Systematic implementation of an advance directive program in nursing homes: a randomized controlled trial

JAMA. 2000 Mar 15;283(11):1437-44. doi: 10.1001/jama.283.11.1437.


Context: Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation.

Objectives: To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs.

Design: Randomized controlled trial conducted June 1, 1994, to August 31, 1998.

Setting and participants: A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each.

Intervention: The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives.

Main outcome measures: Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes.

Results: Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95 % confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20).

Conclusion: Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.

Publication types

  • Clinical Trial
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Advance Directives*
  • Aged
  • Aged, 80 and over
  • Decision Making
  • Female
  • Health Care Costs
  • Health Resources / statistics & numerical data
  • Homes for the Aged* / economics
  • Homes for the Aged* / standards
  • Hospitalization / statistics & numerical data
  • Humans
  • Male
  • Matched-Pair Analysis
  • Nursing Homes* / economics
  • Nursing Homes* / standards
  • Ontario
  • Outcome and Process Assessment, Health Care*
  • Patient Satisfaction
  • Survival Analysis