Brief Communication: The Relationship between Having a Living Will and Dying in Place

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Abstract
Living wills, a type of advance directive, are promoted as a way for patients to document preferences for life-sustaining treatments should they become incompetent. Previous research, however, has found that these documents do not guide decision making in the hospital. To test the hypothesis that people with living wills are less likely to die in a hospital than in their residence before death. Secondary analysis of data from a nationally representative longitudinal study. Publicly available data from the Asset and Health Dynamics Among the Oldest Old (AHEAD) study. People older than 70 years of age living in the community in 1993 who died between 1993 and 1995. Self-report and proxy informant interviews conducted in 1993 and 1995. Having a living will was associated with lower probability of dying in a hospital for nursing home residents and people living in the community. For people living in the community, the probability of in-hospital death decreased from 0.65 (95% CI, 0.58 to 0.71) to 0.52 (CI, 0.42 to 0.62). For people living in nursing homes, the probability of in-hospital death decreased from 0.35 (CI, 0.23 to 0.49) to 0.13 (CI, 0.07 to 0.22). Retrospective survey data do not contain detailed clinical information on whether the living will was consulted. Living wills are associated with dying in place rather than in a hospital. This implies that previous research examining only people who died in a hospital suffers from selection bias. During advance care planning, physicians should discuss patients' preferences for location of death.

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