Do Living Wills Affect the Setting Where People Die in the United States?

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The summary below is from the full report titled "Brief Communication: The Relationship between Having a Living Will and Dying in Place." It is in the 20 July 2004 issue of Annals of Internal Medicine (volume 141, pages 113-117). The authors are H.B. Degenholtz, Y. Rhee, and R.M. Arnold.

What is the problem and what is known about it so far?

Living wills allow people to explain in writing which medical treatments they do or do not want if they have a serious or terminal illness and are too ill to voice their wishes. Surveys show that many people in the United States favor having living wills. Many say that they would limit certain medical treatments if told that they were terminally ill. Also, many would prefer to die at home rather than in a hospital. However, only 20% of people in the United States have a living will. Evidence that these wills influence end-of-life care is mixed and sometimes scant. In particular, no studies address whether having a living will influences where people die.

Why did the researchers do this particular study?

To find out whether living wills affect where people die in the United States.

Who was studied?

539 people older than 70 years of age who died in the United States between 1993 and 1995.

How was the study done?

The researchers used data from a large study of older people born before 1924 who were living in their own home or in the home of a relative in 1993. Contacts for 539 of the seniors who had died by 1995 gave the researchers specific information about living wills and deaths. The researchers then compared this information between seniors who did and did not have living wills before their death.

What did the researchers find?

40% of the seniors had living wills. Living wills usually included wishes to prevent pain and limit or withhold treatments in certain circumstances. Compared with those without living wills, seniors with living wills more often received treatment to keep them pain-free and comfortable and also more often had other treatments withheld. The main finding was that those with living wills were more likely to die at home or in a nursing home rather than in a hospital.

What were the limitations of the study?

The researchers excluded 188 patients who died unexpectedly or suddenly. Medical charts were not available, so researchers could not see whether consultation of living wills was documented. Rather than other people consulting the living will and making decisions on patients' behalf, some people who prefer to die outside of the hospital who had living wills may have made decisions themselves.

What are the implications of the study?

Having a living will is associated with dying in a setting other than a hospital.