Advance directives may improve end-of-life care

NEW YORK, Mar 10 (Reuters) Families of patients who completed advance directives before their deaths tend to feel their loved ones received somewhat better end-of-life care, according to a new study.

Nonetheless, there's still room for improvement.

Advance directives, in the form of a ''living will'' or medical power of attorney, are legal documents that allow people to state their wishes for end-of-life care ahead of time, in the event that they become too sick to make their own medical decisions.

The point is to help terminally ill people die in a manner they would prefer -- at home, for example, instead of at a hospital. They choose whether they want aggressive life-prolonging measures like being placed on a ventilator or a feeding tube, or being resuscitated if their breathing or heartbeat stops.

However, research has raised questions of whether advance directives truly improve end-of-life care.

The new study, published in the Journal of the American Geriatrics Society, asked bereaved family members about the treatment and care given to some 1500 people who died, 71 per cent of whom had an advance directive.

The survey found that families felt better about their communication with their loved one's doctor when there was an advance directive. They also felt they were more informed about what to expect during the dying process.

Patients with advance directives were also more likely than those without to die in a hospice facility, where the focus is on making dying patients comfortable, and they were less likely to die in a hospital or intensive care unit.

Still, the findings also point to plenty of room for improvement in end-of-life care. Whether the patient had an advance directive or not, families commonly felt the dying person did not receive enough care for pain or breathing problems, or enough emotional support.

Advance directives are a good start to improving end-of-life care, according to lead study author Dr Joan M Teno of Brown Medical School in Providence, Rhode Island.

To make sure their wishes will be followed, people need to think of an advance directive as a ''three-step process,'' she told Reuters Health.

''First, formulate your goals and treatment wishes,'' Teno advised. ''Second, discuss this with your family and healthcare provider.'' Third, she said, people who want to forgo life-sustaining measures should ask their doctors specifically how they will make sure that their wishes are honored and that they receive good end-of-life care.

According to Teno, people should discuss a ''plan of action'' with their doctors, detailing, for example, that if they are in pain, they will get particular medications to make sure the pain is controlled.

Even with these measures, advance directives alone are not the complete answer to improving Americans' end-of-life care, Teno and her colleagues say. It's a public health issue, Teno noted, that requires, among other things, more education for doctors and the public, and the ''right accountability measures'' to ensure that people get quality care in their last days.

''People need to demand improved end-of-life care,'' she said.

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