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Background Advance Directives (ADs) are instruments in trying to improve quality of end-of-life care. The stability of preferences concerning end-of-life care says something about the validity of ADs. Aim Investigate the stability of end-of-life treatment preferences of people owning an AD over a 4,5-year period. Methods A longitudinal cohort study with a population of people owning different types of ADs, consisting of members of Right to Die-NL (NVVE, n = 4279) and the Christian orientated Nederlandse Patienten Vereniging (NPV, n = 1014), answered written questionnaires between 2005 and 2010. We used hypothetical scenarios about cancer and dementia to assess preferences for continuing or forgoing resuscitation, mechanical ventilation, artificial nutrition and hydration, and antibiotics. Using a multi-state model we analysed whether health status and life events influenced changes in preferences. Results From the NPV 24–33% changed their preferences from forgoing to continuing treatment or the other way around for the different treatments and scenarios. The part from the NVVE that changed ranged from 2–24%. A person’s own health, a change in the health or the death of a loved one were associated with a change in preferences. Discussion Preferences concerning continuing or forgoing treatment at the end of life stay stable for a majority of people owning ADs. Higher percentages of instability in the NPV group might be related to their AD (a will to live statement) neither clearly in- or excluding forgoing treatment at the end of life. Conclusion The high stability found supports validity of Ads; on-going communication about their content is recommended.

Background In the Netherlands, advance euthanasia directives (AED) are used to request euthanasia under specific circumstances. Although representative of patient wishes, they are not legally binding. Examining AED completion before and after the implementation of the 2002 Dutch euthanasia law can provide some insight on its influence. Aim To describe self-reported AED completion among representative samples of Dutch older people in 1998, 2005, 2008 and 2011 and to analyse associations between personal characteristics and AED completion. Methods Participants reported their AED completion in face-to-face interviews. AED prevalence was described and associated factors analysed with multivariable logistic regression using generalised estimating equations. Results AED completion of 2576 older people was recorded. Prevalence was 6.8%, 4.3%, 6.4% and 6.2%, in 1998, 2005, 2008 and 2011 respectively. The odds of completion were significantly lower in 2005 compared with 1998, although there were no significant differences in 2008 and 2011 compared with 1998. Completion was associated with increasing age, female gender, higher education and income, and negatively associated with being Catholic or Protestant. Health factors had no influence on AED completion. Discussion/conclusion Following the enactment of the 2002 Dutch euthanasia law, there was a slight decrease in AED completion which, overall, remained low. Legal recognition did not, therefore, lead to their increased use and may even have been associated with their decline in the first instance. The lack of association between AED completion and health factors indicates that older people with a range of health statuses completed AEDs, not just those with serious illness.