Quality of Life and Cost of Care at the End of Life: The Role of Advance Directives

J Pain Symptom Manage. 2015 May;49(5):828-35. doi: 10.1016/j.jpainsymman.2014.09.015. Epub 2014 Dec 11.


Context: Advance directives (ADs) are expected to improve patients' end-of-life outcomes, but retrospective analyses, surrogate recall of patients' preferences, and selection bias have hampered efforts to determine ADs' effects on patient outcomes.

Objectives: The aim was to examine associations among ADs, quality of life, and estimated costs of care in the week before death.

Methods: We used prospective data from interviews of 336 patients with advanced cancer and their caregivers and analyzed patient baseline interview and caregiver and provider post-mortem evaluation data from the Coping with Cancer study. Cost estimates were from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample and published Medicare payment rates and cost estimates. Outcomes were quality of life (range 0-10) and estimated costs of care received in the week before death. Because patient end-of-life care preferences influence both AD completion and care use, analyses were stratified by preferences regarding heroic end-of-life measures (everything possible to remain alive).

Results: Most patients did not want heroic measures (76%). Do-not-resuscitate (DNR) orders were associated with higher quality of life (β = 0.75, standard error = 0.30, P = 0.01) across the entire sample. There were no statistically significant relationships between DNR orders and outcomes among patients when we stratified by patient preference or between living wills/durable powers of attorney and outcomes in any of the patient groups.

Conclusion: The associations between DNR orders and better quality of life in the week before death indicate that documenting preferences against resuscitation in medical orders may be beneficial to many patients.

Keywords: DNR; Quality of life; advance directives; costs of care; end-of-life care.

Publication types

  • Multicenter Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Advance Directives / economics*
  • Female
  • Health Care Costs / statistics & numerical data*
  • Humans
  • Male
  • Neoplasms / economics*
  • Neoplasms / mortality*
  • Prevalence
  • Quality of Life*
  • Resuscitation Orders
  • Right to Die
  • Risk Factors
  • Terminal Care / economics*
  • Terminal Care / statistics & numerical data
  • United States / epidemiology