Effects of offering advance directives on medical treatments and costs

Ann Intern Med. 1992 Oct 1;117(7):599-606. doi: 10.7326/0003-4819-117-7-599.


Objective: To examine the effects of advance directives on medical treatments and on patient satisfaction and well-being and to determine whether the enhancement of patient autonomy through advance directives provides a more ethically feasible approach to cost control than does the imposition of limits through rationing.

Design: Randomized, controlled trial.

Setting: University and Veterans Affairs medical center.

Patients: Two hundred and four patients with life-threatening illnesses, 100 of whom died after enrollment in the study.

Intervention: Patients randomly assigned to the experimental group were offered the California Durable Power of Attorney (a typical proxy-instruction directive), and patients assigned to the control group were not offered the advance directive. Hospital admissions were monitored to assure that a summary of the document was present in the active medical record at each hospitalization.

Measurements: Cognitive function, patient satisfaction, psychological well-being, health locus of control, sense of coherence, health-related quality of life, receipt of medical treatments, and medical treatment charges.

Results: No significant differences were found between advance-directive and control groups regarding psychosocial variables, health outcome variables, and medical treatments or charges. Patients offered an advance directive had an average hospital stay of 40.8 days (95% CI, 32.2 to 49.4 days), compared with an average of 33.1 days (95% CI, 26.0 to 40.2 days) for controls. Patients offered an advance directive were charged an average of $19,502 (95% CI, $13,030 to $25,974) for medical treatments in the last month of life compared with $19,700 (95% CI, $13,704 to $25,696) for controls.

Conclusions: Despite claims that public demand for longer life accounts for rising medical costs, most surveys suggest that patients are calling for less, not more, of the expensive, high-technology treatment often used in terminal phases of illness. Executing the California Durable Power of Attorney for Health Care and having a summary copy placed in the patient's medical record had no significant positive or negative effect on a patient's well-being, health status, medical treatments, or medical treatment charges.

Publication types

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

MeSH terms

  • Advance Directives / economics*
  • Advance Directives / psychology
  • California
  • Control Groups
  • Cost Control / methods
  • Hospitals, University
  • Hospitals, Veterans
  • Humans
  • Life Support Care / economics
  • Life Support Care / statistics & numerical data*
  • Patient Satisfaction / statistics & numerical data*
  • Personal Autonomy
  • Prospective Studies
  • Resource Allocation
  • Risk Assessment*
  • Withholding Treatment