Date of Award


Degree Type


Degree Name

Doctor of Philosophy


Human Ecology

Major Professor

James J. Neutens

Committee Members

June Gorski, Diane A. Klein, Ralph G. Brockett


The Patient Self-Determination Act of 1990 was expected to popularize the use of advance directives (living wills and durable powers of attorney for healthcare (DPOA-HC)). Since the law was passed, researchers have found that the use of the documents has not increased as expected and that the documents, when present, were not always respected by healthcare providers.

The purpose of this study was to analyze the end-of-life choices of elderly patients and their healthcare providers in a community hospital setting. The subjects of this study were 160 patients, aged 65 years and older, who died in a community hospital in Tennessee in 2002. Medical record data were abstracted using a modified form of the Chart Abstraction Instrument developed by Fins, Miller, Acres, Bacchetta, Huzzard, & Rapkin (1999). Chi square tests and binary logistic regression were used to analyze the data.

The findings of this study confirmed that the use of advance directives has not changed much over the past decade. Nearly 27% of the patients had living wills, 20.6% of the patients had a formal DPOA-HC, and an informal DPOA-HC was recognized by staff for 76.3% patients.

Healthcare providers were not influenced by the presence of any advance directive in their decisions involving the unit of treatment, use of life-sustaining treatments, or initiation of comfort care plans. Over half of the patients (56.3%) experienced pain during their last two days of life. More than one-quarter of the patients with pain were not treated with medications accepted as standard-of-care. Healthcare providers did appear to be influenced by the presence of a living will in their decisions to write do-not-resuscitate orders more often (p < 0.05) and use cardiopulmonary resuscitation less often (p < 0.05) for patients possessing the document.

Recommendations for future research included study replication using samples drawn from facilities in other regions of the country and the evaluation of educational initiatives for both healthcare consumers and healthcare providers. The continued development and implementation of evidence-based protocols was also recommended.

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