Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Original article

Vol. 148 No. 2930 (2018)

Awareness, approval and completion of advance directives in older adults in Switzerland

  • Sarah Vilpert
  • Carmen Borrat-Besson
  • Jürgen Maurer
  • Gian Domenico Borasio
DOI
https://doi.org/10.4414/smw.2018.14642
Cite this as:
Swiss Med Wkly. 2018;148:w14642
Published
29.07.2018

Summary

BACKGROUND

Advance directives enable people to describe their preferences for medical treatment (living will) and/or to appoint a healthcare proxy who may decide on their behalf should they lose decision-making capacity. Advance directives are potentially important in determining the course of end-of-life care, as deaths are frequently preceded by end-of-life treatment decisions, which often require someone to make decisions on the patient’s behalf. Switzerland introduced legally binding advance directives through its new child and adult protection law of 2013. But there is still no comprehensive evidence on older persons’ awareness, attitudes and behaviours with regard to advance directives in Switzerland.

AIM AND METHOD

Our study aimed to assess levels of awareness, approval and completion of advance directives, as well as their respective associations with sociodemographic characteristics in the Swiss population aged 55 and older. Our study was cross-sectional and used data from the Survey of Health, Ageing and Retirement in Europe (SHARE), which included a special module on end-of-life issues in wave 6 (2015) in Switzerland (n = 2085).

RESULTS

Two years after the introduction of advance directives in Switzerland, 78.7% of adults aged 55 years and older had heard of them prior to the survey and 24% reported that they had completed one. Awareness of advance directives was higher in the German-speaking part of Switzerland (91%) than in the Italian- (57.1%) and French-speaking (43.3%) regions (p <0.001). Advance directive completion also differed significantly between the German- (28.7%), French- (10.3%) and Italian-speaking (17.9%) regions of Switzerland (p <0.001). Overall, 76.7% of Swiss adults aged 55 and older generally approved of advance directives, i.e., they either reported having already completed one or were planning to do so in the future. Of those who had not yet completed an advance directive, 32.9% believed that it was still “too early” for them to do so and 30.1% believed that they would not need one. Levels of awareness, approval and completion of advance directives also varied significantly by sex, age, education level and household composition.

DISCUSSION

Our results show some potential for improvement in levels of advance directive awareness and, especially, completion among older adults, notably in the French- and Italian-speaking Switzerland. In view of the generally high levels of approval of advance directives, our findings point to important barriers to their completion by older persons that should be addressed by policy makers in order to ensure an effective translation of individual intentions to complete an advance directive sometime in the future into concrete and timely actions toward this end.

