Original research BMJ Support Palliat Care: first published as 10.1136/bmjspcare-2020-002851 on 22 March 2021. Downloaded from http://spcare.bmj.com/ on July 17, 2023 at Sant Paul Hospital Consortia. Advance directives and real-­world end-­of-­life clinical practice: a case– control study Albert Dalmau-­Bueno,1 Anna Saura-­Lazaro,2 Josep Ma Busquets,3 Ingrid Bullich-­Marín,3 Anna García-­Altés ‍ ‍4,5 1 Catalan Health System ABSTRACT Observatory, Agency for Key messages Background Advance directives (ADs) have Health Quality and Assessment (AQuAS), Barcelona, Spain been legally regulated to promote autonomy What was already known? 2 Catalan Institute of Oncology, over health decisions among patients who later ⇒ Advance directives (ADs) have been legally Barcelona, Spain lose decision-­making capacity. regulated to promote autonomy over 3 Ministry of Health, Government Aims and objectives To analyse the differences health decisions among patients who later of Catalonia, Barcelona, Catalonia, Spain in clinical practice at end of life among people lose decision making capacity. 4 Biomedical Research Institute who had completed an AD versus those who ⇒ Earlier studies on ADs have been carried (IIB Sant Pau), Barcelona, Spain had not. out examining the clinical record or by 5 CIBER de Epidemiología y Salud means of surveys, not using population-­ Methods Retrospective case–control study Pública (CIBERESP), Barcelona, based registries. Spain (1:2), matched by age, sex, year, cause of death and region of residence. The data sources used What are the new findings? Correspondence to were the ADs registry, central registry of insured ⇒ Patients who died and had written an Dr Anna García-­Altés, Catalan Protected by copyright. Health System Observatory, persons, hospital discharge, pharmacy and billing AD received invasive or life-­sustaining Catalan Agency for Health databases, and the mortality registry. Conditional procedures less frequently than persons Quality and Evaluation (AQuAS), logistic regression models (crude and adjusted who died without completing an AD. Barcelona, Spain; by socioeconomic level) were performed. The ⇒ This paper has analysed individual ​agarciaaltes@​gencat.c​ at information from more than 5,000 people outcome variable was the frequency of medical (1,723 with ADs), one of the largest Received 10 December 2020 procedures performed during the last year of life. Revised 2 March 2021 samples analysed so far. Results 1723 people with ADs who died in Accepted 5 March 2021 What is their significance? Catalonia during 2014–2015 were matched with Published Online First 3446 dead controls (without ADs). Thoracentesis ⇒ These results can help better planning of 22 March 2021 was the procedure with the greatest reduction the treatment of patients with ADs, as well as increasing the awareness of ADs, as is among women with an AD (adjusted OR (ORadj) an indication that some part of society 0.54, 95% CI: 0.32 to 0.89) in conjunction with makes end-­of-­life decisions in advance. artificial nutrition (ORadj 0.54, 95% CI: 0.31 to 0.95). Intubation was the procedure with the greatest reduction (ORadj 0.56, 95% CI: 0.33 sustaining medical treatment are life-­ to 0.94) among men. Slight differences could respected when decision-­making capacity be seen in the case of cancer deaths. There is lost, and that can elect a surrogate were no relevant differences when adjusting by decision-­maker. Therefore, ADs are a socioeconomic level. guard against unwanted and often futile Conclusions ADs are an effective tool to adjust interventions that only prolong the dying the realisation of some procedures at end of process, and so help to relieve anxiety life. These results can help better plan for the about loss of control and the burdens treatment of patients with ADs, as well as that can fall on others during end-­of-­life © Author(s) (or their employer(s)) 2022. Re-­use increase the awareness among clinical