Nearly one-third of older adults need end-of-life decisions made but lack ability

About 30% of older adults near the end of life needed decisions made about medical treatment but lacked such decision-making capacity, a new study found, and most of those with advance directives got the care they had specified.

Using data from the Health and Retirement Study, researchers studied 3,746 adults age 60 years or older who had died between 2000 and 2006 and for whom a proxy answered study questions after the patient died. Outcomes included whether the patient had completed a living will or durable power of attorney, maintained decision-making capacity, and needed decision making at the end of his or her life. Data were also collected on care preferences of subjects who completed a living will, and researchers compared these preferences with the outcomes of surrogate decision making. Results were published in the April 1 New England Journal of Medicine.

Forty-two-and-a-half percent of study patients needed decision making, and of these, 70.3% lacked the capacity to make decisions for themselves. Within this subgroup, 67.6% of patients had advance directives, 6.8% had only a living will, 21.3% had only appointed a durable power of attorney, and 39.4% had both prepared a living will and appointed a durable power of attorney. Among those patients who had completed living wills and stated preferences for or against all care possible, there was strong agreement between their preference and the care received (P<0.001). Eighty-three percent of those who requested limited care, and 97.1% of those who requested comfort care, got care consistent with these preferences. Those who requested all care possible were more likely to get it than those who didn't request it (adjusted odds ratio, 22.62; 95% CI, 4.45 to 115), but 7.1% (n=30) of those who didn't indicate an all-care preference got it anyway, and 50% (n=5) of those who wanted all care didn't receive it.

While the results suggest more than a quarter of older adults may need surrogate decision making before death, the data also indicate it's difficult to predict who will need this decision making, the authors noted. The fact that so many older adults have advance directives suggests they find them acceptable, familiar, available and valuable, they said. A causal relationship can't be inferred, but the findings do suggest advance directives influence end-of-life decisions, they added. Of those patients who wanted aggressive care but didn't receive it, the decisions may have been overridden by their surrogates, or such care may not have been an option. Overall, the study suggests the health care system should ensure clinicians receive the time and reimbursement needed to help patients plan for the end of life, the authors concluded.