Preparing for the End of Life – Making “Advance Directives”

In today’s health environment, many older people loose their mental faculties before their body gives up. In too many cases, this happens before they have made their wishes known about how they want to be cared for in their final days. Doctors and other health professionals are supposed to help patients engage in advance care planning, culminating in written Advance Directives, which cover a range of important topics. To make their advice more effective, Boston physicians have made a video to improve the patient’s understanding of the situation and possible choices.

In a study published in the British Medical Journal, 200 healthy people over 65 were interviewed about their health and scored on their knowledge of advanced dementia before being divided into two groups; one group listened to a description of advancing dementia, while the other listened to the description and watched the video. Afterwards, they all had 3 choices for their preferred care goals: life-prolonging care, at possible cost to their comfort; limited care, aimed at maintaining physical functioning; and comfort care, maximizing comfort and relieving pain. The subjects were re-interviewed again after 6 weeks.

The average age of the participants was 75; 58% were women. There were 106 in the verbal description alone group, and 94 who also saw the video. In the verbal alone group, 64% chose comfort care, 19% chose limited care, and 14% chose life-prolonging care; 3% were undecided. In the video-watching group, 86% chose comfort care, 9% chose limited care, and 4% chose life-prolonging care; one (1%) was undecided. It’s clear that a significant greater proportion in the video group chose comfort care. These subjects were more likely to be white, a college graduate, in good health, and be more knowledgeable about health matters. After 6 weeks, more subjects in the verbal-only group changed their preferences, compared with those in the video group who changed (29% vs. 6%).

Two points appear important, to my mind. First, the numbers who chose life-prolonging care after a verbal description of dementia was disappointingly high; one would have hoped that knowledge of the end of life for such patients would be a deterrent for striving to stay alive with such a disease. Second, one should be sure that the dementia video was not so horrifying that it strayed beyond the truth – its ‘effect’ in influencing the comfort choice was quite surprising!

The obvious take-home message from all this is that everyone should have a ‘health power-of-attorney’, who can take over supervision of adherence to a well-prepared Advance Directives. Five Wishes provides an excellent series of fill-in-the-blanks questions that will build an Advance Directive for you.