personnel, healthcare.1 permitted under CC BY-­NC. No families and the general population. Defining the level of healthcare commercial re-­use. See rights and permissions. Published by resources that a person needs at the end BMJ. of their life does not involve only the INTRODUCTION aspects related to their clinical situation, To cite: Dalmau-­ Bueno A, Saura-­Lazaro A, Many countries have enacted laws that but must depend on many other factors— Busquets JM, et al. BMJ recognise advance directives (ADs) such as socioeconomic (SEC) status, avail- Supportive & Palliative Care as the legal instrument that can best ability of family and social support, and 2022;12:e337–e344. ensure an individual’s wishes regarding personal values and wishes—which are Dalmau-­Bueno A, et al. BMJ Supportive & Palliative Care 2022;12:e337–e344. doi:10.1136/bmjspcare-2020-002851 e337 Original research BMJ Support Palliat Care: first published as 10.1136/bmjspcare-2020-002851 on 22 March 2021. Downloaded from http://spcare.bmj.com/ on July 17, 2023 at Sant Paul Hospital Consortia. generally difficult to evaluate and are rarely taken into during the last year of life (see online supplementary account. Moreover, since the percentage of patients appendix 2). who have written ADs is usually small, it makes it The sources of information were the central registry more difficult to take them into account. Undoubtedly, of insured persons, the hospital discharge, pharmacy knowing the values and desires of the patient through and billing databases, and the mortality registry. SEC advance planning allows for much more individual- level, the adjustment variable, was defined according ised and respectful care. Recently, advance care plan- to the information obtained from the levels of phar- ning, a complex process that includes not only ADs, maceutical co-­payment, which is calculated according but also personal reflection and discussion with clini- to personal income (or, if appropriate, according to cians about the patient’s wishes, the appointment of a the Social Security benefits received): exempt from healthcare representative and changes to the health- co-­payment, <€18 000, €18 000–100 000 or >€100 care system, has increasingly been considered.2 The 000. These four categories were renamed to very low effects of different types of advance care planning have SEC, low SEC, medium SEC and high SEC. Data from been studied in various settings and populations, and the different sources were merged in an anonymised there is evidence that it positively impacts the quality way using the unique healthcare ID. of end-­of-­life care.3 4 A descriptive analysis was performed with frequen- At the end of the year 2000 in Catalonia, and in 2002 cies and percentages for both cases and controls, strat- in the rest of Spain, laws that allow citizens to draw up ifying by sex. Χ2 tests were calculated to determine an AD were approved.5 6 Two years later, and to grant associations between cases and controls for sociode- a certain security, a non-­compulsory registry for these mographic variables. Next, conditional logistic regres- types of documents was established. Approximately sion models were carried out where the dependent 44.4% of the population admits to knowing about the variable was the medical procedures performed during option to complete an AD, and 63.1% express their the last year of life. ORs, as a measure of association willingness to do so.7 However, it is a scarcely used with a 95% CI, are presented as crude and adjusted resource and only 2% of the Catalan population has values by socioeconomic level (ORadj). A previously an AD in place.7 Internationally, completion rates are agreed subgroup analysis was performed for the Protected by copyright. higher for older Americans (up to 70%) and Austra- patients whose cause of death was cancer. lians (30%),1 8–10 much lower in Germany,11 the Neth- All analyses were carried out with the statistical