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A recent study published in Health Policy indicates that the use of advance directives (ADs) in Maryland is higher than expected but that there is still room for improvement. Conducted by LifeBridge Health physicians Dan Morhaim, M.D., Northwest Hospital Emergency department, and Michael A. Williams, M.D., medical director of the Sandra and Malcolm Berman Brain & Spine Institute, with lead author Dr. Keshia M. Pollack from the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, the research was initiated to better understand the public's perception regarding ADs and to identify potential policy solutions to increase their use. ADs, also known as living wills, are documents that allow persons 1) to indicate their wishes for treatment should they become unable to make medical decisions for themselves and 2) to appoint a specific person to make decisions on their behalf.

Unlike most studies of the use of ADs, which have focused either on the elderly population or on groups with critical illness or cancer, the current study surveyed Maryland adults of all ages who were at home. The authors found that 34% of Maryland adults have ADs, which is higher than rates of 18% to 30% in other studies. More important, even though only 34% said that they had ADs, 61% of Maryland adults said they had preferences about medical care in the event that they would be unable to make such decisions for themselves. Of these, 83% said that it was very important to them that their preferences be carried out.

In addition, the investigation found that blacks and younger adults are significantly less likely to have ADs than are whites and older adults. These differences can be attributed to cultural differences, distrust in the health care system and lack of knowledge of advance directives.

Dr. Williams, a member of the Ethics Committee at Sinai Hospital, considers the high rate of ADs in Maryland as a tribute to the effectiveness of the Maryland Health Care Decisions Act of 1991 and the efforts of health care professionals to discuss ADs with their patients and their families, but he adds, "Considering that 61% of the respondents in our survey had preferences about medical care and only 34% had ADs, we must find more innovative and effective ways to help patients create their ADs." The study recommends exploring diverse approaches for increasing AD awareness that are culturally sensitive and recognize that the existing methods of using only a written document or only a single decision maker may not be well suited for persons of all cultural or ethnic backgrounds, stating, "Policy development should recognize the variety of values and preferences found among diverse racial or ethnic groups."

"These results indicate a need for increased education about the necessity for an advance directive and possibly regulatory incentives for physicians to discuss advance care planning with their patients," said Dr. Morhaim.

LifeBridge Health, one of the largest, most comprehensive providers of health services in Northwest Baltimore, includes Sinai Hospital, Northwest Hospital, Levindale Hebrew Geriatric Center and Hospital, Courtland Gardens Nursing & Rehabilitation Center, and related subsidiaries and affiliates. For more information, visit www.lifebridgehealth.org.

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