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Patient’s advance directives, such as living wills, could be a powerful tool for controlling costs in end-of-life care, , but only in parts of the U.S. where those costs already run relatively high.

In those areas, a patient’s treatment for the last six months of life ran more than $39,500, on average, without an advance directive. Care for patients who did have an advance directive were 14 percent less on average. In other regions, however, the use of advance directives had little effect on costs.

The findings, published in the Oct. 5 Journal of the American Medical Association, represent a “nice win” for those advocating for advance directives as a cost-saving measure, said lead author Lauren Hersch Nicholas, a researcher at the University of Michigan Institute for Social Research, in an interview.

Nicholas added that the results more importantly point toward quality improvements for those with the – less aggressive treatment when death is near, hospice care and the ability to be at home. The study showed that 41 percent of Medicare patients with an advance directive entered hospice care, compared with 24 percent of those without a directive. The patients with living wills were also much less likely to die in the hospital.

She noted, however, that patients with advance directives were just as likely to receive aggressive care as those without, but they may have moved to palliative or hospice care sooner.

Previous research has been mixed on whether advance directives, which theoretically bring down costs by avoiding unwanted hospital care and better using palliative care, change the course of treatment. End-of-life care makes up a substantial portion of national health care costs. In 2006, treatment during the last year of life accounted for a of Medicare expenditures.

Nicholas and her fellow researchers looked at expenditures in the last six months of life for 3,302 Medicare beneficiaries who died between 1998 and 2007. About 39 percent of the beneficiaries had treatment-limiting advance directives, according to interviews with family members. Patients were sorted into local hospital markets, and the researchers characterized these regions by level of end-of-life spending – high, medium or low.

Advance directives had no statistically significant effect on expenditures in the medium- and low-spending regions. Patients in those levels – with or without a directive – averaged around $26,000 and $21,500, respectively, for the last six months of care.

“We probably don’t see a difference in [medium- and low-spending] settings because they’re already taking patient preference into account,” said Sean Morrison, director of the National Palliative Care Research Center, who was not involved with the study. “They’re more aligned with patient goals and preferences for care.”

Kathy Brandt, a senior vice president at the National Hospice and Palliative Care Organization, agreed, noting that high-spending regions “have more room to change.” An advance directive may provide guidance that goes against the local norm of aggressive treatment and allows for earlier withdrawal from hospital care.

In an , Douglas White and Robert Arnold of the University of Pittsburgh School of Medicine wrote that the findings “may reveal as much about the power of local norms to shape care as about the power of advance directives to overcome them.” They cautioned, however, findings “are insufficient to justify changes in health policy regarding advance directives.”

Brandt said she hopes that the study will at least “spark more discussion” about the utility of advance directives. Brandt is a proponent of reimbursing providers who conduct end-of-life planning with Medicare patients – an in the debate on the 2010 federal health law but ultimately abandoned.   Even if implementing reimbursement remains unlikely, Brandt said, the study nonetheless shows how advance directives can improve quality of care.

The Medicare controversy was part of what motivated the JAMA study. “We need to revamp medical culture to ensure time for these kinds of discussions,” Nicholas said, describing how there’s often a communication barrier between patients and providers.  Patients are afraid to discuss end-of-life care, while doctors don’t make the time for or prioritize planning.

Aside from encouraging doctors and expanding communication efforts, Morrison said that policymakers can ensure improved access to care alternatives at the end of life.

“We need to make sure that palliative care is present in any new care organization, and in hospitals,” Morrison said. “Ensuring palliative care is more important, evidence has shown, than ensuring an advance directive is available.”

christiant@kff.org