erlands12 and the UK,13 with rates between 8% and program STATA V.14.2 SE. The results with a p value 10%, respectively, and even lower uptake of ADs has of <0.05 were considered statistically significant. been reported in other nations such as Spain14 and China.15 RESULTS Despite the desire for ADs, earlier studies have In Catalonia between 2014 and 2015, 125 185 people shown that they are not as effective as thought.16–18 died. Of those, 1723 (1.4%) had an AD, representing However, most of these studies have been carried out all the cases analysed in this study. From the same examining the clinical record or by means of surveys, pool of deceased individuals, 3446 matched controls not using population-­based registries. were chosen. Regarding the cause of death, cancer The objective of this study is to assess the impact represents the highest percentage of ADs (42.7% of ADs on clinical care at the end of life, analysing among women and 48.1% among men), followed by the differences in the use of medical procedures during circulatory system cause of death (30.0% and 27.7% end-­of-­life care among patients who had completed among women and men, respectively) (table 1). ADs compared with those who had not. Regarding the SEC level, there were statistically signif- icant differences between people who had completed an AD and those who had not, with the former having METHODS a higher SEC level (table 1). A retrospective matched case–control study was For both sexes, the frequencies of the selected proce- designed, assigning two controls per case (1:2). The dures performed during the last year of life were lower cases were those people who had completed an AD among people who died having an AD in place versus and died in Catalonia during 2014 and 2015; controls those who did not have one (online supplementary were selected in two steps from people who died table S1). After adjusting by SEC level, the estimates during the same period, but without any ADs: first, did not change, and the explained reduction remained by matching criteria for the variables age, sex, region statistically significant (table 2). of residency and cause of death; second, by randomly Considering that there were differences regarding the selecting two controls in each combined matching SEC level between cases and controls, adjusted models variables. The variables included in the analysis were were applied to know the effect of ADs in the anal- sociodemographic (age, sex, region of residency and ysed procedures. Regarding women, the procedures SEC level), cause of death (see online supplemen- with statistically significant reductions were surgery, tary appendix 1) and medical procedures performed artificial nutrition, endoscopy, blood transfusions, e338 Dalmau-­Bueno A, et al. BMJ Supportive & Palliative Care 2022;12:e337–e344. doi:10.1136/bmjspcare-2020-002851 Original research BMJ Support Palliat Care: first published as 10.1136/bmjspcare-2020-002851 on 22 March 2021. Downloaded from http://spcare.bmj.com/ on July 17, 2023 at Sant Paul Hospital Consortia. Table 1 Sociodemographic characteristics of ADs patients and control patients by sex Women Men Cases (n=937) Controls (n=1.871) Cases (786) Controls (1.575) Variable N % N % P value N % N % P value Age (years)  <65 122 13.02 248 13.25 0.99 100 12.72 199 12.63 0.99  65–74 133 14.19 267 14.27 154 19.59 309 19.62  75–84 216 23.05 425 22.72 220 27.99 437 27.75  85 and over 466 49.73 931 49.76 312 39.69 630 40.00. Socioeconomic (SEC) level  Very low SEC 77 8.22 155 8.28 <0.001 43 5.47 75 4.76 <0.001  Low SEC 610 65.10 1425 76.16 419 53.31 1102 69.97  Medium SEC 243 25.93 279 14.91 297 37.79 384 24.38  High SEC 7 0.75 12 0.64 27 3.44 14 0.89 Cause of death  Cancer 400 42.69 799 42.70 0.99 378 48.09 761 48.32 0.99  Mental diseases 43 4.59 86 4.60 27 3.44 56 3.56  Nervous system 93 9.93 185 9.89 62 7.89 123 7.81  Circulatory system 281 29.99 564 30.14 218 27.74 434 27.56  Respiratory