More Health Care Plays

A good death should be as commonplace as a good life. Too often, however, health care at the end of life stands in the way. According to researchers at the Dartmouth Medical School, end-of-life medical care is, to a great extent, wasteful and even harmful to patients. Consider that one-fourth of all health care dollars is spent in the last two years of life. That figure is unnecessarily high at least in part because patients fail to make their end-of-life preferences known.

Americans can avoid confusion about their end-of-life preferences by using living wills, advanced directives, and powers of attorney. These legal documents don't do much good if they are locked up in a filing cabinet where they are hard to get. They need to be available to doctors and nurses when they make decisions about providing care.

Several states have created online registries of advanced directives and powers of attorney, which give doctors and hospitals ready access to these documents electronically. To protect patient privacy, they deny access to any provider unless the patient or family has specifically granted access. Emergency care providers can also be given access to the databases.

The costs of these services are minimal. They typically involve one full-time employee for a medium-size state plus start-up and marketing expenses. States can also work with existing systems like U.S. Living Will Registry, a private foundation.

North Carolina was the first state to offer an online advance health directive registry. Since its launch in 2002, the state registry, which charges a $10 fee per document, has had a modest, but rising, turn-out rate. Arizona was the first state to offer free participation in an online registry, which has been run through the state Secretary of State's office since May 2004. Montana passed a law in 2005 to establish an online registry through the state's Attorney General's office. Montanans simply have to download the living will form from the state website, complete it, and mail it to the appropriate office. The document is scanned into the Internet registry and the original copy is returned to the applicant. Then, the applicant is given a wallet-sized card that indicates that he/she is a participant in the registry.

"The registry is an extremely effective way to ensure that your wishes are known and respected." -- Mike McGrath, Montana Attorney General.

States should also limit roadblocks to advance health planning and organize an awareness campaign. States that currently require living wills and advance directives to be written in legalese and signed by notaries public ought to simplify their policies. Enabling citizens to complete such forms without a hassle will encourage greater participation.

Ideally, online registries should be part of broader health information technology initiatives. They should be linked to electronic medical records used by doctors and personal health records that patients control. In addition, registries should incorporate organ donor information.

By making access to living wills easier for everyone involved in end-of-life care, an online registry can enable patients to make their preferences clear before they are unable to speak for themselves. Since most people choose conservative care when given the choice, living will registries will also reduce health care costs overall.

Resources for Action

Arizona Advance Directive Registry
www.azsos.gov/adv_dir/

Montana Advance Health Care Directives
http://doj.state.mt.us/consumer/consumer/advancedirectives.asp

North Carolina Advance Health Care Directive Registry
www.secretary.state.nc.us/ahcdr/

U.S. Living Will Registry
http://uslivingwillregistry.com/

It's My Choice Online, Inc.
www.itsmychoiceonline.com/

Montana Law
http://data.opi.mt.gov/bills/mca/50/9/50-9-103.htm

Washington Law
http://apps.leg.wa.gov/billinfo/summary.aspx?bill=2342

Additional Reading

Christopher Hogan, et al., "Medicare Beneficiaries' Costs of Care in the Last Year of Life," Health Affairs 20, (2001): 188-195
http://content.healthaffairs.org/cgi/content/abstract/20/4/188

Washington State Living Will Registry
http://www.doh.wa.gov/livingwill/

Contacts Carol Wozniak
Washington State Department of Health
Living Will Registry
101 Israel Rd SE
PO Box 47814
Olympia, WA 98504-7814
LivingWill@doh.wa.gov
360-236-4369

David Kendall
Senior Fellow for Health Policy
Progressive Policy Institute
4021 Heritage Way
Missoula, MT 59802
(406) 543-2265
dkendall@ppionline.org