Advance Directives and Quality of Care at the End of Life: Implications for Social Work

Purpose: One quarter of the annual Medicare budget is spent on people who are in the last year of their life. In spite of this substantial financial commitment to care at the end-of-life, such care has been reported to be unsatisfactory to patients and their families. Advance directives were developed partly to improve quality of life and end-of-life care by encouraging patients to better communicate with their physicians about their treatment wishes, and to contain the cost of unwanted care at the end-of-life. The ideal result of physicians' discussions about advance directives with their patients is to have accurate portrayal and documentation of the patients' wishes regarding end-of-life care, and to provide physicians with clear guidance when the patient is no longer able to communicate such wishes directly. Living wills serve the purpose of being “worksheets” used to facilitate such communication. The purpose of this study was to determine the use of advance directives in a medium sized urban nursing home, and to examine the extent to which its residents' advance directives (as expressed in their living wills) as well as their physicians' orders not to be resuscitated were followed. Additionally, information about the impact of having input from family members and the treating physician on how accurately patients' wishes were followed were also collected. Method: This study was conducted in a licensed nursing home with a 240-bed capacity. The chart review was initiated upon approval of the University of South Florida Institutional Review Board. The medical records of all seventy-five residents who died in the facility during a one year period were reviewed.

Results: During the study period, 48 women (64%) and 27 men (36%) died in the nursing home facility. Most of the residents were Caucasian, 62 (82.7%); 8 (10.7%) were African-American; and 5 (6.7%) were Hispanic. At the time of death, the age of the residents ranged from 53-99, with a mean age of 84.87 years. Two-thirds of the residents had completed a living will or designated an identified person as their health care surrogate, and 90.7% had a do-not-resuscitate order.

Conclusions . This study confirmed that in the cases where the residents' advance directives were not followed, the resident's intent and the contents of the available documents were not clear. The clinical social workers played a significant role in discussing end-of-life decisionmaking with residents and their decisionmakers, and in clarifying the residents' wishes when the advance directives were general and vague. We speculate that the availability of two master prepared licensed clinical social workers in the study facility may account for the very high rate of compliance with residents' end-of-life care wishes seen in this study. Findings underscore the key role that social workers who understand both the letter and spirit of the law can play. In contrast to the low compliance rate reported in the literature, we see in this study that in a facility employing masters prepared social workers, a very high degree of compliance with end-of-life directives can be achieved.