The use of living wills at the end of life. A national study.

BACKGROUND: Knowing more about who uses living wills may help explain their limited acceptance.
METHODS: We analyzed the 1986 National Mortality Followback Survey, a random sample of all US deaths linked to a survey about decedents' use of living wills, their social and health status, and their use of medical services. Decedents with and without living wills were compared for differences in social and health characteristics and use of medical services.
RESULTS: There were 16,678 decedents; 9.8% had a living will. Rates of use were higher for decedents who were white (10.7%), were female (11.0%), had private insurance (13.8%), had incomes of $22,000 or more (14.5%), or had college educations (18.7%). The use of living wills was lower among blacks (2.7%), Medicaid recipients (6.3%), those with incomes of less than $5,000 (7.5%), or those with less than 8 years of education (4.0%). Health was also related to use of living wills. Functionally independent persons were unlikely to have a living will (5.5%); use increased with dependency. Cognitive impairment made it less likely that a decedent had a living will (6.7%). Persons who died of cancer (16.4%) or pulmonary disease (11.4%) were more likely to have one. All demographic and health characteristics remained significant in multivariate analyses. Controlling for health status, decedents with living wills used more physician visits (five to nine vs two to four, P < .001) and hospital days (37 vs 30, P < .001). Although more likely to use hospices (19.5% vs 8.4%, P < .001) and half as likely to receive cardiopulmonary resuscitation or ventilatory support, they were still 20% more likely to die in the hospital.
CONCLUSIONS: Patients who are black, poorly educated, underinsured, or cognitively impaired are least likely to prepare a living will. Decedents with living wills forgo specific treatments, but remain intensive users of routine medical services.