RESUMEN
PURPOSE OF REVIEW: To review the definition of advanced directive, understand the implications for the patient, family and healthcare team, and address the obstacles involved in the implementation. RECENT FINDINGS: Advanced directives propose a model of healthcare based on patient preferences. Although there is sufficient evidence related to their usefulness, various factors are known to affect the use of advanced directives. Therefore, rules need to be established in order to optimize the implementation process. SUMMARY: An advanced directive is a legal document based on the principle of autonomy that expresses the desire of the patient in relation to different medical treatments when the patient is unable to make those decisions. The advanced directives are represented in three formats: Living Will, Appointment of a Healthcare Proxy and Legal Status of Preferences. The uses of advanced directives have an impact not only on the patients and their families, but also on the healthcare team. Despite their utility being well known, there are several general barriers that affect implementation, as well as factors related to characteristics of each study population.
Asunto(s)
Adhesión a las Directivas Anticipadas , Directivas Anticipadas/legislación & jurisprudencia , Cuidados Paliativos/normas , Prioridad del Paciente , Enfermo Terminal/psicología , Directivas Anticipadas/economía , Directivas Anticipadas/psicología , Humanos , Cuidados Paliativos/economía , Cuidados Paliativos/psicología , Estados UnidosRESUMEN
OBJECTIVE: There is a growing demand both for respect for patient autonomy regarding the use of sophisticated technology and for consideration of health care expenditures at the end of life. The major objective of this study was to assess the relationship between the documentation of a discussion of advance directives and hospital charges for Medicare patients during the last hospitalization of the patient's life. DESIGN: Multivariate analysis of a retrospective cohort. SETTING: Large (700+ beds), private university, tertiary care hospital. PATIENTS: All 474 patients who had Medicare listed as their primary insurer and who died in the hospital between January 1 and June 30 in 1990, 1991, or 1992. MAIN OUTCOME MEASURE: Total inpatient charges. RESULTS: The mean inpatient charge for the 342 patients without documentation of a discussion of advance directives was more than three times that of the 132 patients with such documentation ($95.305 vs $30,478). This relationship remained statistically significant after controlling for severity of disease, use of an intensive care unit, and number of procedures. Demographics, length of stay, admitting service, admitting diagnosis, and previous admission to the study hospital did not contribute to the predictive model. CONCLUSIONS: During discussions of advance directives, patients often opt to limit the extent of care they desire in certain situations. Although the most appropriate setting for developing advance directives is not clear, the results of this study imply that an enormous cost savings to society may be realized if such discussions take place, while, at the same time, autonomous patient choice will be respected.