system 89 9.50 176 9.41 83 10.56 165 10.48  Kidney diseases 31 3.31 61 3.26 18 2.29 36 2.29 ADs, advance directives. thoracentesis, transfers to other centres and visits to procedures less frequently than persons who died Protected by copyright. the emergency department. Thoracentesis was the without completing an AD. In this sense, it seems that procedure with the greatest reduction among women, ADs are an effective tool when adjusting the perfor- with an AD (ORadj 0.54, 95% CI: 0.32 to 0.89), in mance of certain procedures at the final stage of life, conjunction with artificial nutrition (ORadj 0.54, 95% including surgery, artificial nutrition, endoscopy, trans- CI: 0.31 to 0.95). Regarding men, the procedures with fusions, thoracentesis and transfers to other centres statistically significant reductions among those who among women; and mechanical ventilation, intubation had an AD were fewer than in women, and included and emergency consultations among men. Very few mechanical ventilation, visits to emergency department changes were observed when analysing the subgroup and intubations, with the latter having the greatest of patients who died of cancer, although some proce- reduction (ORadj 0.56, 95% CI: 0.33 to 0.94). dures were used even less frequently, including surgery, For the people who died of cancer, statistically ostomy, endoscopy, thoracentesis and emergency significant reductions were observed for women in consultations among women, and mechanical ventila- procedures such as surgery, ostomy, endoscopy, thora- tion and emergency consultations among men. centesis and visits to emergency departments, with a greater reduction than those observed in all causes of Strengths and weaknesses/limitations of the study death analyses (table 3 and online supplementary table S2). The highest reduction was for ostomy, with 84% Previous studies carried out in our context, being less use (ORadj 0.16, 95% CI: 0.03 to 0.79), followed based on small population samples, have shown that by thoracentesis, with 58% less use (ORadj 0.42, 95% ADs improve patient and physician decision-­making CI: 0.22 to 0.80). For men, the reduction in the use (patients who have had a DVA are more involved in of procedures was statistically significant in those with decision-­making, and these decisions are more accepted an AD for mechanical ventilation and visits to emer- by the care team),19 and the representatives’ percep- gency departments. The highest reduction in men was tion of a more comfortable death.20 This paper has for visits to emergency departments, with 46% less analysed individual information from more than 5000 use (ORadj 0.54, 95% CI: 0.38 to 0.78), followed by people (1723 with ADs), one of the largest samples mechanical ventilation, with 38% less use (ORadj 0.62, analysed so far. Moreover, real-­word data have been 95% CI: 0.40 to 0.94). used, taken from the ADs and mortality registries, as well as all clinical-­administrative databases used for DISCUSSION quality assurance and payment purposes in the Catalan Main results of the study public healthcare system, which include all contacts of This study showed that patients who died and had citizens with the health services. All of this has allowed written an AD received invasive or life-­ sustaining for a wider assessment of procedures and healthcare Dalmau-­Bueno A, et al. BMJ Supportive & Palliative Care 2022;12:e337–e344. doi:10.1136/bmjspcare-2020-002851 e339 e340 Table 2 Frequency of the procedures performed during the last year of life among people who died in Catalonia 2014–2015 and had completed ADs versus those who had not, stratified by sex; Original research adjusted ORs (95% CI) by socioeconomic level Women Men Cases Controls Adjusted model Cases Controls Adjusted model OR OR Procedures N % N % (95% CI) P value % N % N (95% CI) P value Surgery 68 7.26 206 11.00 0.63 (0.47 to 0.84) <0.01 95 12.09 200 12.67 0.97 (0.73 to 1.28) 0.81 Pain treatment 1 0.11 