Living wills are poor predictors of actual treatment preferences at the end of life

Living wills often do not represent a patient's actual treatment preferences when faced with real end-of-life circumstances and should be redesigned to guide more realistic advance decision-making, according to a study published in Journal of Palliative Medicine, a peer-reviewed journal from Mary Ann Liebert, Inc. Journal of Palliative Medicine is the official journal of the Center to Advance Palliative Care (CAPC) and an official journal of the Hospice and Palliative Nurses Association (HPNA).

"Ask a Different Question, Get a Different Answer: Why Living Wills are Poor Guides to Care Preferences at the End of Life" is the title of a study designed to assess how closely responses to questions on a standard living will represent an individual's preferences for end-of-life care in six different scenarios. Laraine Winter, PhD, Susan Parks, MD, and James Diamond, PhD, from Thomas Jefferson University in Philadelphia, PA, surveyed 202 men and women 70 years of age or older and asked them whether they would want life-sustaining treatments to be withheld if they served only to prolong the process of dying, a standard question on a living will. They then asked the study participants to predict their preferences for receiving four specific treatments in six end-of-life scenarios.

The results demonstrated that although there was some association between the living will response and treatment preferences in the six scenarios, these associations were relatively weak. The authors suggest that the hypothetical end-of-life scenario presented in the standard living will is often quite different than the circumstances patients will actually face, which accounts at least in part for the weak link between their responses on the living will and their treatment preferences. The authors propose substituting in the living will scenarios that more closely approximate what people are likely to experience and including estimates of how effective specific treatment options would be in sustaining life to help guide advance care decisions.

"It is so important to move the field of advance care planning forward," says Charles F. von Gunten, MD, PhD, Editor-in-Chief of Journal of Palliative Medicine, and Provost, Institute for Palliative Medicine at San Diego Hospice. Further, he says, "This should form the basis for innovative new approaches for help in decision-making."