Authors' objectives:

This study aims to assess the published scientific evidence on the impact that the use of advance directives (ADs) could have on health care costs near the end of life. The target population is represented by seniors resident in long-term care facilities.

Authors' recommendations: ADs were developed with the aim to increase patients' autonomy, decision making, and well-being at the end of life. Also, it was assumed that ADs may be effective in decreasing health care costs, if signed prior to incompetency by those completing ADs choosing less intensive interventions. ADs are available in Canada but there is no legislative pressure for hospital or other medical institutions to promote the concept as exists under the PSDA in the United States. The percentage of Canadians that might use ADs and the costs associated with ADs use is information that is currently not collected. Authors of a Canadian study considered that if ADs are to be mandated by legislation in Canada, the subject would be politically controversial and might increase the debate around the legal and ethical aspects. However, the level of potential savings that may be obtained with the implementation of ADs seems to indicate a need to have the requisite debate about their introduction at the earliest possible opportunity in the opinion of the authors. Economic analysis to provide information on cost-effectiveness, cost-benefit and/or cost-utility obtained with different types of ADs would be useful to confirm the accuracy of the hypothesis which assumes that ADs improve the quality of life wellbeing, and autonomy of patients and also decrease the costs with health care. The cost impact of the various types of ADs seems to be different and there is a need for more research to clarify these results and also to establish the right time for completion of these documents from the beneficial (patient and family), ethical, and economical perspectives. Information was obtained from one RCT conducted in Ontario, Canada which focused on cost with care for seniors living in nursing homes. The authors of this RCT concluded that a systematic application of a Let Me Decide (LMD) AD program can decrease the health care costs substantially by reducing hospitalizations without affecting satisfaction or mortality. This program provides a range of health care choices for life-threatening illness, cardiac arrest, and feeding. Interestingly, Do Not Resuscitate (DNR) orders and other documents (living wills, power of attorney) completed by residents in the comparative group were not associated with a reduction in the total costs for health care. The authors emphasized the need for other resources if LMD AD program is applied extensively in Canada which would involve training of nursing homes personnel on ADs and providing palliative care and equipping nursing homes with technologies for symptom relief and terminal care at the end of life. These costs were not taken into account in the present analysis. Based on the results of one Canadian study the application of the LMD AD program in nursing homes would decrease resource use if there is compliance with the wishes of the nursing home resident. The projected savings estimated in this study is a over estimation since implementation and program operational costs were not included. As well, these types of studies need to measure other intangible costs/benefits such as the well being and autonomy of nursing home residents and the impact of an AD program on the family members.

Authors' methods: Overview

Project Status: Completed

Year Published: 2005

URL for published report: https://www.ihe.ca/advanced-search?type=1020

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Canada

Organisation Name: Institute of Health Economics

Contact Address: 1200, 10405 Jasper Avenue, Edmonton, Alberta, Canada, T5J 3N4. Tel: +1 780 448 4881; Fax: +1 780 448 0018;

Contact Name: djuzwishin@ihe.ca

Contact Email: djuzwishin@ihe.ca

Copyright: <p>Alberta Heritage Foundation for Medical Research (AHFMR)</p>