Advance directives also were associated with higher adjusted probabilities of hospice use in high-and medium spending regions of the country, but not in lower spending regions, indicating that perhaps practitioners in lower spending regions are culturally less likely to push for, and patients less likely to demand, expensive end of life care.
In a related editorial, Douglas B. White, MD, and Robert M. Arnold, MD, of the University of Pittsburgh, said the results "raise several important questions about the 'mechanisms of action' of advance directives.
"It may be that treatment-limiting advance directives work not by making the decisions, but by giving surrogates and physicians psychological permission to cease life support at some point," they wrote.
Treatment limiting advance directives were associated with savings in high-spending parts of the country but not in low-cost regions, perhaps because in low-spending areas, cultural norms around medical care at the end of life prevail. "In other words, patients tend to die like their neighbors, unless there is a clearly stated preference to the contrary," Arnold and White wrote.