8 0.43 * 2 0.25 3 0.19 * Transplant 2 0.21 4 0.21 * 4 0.51 3 0.19 * Palliative care 47 5.02 92 4.91 1.04 (0.70 to 1.52) 0.86 46 5.85 78 4.94 1.37 (0.89 to 2.10) 0.16 Mechanical ventilation 120 12.81 261 13.93 0.91 (0.71 to 1.16) 0.44 109 13.87 293 18.57 0.71 (0.55 to 0.92) 0.01 Ostomy† 11 1.17 26 1.39 0.75 (0.34 to 1.63) 0.47 13 1.65 19 1.20 1.29 (0.60 to 2.78) 0.51 Artificial nutrition 17 1.81 62 3.31 0.54 (0.31 to 0.95) 0.03 18 2.29 46 2.92 0.84 (0.47 to 1.51) 0.56 Cardiopulmonary resuscitation 3 0.32 5 0.27 * 2 0.25 7 0.44 * Nasogastric probe 13 1.39 26 1.39 0.94 (0.46 to 1.93) 0.86 9 1.15 25 1.58 0.68 (0.29 to 1.59) 0.37 Endoscopy 55 5.87 162 8.65 0.67 (0.48 to 0.93) 0.02 71 9.03 185 11.72 0.76 (0.56 to 1.02) 0.07 Transfusions 71 7.58 201 10.73 0.69 (0.52 to 0.93) 0.01 87 11.07 196 12.42 0.92 (0.69 to 1.24) 0.59 Thoracentesis 20 2.13 74 3.95 0.54 (0.32 to 0.89) 0.02 30 3.82 61 3.87 1.00 (0.63 to 1.59) 1.00 IV fluids/drugs 225 24.01 481 25.68 0.93 (0.76 to 1.13) 0.45 218 27.74 472 29.91 0.98 (0.79 to 1.22) 0.85 Antibiotics 109 11.63 248 13.24 0.88 (0.68 to 1.13) 0.31 114 14.50 252 15.97 0.97 (0.75 to 1.26) 0.83 Tracheostomy 1 0.11 13 0.69 * 5 0.64 34 2.15 * Dialysis 12 1.28 12 0.64 2.27 (0.93 to 5.55) 0.07 12 1.53 25 1.58 0.95 (0.44 to 2.05) 0.89 Amputation 2 0.21 9 0.48 * 6 0.76 13 0.82 * Intubation 21 2.24 47 2.51 0.91 (0.53 to 1.56) 0.73 23 2.93 73 4.63 0.56 (0.33 to 0.94) 0.03 Transfers 152 16.22 369 19.70 0.81 (0.65 to 1.00) 0.05 127 16.16 314 19.90 0.86 (0.68 to 1.09) 0.21 Emergencies 714 76.20 1496 79.87 0.85 (0.69 to 1.04) 0.11 608 77.35 1329 84.22 0.68 (0.54 to 0.86) <0.01 *Not enough cases for modelling. †Gastrostomy, ileostomy, colostomy and resections. ADs, advance directives; IV, intravenous. Dalmau-­Bueno A, et al. BMJ Supportive & Palliative Care 2022;12:e337–e344. doi:10.1136/bmjspcare-2020-002851 Protected by copyright. BMJ Support Palliat Care: first published as 10.1136/bmjspcare-2020-002851 on 22 March 2021. Downloaded from http://spcare.bmj.com/ on July 17, 2023 at Sant Paul Hospital Consortia. Table 3 Frequency of the procedures performed during the last year of life among people who died of cancer in Catalonia 2014–2015 and had completed ADs versus those who had not, stratified by sex; adjusted ORs (95% CI) by socioeconomic level Women Men Cases Controls Adjusted model Cases Controls Adjusted model OR OR Procedures N % N % (95% CI) P value N % N % (95% CI) P value Surgery 47 11.75 147 18.35 0.60 (0.42 to 0.86) 0.01 67 17.72 140 18.32 0.99 (0.70 to 1.40) 0.95 Pain treatment 1 0.25 4 0.50 * 2 0.53 2 0.26 * Transplant 2 0.50 3 0.37 * 3 0.79 3 0.39 * Palliative care 37 9.25 76 9.49 0.95 (0.61 to 1.48) 0.82 44 11.64 73 9.55 1.43 (0.91 to 2.23) 0.12 Mechanical ventilation 30 7.50 85 10.61 0.70 (0.45 to 1.08) 0.11 36 9.52 116 15.18 0.62 (0.40 to 0.94) 0.02 Ostomy† 2 0.50 17 2.12 0.16 (0.03 to 0.79) 0.02 4 1.06 14 1.83 0.59 (0.18 to 2.00) 0.40 Artificial nutrition 9 2.25 34 4.24 0.50 (0.23 to 1.08) 0.08 9 2.38 29 3.80 0.72 (0.33 to 1.58) 0.41 Cardiopulmonary resuscitation 0 0.00 2 0.25 * 0 0.00 0 0.00 * Nasogastric probe 10 2.50 17 2.12 1.17 (0.49 to 2.80) 0.73 8 2.12 19 2.49 1.05 (0.42 to 2.67) 0.91 Endoscopy 37 9.25 133 16.60 0.53 (0.36 to 0.79) <0.01 58 15.34 143 18.72 0.82 (0.59 to 1.15) 0.25 Transfusions 51 12.75 123 15.36 0.83 (0.58 to 1.18) 0.30 51 13.49 128 16.75 0.81 (0.55 to 1.18) 0.27 Thoracentesis 12 3.00 56 6.99 0.42 (0.22 to 0.80) 0.01 21 5.56 45 5.89 0.98 (0.56 to 1.70) 0.94 IV fluids/drugs 114 28.50 261 32.58 0.82 (0.63 to 1.09) 0.17 129 34.13 266 34.82 1.06 (0.79 to 1.44) 0.69 Antibiotics 49 12.25 119 14.86 0.83 (0.58 to 1.18) 0.29 74 19.58 130 17.02 1.30 (0.91 to 1.85) 0.14 Dalmau-­Bueno A, et al. BMJ Supportive & Palliative Care 2022;12:e337–e344. doi:10.1136/bmjspcare-2020-002851 Tracheostomy 1 0.25 5 0.62 * 1 0.26 17 2.23 * Dialysis 3 0.75 3 0.37 3.40 (0.38 to 30.25) 0.27 3 0.79 13 1.70 0.64 (0.17 to 2.49) 0.52 Amputation 1 0.25 1 0.12 * 0 0.00 3 0.39 * Intubation 