References

  1. Décès. Neuchâtel: Office fédéral de la statistique; 2018 [cited 2018 06.02]; Available from: https://www.bfs.admin.ch/bfs/fr/home/statistiques/population/naissances-deces/deces.html.
  2. Bosshard G, Zellweger U, Bopp M, Schmid M, Hurst SA, Puhan MA, et al. Medical End-of-Life Practices in Switzerland: A Comparison of 2001 and 2013. JAMA Intern Med. 2016;176(4):555–6. doi:.https://doi.org/10.1001/jamainternmed.2015.7676
  3. Reich O, Signorell A, Busato A. Place of death and health care utilization for people in the last 6 months of life in Switzerland: a retrospective analysis using administrative data. BMC Health Serv Res. 2013;13(1):116. doi:.https://doi.org/10.1186/1472-6963-13-116
  4. Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211–8. doi:.https://doi.org/10.1056/NEJMsa0907901
  5. Pautex S, Herrmann FR, Zulian GB. Role of advance directives in palliative care units: a prospective study. Palliat Med. 2008;22(7):835–41. doi:.https://doi.org/10.1177/0269216308094336
  6. van Wijmen MP, Pasman HR, Widdershoven GA, Onwuteaka-Philipsen BD. Motivations, aims and communication around advance directives: a mixed-methods study into the perspective of their owners and the influence of a current illness. Patient Educ Couns. 2014;95(3):393–9. doi:.https://doi.org/10.1016/j.pec.2014.03.009
  7. Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340(mar23 1):c1345. doi:.https://doi.org/10.1136/bmj.c1345
  8. Martin DK, Emanuel LL, Singer PA. Planning for the end of life. Lancet. 2000;356(9242):1672–6. doi:.https://doi.org/10.1016/S0140-6736(00)03168-8
  9. Carr D, Luth E. Advance Care Planning: Contemporary Issues and Future Directions. Innovation in Aging. 2017;1(1):igx012. doi:.https://doi.org/10.1093/geroni/igx012
  10. Carr D. Death and dying in the contemporary United States: what are the psychological implications of anticipated death? Soc Personal Psychol Compass. 2012;6(2):184–95. doi:.https://doi.org/10.1111/j.1751-9004.2011.00416.x
  11. Des directives anticipées du patient, Art. 370 (2008). Available from: http://www.loisuisse.ch/fra/sr/210/210_033.htm
  12. Directives anticipées – pour plus de sécurité. Fédération des médecins suisses; 2018 [cited 2018 06.02]; Available from: https://www.fmh.ch/files/pdf16/FMH_PV_AV_2015_f.pdf.
  13. Dossier pour les directives anticipées. ProSenectute; 2018 [cited 2018 06.02]; Available from: https://www.prosenectute.ch/fr/shop/dossier-pour-les-directives-anticip%C3%A9es.html.
  14. Etablissez vos directives anticipées avec nous. Croix Rouge Suisse; 2018 [cited 2018 06.02]; Available from: http://directives-anticipees.redcross.ch/.
  15. SHARE. End-of-life questionnaire. Munich: Max Planck Institute for Social Law and Social Policy (MEA); 2018 [cited 2018 14.05.2018]; Available from: http://www.share-project.org/fileadmin/pdf_questionnaire_wave_6/DO_EN_SHARE_04.12.2014corr.pdf.
  16. Börsch-Supan A. Survey of Health, Ageing and Retirement in Europe (SHARE) Wave 6. Release version: 6.0.0. In: SHARE-ERIC, editor. 2017.
  17. Klevmarken A, Hesselius P, Swensson P. The SHARE Sampling Procedures and Calibrated Designs Weights In: Börsch-Supan A, Jürges H, editors. The Survey of Health, Ageing and Retirement in Europe – Methodology. Mannheim: Mannheim Research Institute for the Economics of Aging (MEA); 2005. p. 66-9.
  18. Lynn P, De Luca G, Ganninger M, Häder S. Sample Design in SHARE Wave Four. In: Malter F, Börsch-Supan A, editors. SHARE Wave 4: Innovations & Methodology. Munich Munich Center for the Economics of Aging (MEA); 2013. p. 91-3.
  19. SHARE Release Guide 6.0.0. Munich: MEA, Munich Center for the Economics of Aging; 2017.
  20. Solon G, Haider SJ, Wooldridge J. What Are We Weighting For? NBER working paper series. 2013. Available from: https://msu.edu/~solon/WAWWFfeb2013.pdf
  21. Williams R. Using the margins command to estimate and interpret adjusted predictions and marginal effects. Stata J. 2012;12(2):308–31.
  22. Andorno R, Biller-Andorno N, Brauer S. Advance health care directives: towards a coordinated European policy? Eur J Health Law. 2009;16(3):207–27. doi:.https://doi.org/10.1163/157180909X453053
  23. Yadav KN, Gabler NB, Cooney E, Kent S, Kim J, Herbst N, et al. Approximately One In Three US Adults Completes Any Type Of Advance Directive For End-Of-Life Care. Health Aff (Millwood). 2017;36(7):1244–51. doi:.https://doi.org/10.1377/hlthaff.2017.0175
  24. Alano GJ, Pekmezaris R, Tai JY, Hussain MJ, Jeune J, Louis B, et al. Factors influencing older adults to complete advance directives. Palliat Support Care. 2010;8(3):267–75. doi:.https://doi.org/10.1017/S1478951510000064
  25. del Pozo Puente K, Hidalgo JL, Herráez MJ, Bravo BN, Rodríguez JO, Guillén VG. Study of the factors influencing the preparation of advance directives. Arch Gerontol Geriatr. 2014;58(1):20–4. doi:.https://doi.org/10.1016/j.archger.2013.07.009
