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Why Don't Emergency Department Patients Have Advance Directives?
Abstract
Objectives:
In 1997 the authors determined that only 27% of their adult ED patients had advance directives (ADs). The purpose of this follow-up study was to determine the reasons why their adult ED patients do not have ADs.
Methods:
This prospective study enrolled patients from a convenience sample of representative shifts in the ED selected over a three-month period. Survey questions included demographic information, whether the patients had a life-threatening medical problem, whether they had an AD, with whom they had discussed their ADs, and the reasons why they did not have an AD. We excluded those who refused participation or who were incapacitated (i.e., any patient with a condition that precluded him or her from answering the questionnaire himself or herself, such as an altered level of consciousness, dementia, mental retardation, or inability to understand English).
Results:
Four hundred seventy-six subjects were enrolled during the study period from an ED census of 816 adult patients. Three hundred forty patients were not included in the study for the following reasons: inability to complete the survey, refusal to participate, or not being approached by the interviewers. Of those enrolled, 77% of the patients did not have an AD (females, 73%; males, 80%). The most frequent reasons given for not having an AD were: 40% never thought about it, 24% preferred family to make the decision, and 23% were procrastinating. Factors jointly predictive of having an AD were older age, having a specialist, having a life-threatening medical problem, and not being Catholic. Patients who had ADs were discussing their ADs with their primary care physicians (PCPs) only 5% of the time.
Conclusion:
Many patients, even when they have life-threatening medical problems, do not have an AD, and several reasons for this have been identified. Few of these ED patients who had ADs had discussed them with their physicians. Further studies should assess whether more physician intervention would increase the percentage of patients who have ADs.
... 27 more were identified by screening the bibliographies of all included studies. After removing duplicates (n = 97) and applying the in-and exclusion criteria, a total of 22 studies were included in the analysis [4,11,[20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38], whereas 104 studies (Supplementary, Tab. s2) were excluded ( Fig. 1). ...
... The proportion of all ED patients having DPW was reported to range from 19.9% [36] to 27.8% [28], as described by five of the included studies [21,22,27,28,36] (Fig. 2). Slankamenac et al. conducted a follow-up after 60 days via e-mail, in which the rate of DPW had increased by 2.7% (loss-to-follow-up: 56.8%), simply due to having come into contact with the topic [36]. ...
... All studies that examined potential predicting factors [5,21,22,24,28,[30][31][32]36], except one [39] identified older age as a positive predictor of documented patient wishes Likewise, several studies found a correlation between comorbidities or self-rating of generally poorer health and increased likelihood of holding a DPW [22,29,36]. The use of health care services, especially NH or similar institutions, seems to correlate with a higher rate of DPW [29,30,36]. ...
Background
Providing individualised healthcare in line with patient wishes is a particular challenge for emergency healthcare professionals. Documentation of patient wishes (DPW), e.g. as advance directives, can guide clinicians in making end-of-life decisions that respect the patient’s wishes and autonomy. However, patient centered decisions are hindered by limited availability of DPWs in emergency settings.
Objective
This systematic review aims to congregate present data on recorded rates for DPW existence and availability in the emergency department (ED) as well as contributing factors for these rates.
Methods
We searched MEDLINE, Google Scholar, Embase and Web of Science databases in September 2023. Publications providing primary quantitative data on DPW in the ED were assessed. Publications referring only to a subset of ED patients (other than geriatric) and investigating DPW issued after admission were excluded.
Results
A total of 22 studies from 1996 to 2021 were included in the analysis. Most were from the US (n = 12), followed by Australia (n = 4), Canada (n = 2), South Korea, Germany, the United Kingdom and Switzerland (n = 1 each). In the general adult population presenting to the ED, 19.9–27.8% of patients reported having some form of DPW, but only in 6.8% or less it was available on presentation. In the geriatric population, DPW rates (2.6–79%) as well as their availability (1.1–48.8%) varied widely. The following variables were identified as positive predictors of having DPW, among others: higher age, poorer overall health, as well as sociodemographic factors, such as female gender, having children, being in a relationship, higher level of education or a recent previous presentation to hospital.
Conclusions
Existence and availability of a recorded DPW among ED patients was low in general and even in geriatric populations mostly well below 50%. While we were able to gather data on prevalence and predictors, this was limited by heterogeneous data. We believe further research is needed to explore the quality of DPW and measures to increase both rates of existence and availability of DPW in the ED.
