Research Review

More Than One Quarter of Elders Lack Decision-Making Capacity at Death

More than one in four elder Americans lacked the capacity to make their own medical care decisions at the end of life, according to a study of 3,746 people in The New England Journal of Medicine.

Those who had advance directives—including living wills or durable powers of attorney for healthcare—received the care they wanted most of the time, says lead author Maria Silveira, MD, MPH, a physician scientist at the VA Ann Arbor Healthcare System’s Clinical Management Research and an assistant professor of Internal Medicine at the University of Michigan.

"Prior to our study, no one knew how many elderly adults might need others to make complex medical decisions on their behalf at the end of life," says Silveira. "Our research shows that a substantial number of older adults need someone else to make decisions about whether aggressive, limited, or comfort care should be provided at the end of life."

Advance directives usually document patients’ wishes for life-sustaining treatment in a living will, as well as their choice of a proxy decision-maker in a durable power of attorney for healthcare. Advance directives are sanctioned in all 50 states and can be completed for free without the aid of an attorney.

Of the subjects studied, 61% had advance directives. Of those, more than 90% requested either limited or comfort care at the end of life. Among those who needed decisions made, but couldn’t make them themselves, 83% who had requested limited care and 97% who had requested comfort care, received the care that was in line with their wishes, Silveira says.

"Folks with a living will or durable power of attorney for healthcare were less likely to die in a hospital or to get aggressive care—but that is what most of them wanted," she says.

One interesting finding suggests the importance of having both a living will as well as an appointed surrogate decision-maker. The study showed that among the handful of subjects who indicated a preference for aggressive care, one half did not receive it.

"Given this, some might conclude that advance directives are used to deny wanted healthcare, but our study showed that a preference for aggressive care had a very strong association with receiving such care, when compared to those who did not state a preference for it. It's just that at the end of life, aggressive treatment is often not an option; limited care and comfort care are always an option," Silveira says.

— Source: University of Michigan Health System