• E J Emanuel, D S Weinberg, R Gonin, L R Hummel, and L L Emanuel.
• Division of Cancer Epidemiology and Control, Dana-Farber Cancer Institute, Boston, MA.
• Am. J. Med. 1993 Dec 1;95(6):619-28.

ObjectivesTo assess the association between implementation of the Patient Self-Determination Act (PSDA) and (1) the use of formal, written advance directives, (2) the use of informal advance care arrangements, and (3) discussions between patients and their physicians and proxies an advance care planning and end-of-life treatment preferences.DesignA time-sequence study in which patients discharged from acute care hospitals 1 month before the implementation of the PSDA and 5 months after implementation of the PSDA were interviewed.SettingTwo medical school-affiliated, major teaching hospitals with more than 500 beds and 3 nonteaching community hospitals with fewer than 400 beds in eastern Massachusetts.PatientsA total of 579 adult patients were interviewed: 258 patients discharged before the implementation of the PSDA (pre-PSDA) and 321 patients discharged 5 months after implementation of the PSDA (post-PSDA).MeasurementsPatients were asked about their formal, written or informal advance care planning arrangements, about the frequency of inquiries and information provided on advance care planning by the hospitals, and about their discussions of advance care planning and end-of-life treatment preferences with physicians and their proxies.ResultsIn the pre-PSDA cohort, 60.9% of the patients had some kind of advance care planning, whereas in the post-PSDA cohort, 72.6% did (p = 0.01). However, there was not a significant increase in the proportion of patients who had advance care planning "in a written document" (19.8% of the pre-PSDA cohort compared with 25.5% of the post-PSDA cohort, p = 0.11). The increase in written advance care planning was concentrated in the community, nonteaching hospitals (10.7% pre-PSDA versus 23.7% post-PSDA). Overall, 41.4% of patients recalled inquiries or information about advance care planning during their hospitalization. Implementation of the PSDA was not associated with a significant change in the proportion of patients who discussed advance care planning or end-of-life issues with their physicians (13.6% pre-PSDA versus 17.1% post-PSDA, p = 0.25). However, there was an increase in the proportion of patients with poorer health who spoke with their physicians (15.4% pre-PSDA versus 24.8% post-PSDA). Implementation of the PSDA was associated with an increase in the proportion of patients who had general discussions with proxies about end-of-life issues (61.8% pre-PSDA versus 73.0% post-PSDA, p = 0.024). However, 33.6% of pre-PSDA and 33.2% of post-PSDA patients had detailed discussions with their proxy about specific interventions such as mechanical ventilation or artificial nutrition. Patients with formal proxies had detailed discussions significantly more frequently than other patients (50.0% versus 26.8%, p < 0.0001).ConclusionsThe PSDA was associated with significant effects on general advance care planning issues, increasing the proportion of patients who had (1) some kind of advance care arrangements and (2) general discussions of end-of-life issues with their proxies. However, the PSDA did not appear associated with significant increases (1) in the use of formal, written advance care documents, (2) in the frequency of discussions between patients and their physicians on advance care documents or end-of-life issues, or (3) in the frequency of discussions about specific treatment preferences between patients and their proxies.

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