bereavement counseling), and similar features. Nonetheless, given the accelerating financial pressures on Medicare, it is reasonable to consider continued research to identify the circumstances under which hospice care can reduce the cost of end-of-life care. One area for such research involves the application of the new guidelines for qualifying patients with selected noncancer diagnoses, which were discussed in Chapter 4.

Advance directives specifically and advance care planning more generally are not health care financing mechanisms per se, and the arguments in their favor have primarily to do with patient and family control over end-of-life decisionmaking and with thoughtful consideration of peoples' goals at the end of life (see Chapters 3 and 7). Nonetheless, the potential of advance directives to reduce costs has also attracted attention. The idea is that written directives would eliminate the uncertainty or the dedication to rescue that drives clinicians treating comatose or otherwise mentally incompetent patients to provide ineffectual life-prolonging interventions. In addition, advance care planning might help some people to prepare for decisions that they may face while conscious and mentally competent (e.g., when to elect hospice care, when to accept or refuse another round of chemotherapy) and to be less susceptible to pressure from clinicians or family to agree to unwanted interventions when a crisis arises.

Some research suggests that patients who sign advance directives generate lower costs for their final hospitalizations than patients without such directives (Weeks et al., 1994). Other research, however, indicates the patient and family preferences are often not effectively communicated to or understood by clinicians (SUPPORT Principal Investigators, 1995; see also Chapter 3).

A sense of the outer limits of cost savings comes from an estimate that if every patient who died in 1988 "executed an advance directive, chose hospice care, and refused aggressive, in hospital interventions at the end of life … the total savings in health care expenditures would have been $18.1 billion … or about 3.3 percent of all health care spending" (Emanuel and Emanuel, 1994, p. 542). The savings to the Medicare program would have amounted to about 6 percent of program spending in 1988. Clearly, it is unreasonable to contemplate universal acceptance and implementation of these measures. It is reasonable, however, to expect that some unwanted care and avoidable costs are incurred when care is provided contrary to the oral or written directive of a patient or family. Even if savings were only 10 percent of the high estimate cited above, the amounts, while small in the context of overall spending and spending increases, would not be meaningless.