ADVANCE DIRECTIVES--EFFECTIVENESS OF MANDATORY NOTICE

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Formal advance directives (living wills and durable powers of attorney) are widely encouraged as part of optimal medical decision-making. By December 1991, hospital participation in Medicare and Medicaid will carry the obligation to inform all adult patients of the availability and utility of these legal documents. This proposed study will build upon an ongoing description and intervention study (SUPPORT) that is collecting the frequency of advance directives (as well as an array of other data) among ten thousand hospitalized adults who are at high risk of dying in five U.S. hospitals. The proposed study will allow much more detailed information to be collected after the mandated notice is effectuated. Specific aims include: 1) to understand the impact of the federally mandated requirement to provide information about formal advance directives, 2) to examine the impact of advance directives on medical decisions and outcomes, 3) to identify influences that serve as barriers or encouragements to executing an advance directive, and 4) to investigate the rates and effectiveness of various sources of counselling about advance directives. For the over four thousand patients enrolled in the second phase of SUPPORT, this study will document the awareness, existence, discussion, content, and influence of formal advance directives, from entry into the study through a follow-up of six months. Preferences for care and outcomes are collected in SUPPORT and will be examined for concordance with the preferences stated in the formal documents. This design allows unusually comprehensive and efficient study of a very important public policy intervention.