3 0.75 14 1.75 0.33 (0.08 to 1.35) 0.12 3 0.79 23 3.01 0.28 (0.08 to 1.03) 0.06 Transfers 68 17.00 173 21.60 0.75 (0.54 to 1.04) 0.08 75 19.84 180 23.56 0.90 (0.66 to 1.25) 0.54 Emergencies 290 72.50 653 81.52 0.64 (0.48 to 0.86) <0.01 296 78.31 668 87.43 0.54 (0.38 to 0.78) <0.01 *Not enough cases for modelling. †Gastrostomy, ileostomy, colostomy and resections. ADs, advance directives; IV, intravenous. Original research e341 Protected by copyright. BMJ Support Palliat Care: first published as 10.1136/bmjspcare-2020-002851 on 22 March 2021. Downloaded from http://spcare.bmj.com/ on July 17, 2023 at Sant Paul Hospital Consortia. Original research BMJ Support Palliat Care: first published as 10.1136/bmjspcare-2020-002851 on 22 March 2021. Downloaded from http://spcare.bmj.com/ on July 17, 2023 at Sant Paul Hospital Consortia. services utilisation, and representative results for the associated with a reduced likelihood of advance care whole population. planning uptake.24 Second, this study did not suppose an additional The results also showed that the use of procedures at cost, and was carried out without reviewing clinical end of life is lower in women than in men, with both records and without jeopardising data anonymisation. having completed an AD. This may indicate different Thus, it demonstrates the value of reusing administra- preferences regarding end-­of-­life treatments, a higher tive data for research purposes, something that Euro- respect for women’s ADs—intensified by the fact pean authorities recommend.21 22 that women tend to die once widowed, so there is no Some limitations are worth mentioning. Although partner that could insist on a course of action—or some we included in the analysis procedures that were gender bias introduced by healthcare professionals. performed over the course of 1 year, corresponding It is also well known that, rather than the natural to all people with selected causes of death in 2014 age, it is the final stage of a person’s life that better and 2015 with ADs, some procedures are used very determines their use of healthcare resources.25–27 One infrequently. Extending the study to include more of the explanatory factors is the cause of death, with years would result in a greater number of people to oncological diseases being the ones associated with analyse. Having more ADs among patients without higher expenses.28 Access to end-­ of-­ life healthcare cancer would be especially interesting in the case of services is highly variable, with the worst impact on Alzheimer’s, amyotrophic lateral sclerosis, dementia the most deprived SEC groups,29 also being true in the or neurodegenerative diseases to have sufficient case of access to palliative care.30 Although some cost contingents to reach higher frequencies of the analysed savings may be realised,31 32 looking at the impact of procedures. advance care planning on costs raises delicate ethical Chemotherapy and radiotherapy have not been issues and unduly influences the sensitive communica- included. Related to this, the possible bias introduced tion process, thus jeopardising patient autonomy. because of under-­reporting of procedures by healthcare Causes of death were selected according to their professionals, common to all clinical-­ administrative frequency, with cancer, circulatory system, respiratory databases, is another weakness to consider. system and nervous system being the main causes in Protected by copyright. Finally, ADs have been analysed as a dichotomous Catalonia, for both men and women.33 As some cogni- variable (having ADs/not having ADs), while the legal tive impairment processes can be coded as mental document allows specifying the particular procedures diseases, this category was also included. Also, kidney a person is willing to limit or extend (although, in the diseases were included as a cause of death, and some latter case, the doctor is not legally obliged to perform studies have