Quality of Life and Cost of Care at the End of Life: The Role of Advance Directives
Open accessAbstract
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.
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Advance care planning has been associated with earlier and increased use of hospice care, reduced intensive treatment and hospitalizations at the end of life, and better quality of life in patients with cancer and caregivers.
“Advance care planning has been associated with earlier and increased use of hospice care [12–15], reduced intensive treatment and hospitalizations at the end of life [13, 15–18], and better quality of life in patients with cancer and caregivers [12, 19].”
From Mindfulness to enhance quality of life and support advance care planning: a pilot randomized controlled trial for adults with advanced cancer and their family caregivers. (2024) · cites this paper as [19]
The Results (page not available in our copy) associate DNR orders with better quality of life in the week before death among patients with advanced cancer. The paper uses caregiver reports to evaluate patient quality of life; it does not establish better quality of life for caregivers themselves. Its finding also concerns DNR orders specifically, rather than advance care planning generally. (LLM, conf=0.85)
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- Authors
- Garrido, M. M., Balboni, T. A., Maciejewski, P. K., Bao, Y., & Prigerson, H. G.
- Affiliations
- James J. Peters VA Medical Center (US)
- Harvard University (US)
- Weill Cornell Medicine (US)
- Corresponding author
- Prigerson, Holly G.
- Venue
- Journal of Pain and Symptom Management
- Publisher
- Elsevier BV
- Published
- 2015-05
- Volume
- 49
- Issue
- 5
- Pages
- 828-835
- ISSN
- 0885-3924 (ISSN-L)
- PMC
- PMC4441858
- OpenAlex
- W2007677818
- Cited by
- 126
- References
- 35
- Citations by year
- 2026: 2 · 2025: 6 · 2024: 11 · 2023: 14 · 2022: 11 · 2021: 11 · 2020: 14 · 2019: 15 · 2018: 14 · 2017: 12 · 2016: 11 · 2015: 5
- FWCI
- 9.25
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of Pain and Symptom Management (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (MH63892, K01 MH090087)
- National Cancer Institute (CA 106370)
- Center for Research on End of Life Care (CA 156732)
- Department of Veterans Affairs (CDA 11-201, CDP 12-255)
- Icahn School of Medicine
- NIA (P30 AG028741-01A2)
- Translational Research Institute on Pain in Late Life (5P30AG022845)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
- Keywords
- advance directives, do-not-resuscitate orders, end-of-life care, quality of life, cost of care, advanced cancer, living wills, durable power of attorney, resuscitation preferences, postmortem care, caregiver perspectives, Medicare spending
- MeSH terms
- Female, Humans, Male, Neoplasms, Quality of Life, Right to Die, Risk Factors, Terminal Care, United States, Prevalence, Advance Directives, Resuscitation Orders, Health Care Costs
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