Honoring Advance Directives: A Scoping Review of Adherence and Impact on Value of Care

Introduction: End-of-life clinical decision making can trigger profound emotional and financial distress. Advance directives intend to guide clinicians and surrogate decision makers; it is difficult to know how often they are honored. Moreover, there is limited research on associations between resource use and honoring advance directives. Methods: We performed a scoping review of primary research articles on Web of Science, Embase, and PubMed using search terms involving honoring of advance directives and associations with health care value. Value was defined broadly and included any study in which the quality of care was assessed relative to cost. Results: Twenty-nine studies met inclusion criteria, with 17 related to honoring advance directives, six related to the value of care, and seven examining both dimensions. Evidence regarding advance directive efficacy was mixed. Ten of 23 (43%) demonstrated a positive impact of advance directives on concordant care, ten showed minimal or no care differences between patients with and without advance directives, and three showed mixed evidence. Higher rates of concordant care were associated with do-not-hospitalize orders and physician-orders-for-life-sustaining-treatment as compared to other types. Concerning value, four studies showed reduced hospital length of stay, hospital admissions, and overall costs, whereas five found no difference in these variables. Four considered theoretical value impacts of advance directives on patients, hospitals, and health systems with value varying by stakeholder. There was limited analysis of advance directive implementation practices. Conclusions: There is mixed evidence related to the efficacy of advance directives in aligning care with patient wishes and improving the quality of care relative to cost. Investigation of implementation practices may provide insight into factors determining these varied outcomes. This review highlights opportunities to improve upon methodology for studying advance directives and applying them effectively.