shown that ADs are useful in planning those treatments that are not clinically indicated). So, whether to continue dialysis.34 35 we cannot state that the reduction in procedures in In regard to the medical procedures, these were the AD cohort was consistent with the content of the selected based on the possibility to adjust them during ADs and whether indeed the AD was required (patient the final stage of life, some of them being specifically lacked capacity at the time of the decision-­making). included in the ADs legal document, while others It would be interesting to carry out a more detailed are invasive or life-­ sustaining procedures. Also, the analysis by means of a qualitative review of ADs and number of visits to the emergency department and clinical records. transfers to other centres, that is, long-­ term care centres, were included to assess the performance of palliative care at home and the possibility of dying at What this study adds home. However, it seems from the study results that This study has shown that having an AD was more some techniques may have a more invasive character, frequent among the patients who died of cancer than despite being palliative, than others. This is the case those who died because of any other cause. This could for endoscopy and thoracentesis in comparison with, explain the strong effect of cancer deaths in this anal- for instance, the administration of fluids/drugs or anti- ysis. Moreover, this same pattern has been observed in biotics. Intubation and mechanical ventilation, more other studies,23 indicating the need to raise the aware- common among men, are perhaps the most striking ness of ADs on non-­cancer diseases. cases. One explanation may be that having an intrave- The results showed that SEC level can influence the nous route for the administration of drugs is seen by decision about completing an AD, but this did not patients, family members and healthcare professionals influence the use of procedures at end of life when one as a measure taken within usual care. Even the place- was in place. Related to this, it is worth mentioning the ment of a nasogastric tube for enteral feeding can be change in the SEC level of the ADs population, with viewed from a similar perspective. These results reflect a higher representation of high-­ income classes and that ADs could be taken into greater consideration in cancer cases in the current analysis than in previous the decision to carry out more invasive procedures, ones.7 Younger age, a lower level of education and although all of them are related to end-­of life care. No a lower income have previously been shown to be effects were observed regarding transfusions, which e342 Dalmau-­Bueno A, et al. BMJ Supportive & Palliative Care 2022;12:e337–e344. doi:10.1136/bmjspcare-2020-002851 Original research BMJ Support Palliat Care: first published as 10.1136/bmjspcare-2020-002851 on 22 March 2021. Downloaded from http://spcare.bmj.com/ on July 17, 2023 at Sant Paul Hospital Consortia. would likely be more relevant in causes of death other commercial. See: http://creativecommons.org/licenses/by-nc/4.​ than cancer. 0/. Finally, the number of transfers and visits to the ORCID iD emergency department is lower in patients with ADs, Anna García-­Altés http://orcid.org/0000-0003-3889-5375 although no statistically significant, which may reflect the desire of the patient for stability of care in the REFERENCES environment in which he or she is. Regarding palli- 1 Silveira MJ, Kim SYH, Langa KM. Advance directives and ative care, there are no statistically significant differ- outcomes of surrogate decision making before death. N Engl J ences between patients with and without ADs. Patients Med 2010;362:1211–8. usually want to talk about treatments that keep them 2 Rietjens JAC, Sudore RL, Connolly M, et al. Definition and recommendations for advance care planning: an international alive, not about palliative care in specific, since they consensus supported by the European association for palliative consider it part of the portfolio of their healthcare care. Lancet Oncol 2017;18:e543–51. system. 