the community. For people living in the community, the probability of in-hospital death decreased from 0.65 (95% CI, 0.58 to 0.71) to 0.52 (CI, 0.42 to 0.62). For people living in nursing homes, the probability of in-hospital death decreased from 0.35 (CI, 0.23 to 0.49) to 0.13 (CI, 0.07 to 0.22).

Limitations: Retrospective survey data do not contain detailed clinical information on whether the living will was consulted.

Conclusion: Living wills are associated with dying in place rather than in a hospital. This implies that previous research examining only people who died in a hospital suffers from selection bias. During advance care planning, physicians should discuss patients' preferences for location of death.

Editors' Notes Context Do living wills affect where people die in the United States? Contribution Among a nationally representative sample of 539 people older than 70 years of age who died in the early 1990s, 40% had living wills. Living wills almost always addressed wishes to limit or withhold treatments in certain circumstances and to prevent pain. Compared with those without living wills, decedents with living wills more often died outside of the hospital, had particular treatments withheld, and received palliative treatment to keep them pain-free and comfortable. Implications Living wills seem to be associated with dying in a setting other than a hospital. –The Editors

 

Author and Article Information

From the Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, Pennsylvania.

Preliminary results were presented at the 53rd Annual Scientific Meeting of the Gerontological Society of America, Chicago, Illinois, 14–18 November 2001.

Grant Support: By the National Institute on Aging (grant 1R0 3AG18811-01, "Advance Directives Among the Oldest Old," Howard B. Degenholtz, principal investigator). Dr. Arnold was supported by the Project on Death in America Faculty Scholars Program, Greenwall Foundation, Ladies Hospital Aid Society of Western Pennsylvania, International Union Against Cancer Yumagiwa-Yoshida Memorial International Cancer Study Grant Fellowship, and LAS Trust Foundation.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Howard B. Degenholtz, PhD, Center for Bioethics and Health Law, University of Pittsburgh, 3708 Fifth Avenue, Suite 300, Pittsburgh, PA 15213; e-mail, degen{at}pitt.edu.

Current Author Addresses: Drs. Degenholtz: Center for Bioethics and Health Law, University of Pittsburgh, 3708 5th Avenue, Suite 300, Pittsburgh, PA 15213.

Dr. Arnold: Montefiore University Hospital, 9 South, 3459 Fifth Avenue, Pittsburgh, PA 15213.

Dr. Rhee: Glennan Center for Geriatrics and Gerontology, Eastern Virginia Medical School, Hofheimer Hall, Suite 201, 825 Fairfax Avenue, Norfolk, VA 23507-1912.

Author Contributions: Conception and design: H.B. Degenholtz, Y. Rhee.

Analysis and interpretation of the data: H.B. Degenholtz, Y. Rhee, R.M. Arnold.

Drafting of the article: H.B. Degenholtz, Y. Rhee, R.M. Arnold.

Critical revision of the article for important intellectual content: H.B. Degenholtz, R.M. Arnold.

Final approval of the article: H.B. Degenholtz.

Statistical expertise: H.B. Degenholtz, Y. Rhee.

Obtaining of funding: H.B. Degenholtz.

Administrative, technical, or logistic support: Y. Rhee.

Collection and assembly of data: Y. Rhee.