The savings estimates for advance directives are, in general, vulnerable to the same criticisms that have been raised about research on hospice cost savings (e.g., that those willing to sign directives are not representative of the larger population) (Emanuel, 1996). In particular, skepticism about projections of significant cost savings rests on doubts about (1) the willingness of people to sign such directives, (2) their readiness to forego life-extending care when death is a real, not an abstract, prospect, and (3) the ability of health care systems to implement directives (Schneiderman et al., 1992; Teno et al., 1993; GAO, 1995b; SUPPORT Principal Investigators, 1995; Levinsky, 1996; Scitovsky, 1996; Lynn, Harrell et al., 1997; see also Chapters 3 and 7).

Although there is no evidence to suggest that significant cost savings would soon result, some steps could be taken to increase the potential for advance care planning to avoid some services—and expenditures—that most would agree are unwanted, ineffective, and even damaging to patient well-being. For patients who have completed advance directives (or taken similar steps), better procedures are needed to assure that information on patient wishes is readily available and considered at critical decision points, for example, the transfer of a seriously debilitated, very elderly patient from a nursing home to a hospital. The Oregon initiative described in Chapter 3 provides examples of such procedures.

Some have argued that managed care organizations are particularly well suited to encourage use of advance directives (Fade and Kaplan, 1995). A number of managed care organizations have undertaken systematic efforts to encourage greater use of advance directives (Baines, Barnhart et al., 1996; Christensen, 1996; Hammes and Rooney, 1996). Some caution is, however, warranted about promoting advance directives as a cost-containment measure in this context, and managed care organizations have particular reason to be hesitant about appearing too intent on encouraging people to sign directives limiting certain forms of care. For example, Sulmasy (1995), in discussing concerns about conflict of interest, suggested that advance directives (particularly if assisted suicide were to become legal) could be a "chillingly effective way to control the cost of managed care" (p. 245). He also notes that some have suggested lower insurance premiums for those who have advance directives (see Washington Post, May 2, 1993, C3).

Overall, continued efforts to encourage various forms of advance care planning and goal setting make sense at the margin, notwithstanding the social and cultural obstacles. One caveat: should people suspect that they were being pressured to sign advance directives and that such directives might be used inappropriately to limit care, then the result might be both higher costs and more use of advanced technologies that patients or families would forego in an environment of greater trust. Also, patients might try to

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