  26. Rao JK, Anderson LA, Lin FC, Laux JP. Completion of advance directives among U.S. consumers. Am J Prev Med. 2014;46(1):65–70. doi:.https://doi.org/10.1016/j.amepre.2013.09.008
  27. Rurup ML, Onwuteaka-Philipsen BD, van der Heide A, van der Wal G, Deeg DJ. Frequency and determinants of advance directives concerning end-of-life care in The Netherlands. Soc Sci Med. 2006;62(6):1552–63. doi:.https://doi.org/10.1016/j.socscimed.2005.08.010
  28. van Wijmen MP, Rurup ML, Pasman HR, Kaspers PJ, Onwuteaka-Philipsen BD. Advance directives in the Netherlands: an empirical contribution to the exploration of a cross-cultural perspective on advance directives. Bioethics. 2010;24(3):118–26. doi:.https://doi.org/10.1111/j.1467-8519.2009.01788.x
  29. Wilson DM, Houttekier D, Kunju SA, Birch S, Cohen J, MacLeod R, et al. A population-based study on advance directive completion and completion intention among citizens of the western Canadian province of Alberta. J Palliat Care. 2013;29(1):5–12.
  30. Colombo F, Llena-Nozal A, Mercier J, Tjadens F. The impact of caring on families carers. In: Studies OHP, editor. Help wanted? Providing and paying for long-term care: OECD Publishing; 2011.
  31. Hopp FP. Preferences for surrogate decision makers, informal communication, and advance directives among community-dwelling elders: results from a national study. Gerontologist. 2000;40(4):449–57. doi:.https://doi.org/10.1093/geront/40.4.449
  32. Wiesing U, Jox RJ, Hessler HJ, Borasio GD. A new law on advance directives in Germany. J Med Ethics. 2010;36(12):779–83. doi:.https://doi.org/10.1136/jme.2010.036376
  33. Horn R. “Why Should I Question a Patient’s Wish?” A Comparative Study on Physicians’ Perspectives on Their Duties to Respect Advance Directives. Eur J Health Law. 2017;24(5):523–40. doi:.https://doi.org/10.1163/15718093-12341437
  34. Deutlicher Anstieg bei Patientenverfügungen. Allensbach: Institut für Demoskopie Allensbach; 2014. Available from: https://www.ifd-allensbach.de/uploads/tx_reportsndocs/PD_2014_20.pdf
  35. Palazzolo J. Les nouvelles relations médecin-malade. Cerveau et Psycho. 1999;30 November. Available from: https://www.cerveauetpsycho.fr/sd/medecine/les-nouvelles-relations-medecin-malade-1697.php
  36. LOI n° 2016-87créant de nouveaux droits en faveur des malades et des personnes en fin de vie. 2016. Available from : https://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000031970253&categorieLien=id
  37. C'è l'ok del Senatio, il biotestamento è legge: ecco che cosa prevede. La Stampa. 2017. 14 December. Available from: http://www.lastampa.it/2017/12/14/italia/c-lok-del-senato-il-biotestamento-legge-1JjGIIKEzi7W8autnHwnUO/pagina.html
  38. Busato A, Künzi B. Primary care physician supply and other key determinants of health care utilisation: the case of Switzerland. BMC Health Serv Res. 2008;8(1):8. doi:.https://doi.org/10.1186/1472-6963-8-8
  39. Luta X, Panczak R, Maessen M, Egger M, Goodman DC, Zwahlen M, et al. Dying among older adults in Switzerland: who dies in hospital, who dies in a nursing home? BMC Palliat Care. 2016;15(1):83. doi:.https://doi.org/10.1186/s12904-016-0156-x
  40. Panczak R, Luta X, Maessen M, Stuck AE, Berlin C, Schmidlin K, et al. Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-area Analysis Using Insurance Claims Data. Med Care. 2017;55(2):155–63. doi:.https://doi.org/10.1097/MLR.0000000000000634
  41. Fischer S, Bosshard G, Faisst K, Tschopp A, Fischer J, Bär W, et al. Swiss doctors’ attitudes towards end-of-life decisions and their determinants: a comparison of three language regions. Swiss Med Wkly. 2006;136(23-24):370–6.
  42. Pautex S, Gamondi C, Philippin Y, Gremaud G, Herrmann F, Camartin C, et al. Advance directives and end-of-life decisions in Switzerland: role of patients, relatives and health professionals. BMJ Support Palliat Care. 2015 2 September:bmjspcare-2014-000730. doi:.https://doi.org/10.1136/bmjspcare-2014-000730
  43. Nolan MT, Bruder M. Patients’ attitudes toward advance directives and end-of-life treatment decisions. Nurs Outlook. 1997;45(5):204–8. doi:.https://doi.org/10.1016/S0029-6554(97)90066-X
  44. Otte IC, Jung C, Elger BS, Bally K. Advance directives and the impact of timing. A qualitative study with Swiss general practitioners. Swiss Med Wkly. 2014;144:w14035. doi:.https://doi.org/10.4414/smw.2014.14035
  45. Silveira MJ, Wiitala W, Piette J. Advance directive completion by elderly Americans: a decade of change. J Am Geriatr Soc. 2014;62(4):706–10. doi:.https://doi.org/10.1111/jgs.12736
  46. Seymour J, Gott M, Bellamy G, Ahmedzai SH, Clark D. Planning for the end of life: the views of older people about advance care statements. Soc Sci Med. 2004;59(1):57–68. doi:.https://doi.org/10.1016/j.socscimed.2003.10.005