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A Randomized Controlled Trial

D. William Molloy, MRCP, FRCPC; Gordon H. Guyatt, FRCPC; Rosalie Russo; Ron Goeree, MA; Bernie J. O'Brien, PhD; Michel Bédard, MSc; Andy Willan, PhD; Jan Watson, RPN; Christine Patterson, MScN; Christine Harrison, PhD; Tim Standish, MA; David Strang, FRCPC; Peteris J. Darzins, FRACP, FRCPC; Stephanie Smith; Sacha Dubois, BA

JAMA. 2000;283:1437-1444.

Context  Although advance directives are commonly used in the community, little is known about the effects of their systematic implementation.

Objectives  To examine the effect of systematically implementing an advance directive in nursing homes on patient and family satisfaction with involvement in decision making and on health care costs.

Design  Randomized controlled trial conducted June 1, 1994, to August 31, 1998.

Setting and Participants  A total of 1292 residents in 6 Ontario nursing homes with more than 100 residents each.

Intervention  The Let Me Decide advance directive program included educating staff in local hospitals and nursing homes, residents, and families about advance directives and offering competent residents or next-of-kin of mentally incompetent residents an advance directive that provided a range of health care choices for life-threatening illness, cardiac arrest, and nutrition. The 6 nursing homes were pair-matched on key characteristics, and 1 home per pair was randomized to take part in the program. Control nursing homes continued with prior policies concerning advance directives.

Main Outcome Measures  Residents' and families' satisfaction with health care and health care services utilization over 18 months, compared between intervention and control nursing homes.

Results  Of 527 participating residents in intervention nursing homes, 49% of competent residents and 78% of families of incompetent residents completed advance directives. Satisfaction was not significantly different in intervention and control nursing homes. The mean difference (scale, 1-7) between intervention and control homes was -0.16 (95% confidence interval [CI], -0.41 to 0.10) for competent residents and 0.07 (95% CI, -0.08 to 0.23) for families of incompetent residents. Intervention nursing homes reported fewer hospitalizations per resident (mean, 0.27 vs 0.48; P = .001) and less resource use (average total cost per patient, Can $3490 vs Can $5239; P = .01) than control nursing homes. Proportion of deaths in intervention (24%) and control (28%) nursing homes were similar (P = .20).

Conclusion  Our data suggest that systematic implementation of a program to increase use of advance directives reduces health care services utilization without affecting satisfaction or mortality.

Author Affiliations: Geriatric Research Group, Department of Medicine (Drs Molloy and Harrison, Mss Russo and Smith, and Messrs Standish and Dubois), Department of Clinical Epidemiology and Biostatistics (Drs Guyatt, O'Brien, and Willan, Mr Goeree, and Ms Watson), and School of Nursing (Ms Patterson), McMaster University, Father Sean O'Sullivan Research Centre (Drs O'Brien and Willan, Messrs Goeree and Bédard, and Ms Watson), and Center For Evaluation of Medicines, St Joseph's Hospital (Drs O'Brien and Willan, Mr Goeree, and Ms Watson), Hamilton, Ontario; Department of Medicine, University of Manitoba, Winnipeg (Dr Strang); and National Ageing Research Institute, University of Melbourne, Australia (Dr Darzins). Dr Bédard is now with Lakehead Psychiatric Hospital in Thunder Bay, Ontario. Dr Harrison is now with the Hospital for Sick Children, Toronto, Ontario.

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