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Information From Death Certificates and Informants

Jay A. Jacobson, MD; Evelyn Kasworm; Margaret P. Battin, PhD; Leslie P. Francis, PhD, JD; David Green, MD; Jeffrey Botkin, MD, MPH

Arch Intern Med. 1996;156(16):1862-1868.

Abstract
Background
Advance directives have been studied in different patient populations and institutions. Most reports have shown limited use and little medically observable effect. To our knowledge, no previous study has focused on the use of advance directives by individuals who have died or how their family members perceived the documents' effect.

Methods
We contacted informants listed on Utah Death Certificates from 1992 to estimate the prevalence and effect of advance directives. Eighty-two percent of 1398 informants we contacted agreed to our telephone interview.

Results
More than 50% of decedents reportedly completed an advance directive. Individuals older than 65 years (57.3%), women (58.1%), nursing home residents (63.4%), and hospice users (75.2%) were most likely to have had advance directives. Education, religion, religiosity, and location had no effect on prevalence. Most informants stated that advance directives had no effect on the decedent's care, but a minority felt they helped to limit treatment. Do-not-resuscitate orders were written more often for patients with advance directives. Feeding tubes were removed more often from decedents with living wills than from other decedents. Mechanical ventilatory support was not less frequent in patients with advance directives.

Conclusions
Our study confirms others that found little evidence that advance directives affect life-sustaining treatments. In the infrequent situations when they apply, they may be more persuasive than family members in convincing physicians to limit treatment. We observed that survivors had 2 perceptions about advance directives, not emphasized in previous reports, that they seemed to limit treatment and to ease their burden of decision making.

Arch Intern Med. 1996;156:1862-1868

Author Affiliations
Sid Johnson

From the Division of Medical Ethics, Department of Internal Medicine, LDS Hospital and University of Utah School of Medicine, Salt Lake City.

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