Proposed is a randomized, longitudinal research experiment involving 200 patients with life-threatening illnesses (e.g., chronic renal disease, chronic pulmonary disease, cancer), randomly assigned to experimental and control groups, to explore alternatives to health care rationing as the solution to rising costs among very ill patients. In contrast to rationing, which takes little account of patient wishes and quality of care, major hypotheses are that enhancing personal autonomy through the enactment of advanced directives (living wills, durable power of attorney) may (1) reduce the cost of health care for the experimental (advanced directive) group as compared to the control (no advanced directive) group, and (2) not involve diminution of Well-being among the experimental group. Additional hypotheses, further exploring the complex relationship between enhanced autonomy and outcome, are that executing advanced directives may (3) improve satisfaction with health care by diminishing the unwanted treatment, and (4) improve the psychological well-being of patients by giving them positive control over important aspects of their lives. We shall also determine which of two proposed links between enhanced autonomy and improved outcome (Rotter's Locus of Control vs. Antonovsky's Sense of Coherence) is better support by empirical results. After the initial interview, followups are proposed at three months, six months, one year and two years after signing the advanced directive. Patients will be interviewed and followed at the University of California, San Diego (UCSD) Medical Center, at affiliated hospitals, and in their homes. All potential participants for the study will be screened for mental competency with the mini-mental state examination (MMSE), an instrument designed to identify cognitive dysfunction. Confirmation of the major research hypothesis might have very beneficial consequences for future patients and for the health care system generally by changing the focus of thinking currently prevalent among health policy makers. Solutions to the rationing problem would be considered less in terms of imposing limits, and more in terms of enhancing autonomy.
| Anderson, J P; Kaplan, R M; Coons, S J et al. (1998) Comparison of the Quality of Well-being Scale and the SF-36 results among two samples of ill adults: AIDS and other illnesses. J Clin Epidemiol 51:755-62 |