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Diari Oficial de la may be helpful in increasing awareness among health- Generalitat de Catalunya, núm. 3303, 2001. Available: www.​ parlament.cat/activitat/cataleg/TL 12Con.pdf [Accessed 12 care personnel, families and the population, and a May 2020]. tool to improve communication between healthcare 7 Busquets i Font JM, Hidoine de La Fuente M, Lushchenkova professionals and families.8 In conclusion, this study O, et al. Conocimiento Y valoración POR parte de Los Protected by copyright. has shown that, for some medical procedures at end of ciudadanos de Cataluña sobre LAS voluntades anticipadas Y La life, ADs have a performative force. This finding may atención al final de la vida. Medicina Paliativa 2014;21:153–9. 8 Teno JM, Gruneir A, Schwartz Z, et al. Association between be helpful in raising public awareness of ADs, as is an advance directives and quality of end-­of-­life care: a national indication that some part of society makes end-­of-­life study. J Am Geriatr Soc 2007;55:189–94. decisions in advance. 9 Silveira MJ, Wiitala W, Piette J. Advance directive completion by elderly Americans: a decade of change. J Am Geriatr Soc Acknowledgements Joan MV Pons (Agència de Qualitat i 2014;62:706–10. Avaluació Sanitàries de Catalunya) for the external review 10 Detering KM, Buck K, Ruseckaite R, et al. Prevalence and of the paper, and Keneth Planas (President of the Ethics correlates of advance care directives among older Australians Committee of Hospital Moises Broggi, Barcelona) for the accessing health and residential aged care services: multicentre initial help in the design of the study. audit study. BMJ Open 2019;9:e025255. Contributors AD-­B performed all data management and led 11 Evans N, Bausewein C, Meñaca A, et al. A critical review the statistical analysis and table preparation. AS-­L led the of advance directives in Germany: attitudes, use and data extraction, helped in the statistical analysis and table healthcare professionals' compliance. Patient Educ Couns preparation, and drafted the study protocol. JMB provided 2012;87:277–88. the idea for the research and all the knowledge regarding ADs. 12 van Wijmen MPS, Rurup ML, Pasman HRW, et al. Advance IB-­M provided all knowledge regarding palliative care. AG-­A directives in the Netherlands: an empirical contribution to drafted the article, did the final write-­up and coordinated the the exploration of a cross-­cultural perspective on advance project. directives. Bioethics 2010;24:118–26. Funding The authors have not declared a specific grant for this 13 Aw D, Hayhoe B, Smajdor A, et al. Advance care planning and research from any funding agency in the public, commercial or the older patient. QJM 2012;105:225–30. not-­for-­profit sectors. 14 Simon-­Lorda P, Tamayo-­Velázquez M-­I, Barrio-­Cantalejo I-­M. Advance directives in Spain. perspectives from a medical Competing interests None declared. bioethicist approach. Bioethics 2008;22:346–54. Patient consent for publication Not required. 15 Zheng R-­J, Fu Y, Xiang Q-­F, et al. Knowledge, attitudes, Provenance and peer review Not commissioned; externally and influencing factors of cancer patients toward approving peer reviewed. advance directives in China. Support Care Cancer 2016;24:4097–103. Data availability statement Data are available upon reasonable request. The data cannot be made publicly available. Requests 16 Schneiderman LJ, Kronick R, Kaplan RM, et al. Effects of for data should be sent to the corresponding author. offering advance directives on medical treatments and costs. Ann Intern Med 1992;117:599–606. Open access This is an open access article distributed in 17 Goodman MD, Tarnoff M, Slotman GJ. 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