Urban/Rural Differences in Decision Making and the Use of Advance Directives Among Nursing Home Residents at Admission Robert J. Buchanan, PhD; 1 Jane Bolin, RN, JD, PhD; 2 Suojin Wang, PhD; 3 Li Zhu, PhD; 4 and MyungSuk Kim, MS 5 ABSTRACT: Context: Advance directives promote patient autonomy and encourage greater awareness of final care options while reducing physician and family uncertainty regarding patient preferences. Purpose: To investigate differences in decision making authority and the use of advance directives among nursing home residents admitted from urban and rural areas. Methods: A total of 551,208 admission assessments in the Minimum Data Set were analyzed for all residents admitted to a nursing facility in 2001. Using the Rural Urban Commuting Areas (RUCA) methodology and ZIP code of primary residence before admission, these residents were classified into 4 urban/rural areas. Findings: Residents from rural areas were significantly more likely to have executed a durable power of attorney for health care or for financial decisions than residents admitted from the other areas, with the largest differences observed between residents admitted from urban and rural areas. Almost 6 residents in 10 from urban areas had no advance directives in place at admission compared with only 4 residents in 10 admitted from rural areas. Conclusions: Health providers and social workers in both rural and urban areas should advise patients about the value of advance directives. A dvance directives promote patient auton- omy and encourage greater awareness of final care options while reducing physi- cian and family uncertainty regarding patient preferences. 1-6 Implementation of advance directive programs in nursing facilities also can reduce the utilization of health services, as well as improve treatment of pain without affecting satisfaction with care or increasing mortality rates. 7 Congress, in an effort to reinforce patients’ consti- tutional rights to determine their final health care, passed the Patient Self-Determination Act (PSDA) in 1991. 8,9 The PSDA requires nursing facilities and other health providers that receive Medicare or Medicaid funding to provide each patient with written information about their right to accept or refuse treatment and the right to state their wishes in advance for end-of-life treatment. 9 The PSDA did not create new patient rights, but was designed to ensure that patients are informed of their rights under state law. 10 Facilities that fail to comply with the PSDA must lose all Medicare or Medicaid funding, although there are no documented cases of any facility losing such funding for failure to comply. 11 Some observers argue that nursing facilities and other pro- viders are not meeting expectations of the PSDA because there is systemic failure to initiate or document dis- cussions regarding end-of-life preferences. 8 A review of the literature indicates little research has been conducted on differences in the use of 1 College of Health and Human Services, University of North Carolina at Charlotte. 2 Department of Health Policy and Management, School of Rural Public Health, The Texas A&M University System Health Science Center, College Station, Tex. 3 Department of Statistics, Texas A&M University, College Station, Tex. 4 Department of Epidemiology and Biostatistics, School of Rural Public Health, The Texas A&M University System Health Science Center; and Department of Statistics, Texas A&M University, College Station, Tex. 5 Department of Statistics (doctoral student), Texas A&M University, College Station, Tex. S.W.’s research was supported in part by the National Cancer Institute (CA-57030) and the Texas A&M University Center for Environmental and Rural Health to do statistical methodology research and its application to the health sciences. For further information, contact: Robert J. Buchanan, PhD, Associate Dean for Research, College of Health and Human Services, University of North Carolina at Charlotte, 9201 University City Blvd, Charlotte, NC 28223-0001; email rjbuchan@email.uncc.edu ..... Rural Health Research/Aging ..... Buchanan, Bolin, Wang, Zhu and Kim 131 Spring 2004