Advance Directives Report
The Government Accountability Office (GAO) issued a report that examines how various providers inform and implement advance directives for the individuals they serve. According to the report, approaches used to inform individuals about advanced directives vary by type of provider, but providers face similar challenges, according to stakeholders interviewed and literature GAO reviewed. For example, hospitals, nursing homes, Home Health Agencies (HHAs) and hospices inform individuals about advance directives during the admission process, while MA plans and Medicaid managed care plans inform individuals during enrollment. Challenges in informing individuals about advance directives include discomfort talking about end-of-life issues and lack of staff time for such discussions. Providers may address these challenges by using leading practices, such as patient education or population specific materials.
Many adults have advance directives, but estimated prevalence varies by provider type and an individual's demographic characteristics. In 2013, 47 percent of adults over the age of 40 had an advance directive, according to the Institute of Medicine (IOM) report, Dying in America. However, the prevalence of individuals with advance directives varies by type of provider and demographic characteristic. For example, a National Center for Health Statistics report found that 88 percent of discharged hospice patients had advance directives in 2007 compared to 65 percent of nursing home patients in 2004. Studies GAO reviewed found that individuals who were older, white, had higher education or incomes, or were women were more likely to have advance directives than others.
Through state survey agencies, CMS retains data regarding deficiencies related to advance directives identified during surveys of hospitals, nursing homes, HHAs, and hospices. The data which, according to CMS officials, the agency uses for enforcement actions—indicate that the rate of noncompliance with the advance directive requirement among these four covered provider types in 2012 and 2013 was less than 3 percent for the providers surveyed in each given year. For example, about 2 percent of the 14,161 nursing homes that were surveyed in 2013 had a deficiency related to the advance directive requirement. Deficiencies related to the advance directive that were identified during surveys of the four provider types included providers’ failure to inform individuals about advance directives, including failure to provide individual patients with written information about the providers’ policies regarding advance directives. Providers also failed to accurately document an individual’s advance directive in the medical record.
CMS, in their citations, noted that a provider’s failure to ensure that individuals have an opportunity to formulate complete and accurate directives has the potential to cause harm to individuals who may receive treatment or have treatment withheld when their exact treatment preferences are not known.
Contact: Elliott Frost, efrost@leadingageny.org, 518-867-8832