Study Shows More than One-Quarter of Elderly Individuals Require Surrogate Decision-Making Near the End of Life

FINDINGS:

• Of the 3746 elderly adults (non-Veterans) in this study, 26.8% required decision-making at the end of life and lacked decision-making capacity. Thus, surrogate decision-making was often required.
• Of those requiring surrogate decision-making, 67.6% had advance directives.
• Individuals who authored advance directives received care that was strongly associated with their preferences. And those who requested all care possible were far more likely to receive aggressive care compared to those who did not request it.
• Individuals with advance directives preferred limited (92.7%) and comfort care (96.1%) more than all care possible (1.9%).
• Cognitive impairment, cerebrovascular disease, and nursing home status were associated with the need for decision-making and lost decision-making capacity before death; but these characteristics were so common (present in 65.3% of the study population) as to not be clinically useful risk factors.

BACKGROUND:
Currently, up to 70% of community-dwelling older adults have completed an advance directive detailing their preferences for life-sustaining treatment (via a living will) and/or their choice for a surrogate decision-maker (via a durable power of attorney for health care). However, among recent discussions of healthcare reform, questions arose regarding the value of advance directives. This study sought to determine the prevalence of lost decision-making capacity near the end of life - and to test the association between preferences documented in advance directives and outcomes of surrogate decision-making. Using data collected by the Health and Retirement Study (funded by the National Institute on Aging), a longitudinal survey of a nationally representative cohort of U.S. adults, investigators focused on 3746 adults aged 60 and older who died between 2000 and 2006, and for whom a proxy answered a study directed exit interview after the participant's death.

LIMITATIONS:

• The proxies who provided key data were subject to recall and social desirability bias, especially with regard to subjective details such as patient preferences. Most proxies were interviewed, on average, 13 months after the subject died.

AUTHOR/FUNDING INFORMATION:
Drs. Silveira and Langa are part of HSR&D's Center for Clinical Management Research in Ann Arbor, MI, which provided some funding support for this study.

Silveira M, Kim S, and Langa K. Advance Directives and Outcomes of Surrogate Decision-Making Before Death. The New England Journal of Medicine April 1, 2010;362(13):1211-1218.