... The percentage of patients who gave DNR consent among those receiving palliative care in Germany and the USA has been reported to be approximately 60-70 % [11,12]. The rates at which DNRs are signed in the ICUs and PCUs of major hospitals vary widely, although studies have shown that this is relatively low for ED patients, estimated at 7.9 and 27 % in South Korea and the USA, respectively [13,14]. ...
... Consequently, a high proportion of terminal cancer patients in hospices or acute hospitals also gave DNR consent. Furthermore, differences in DNR decisionmaking exist in different medical institutions and geographic areas [14,17], and very few studies on ED patients' DNR decisions have been conducted in Taiwan. ...
... ED physicians are usually forced to pursue aggressive medical treatment due to the critical nature of patients' conditions. However, the rate at which the surrogates signed DNR consent forms is similar to that reported in other studies [13,14]. While physicians could explain to the surrogates the benefits of palliative care for the terminally ill patients, physicians in ED should initiate discussions with surrogates about the DNR option based on the patient's condition [23,[26][27][28]. ...
Purpose:
The purpose of this study was to investigate the prevalence of do-not-resuscitate (DNR) orders and to identify relevant factors influencing the DNR decision-making process by patients' surrogates in the emergency department (ED).
Methods:
A prospective, descriptive, and correlational research design was adopted. A total of 200 surrogates of cancer or non-cancer terminal patients, regardless of whether they signed a DNR order, were recruited as subjects after physicians of the emergency department explained the patient's conditions, advised on withholding medical treatment, and provided information on palliative care to all surrogates.
Results:
Of the 200 surrogates, 23 % signed a DNR order for the patients. The demographic characteristics of patients and surrogates, the level of understanding of DNR orders, and factors of the DNR decision had no significant influence on the DNR decision. However, greater severity of disease (odds ratio (OR) = 1.38; 95 % confidence interval (CI) = 0.95-1.74), physician's initiative in discussing with the families (OR = 1.42; 95 % CI = 1.21-1.84), and longer length of hospital stay (OR = 1.06; 95 % CI = 1.03-1.08) were contributing factors affecting patient surrogates' DNR decisions.
Conclusions:
The findings of this study indicated that surrogates of patients who were more severe in disease condition, whose physicians initiated the discussion of palliative care, and who stayed longer in hospital were important factors affecting the surrogates' DNR decision-making. Therefore, early initiation of DNR discussions is suggested to improve end-of-life care.
... [1][2][3][4] Moreover, other studies suggest that even when patients have ADs, the existence or specifics of these directives may not be communicated to primary health care providers. [5][6][7] The emergency department (ED) represents a unique setting where physicians frequently encounter patients for the first time and are unfamiliar with their values and beliefs regarding end-of-life care. Moreover, EDs frequently treat critically ill patients, many of whom are not able to communicate with hospital staff, at times without the benefit of an identified substitute decision maker. ...
... Factors found to be predictive of having an AD were older age, having a specialist, having a lifethreatening medical problem, and not being Catholic. 6 In another ED study of 238 patients in Tennessee, Ishihara and colleagues found that 22% of patients had ADs. 5 Of these, 23% brought their ADs along for the ED visit. ...
To date, there has been minimal research on advance directives (ADs) among elderly patients in Canadian emergency departments (EDs). The purpose of this study was to determine the prevalence of ADs among elderly patients visiting an urban ED. We also explored whether there were factors associated with the existence of an AD and possible barriers to having one.
This prospective study ran between October and December 2008. Individuals over the age of 70 who presented to the ED between 7 am and 7 pm, 7 days a week, were considered for enrollment. Exclusion criteria included previous enrollment and inability to provide informed consent. A team of nurses who specialize in assessment of geriatric patients administered a study instrument consisting of 28 questions. Topics included demographics, level of education, medical information, and knowledge of and attitudes toward ADs.
The results from 280 participants, with an average age of 80.6 years, were analyzed. Thirty-five percent of participants reported that they knew what an AD was; 19.3% of participants said they had an AD, but only 5.6% brought it to the hospital; 50.7% were interested in further information regarding ADs; and 67.9% of participants felt that it was important for physicians to know their wishes about life support.
Knowledge of ADs among elderly patients visiting an urban Canadian ED is limited and is likely a significant factor precluding wider prevalence of ADs. There is interest in further discussion about ADs in this population group.
... Barriers to optimal ED end-of-life care include the lack of: advance directive documentation, access to records, primary care provider-to-patient/ED communication, and staff for family support. 2,4,16,17,18 The pressing demand to maximize ED throughput and a general consensus that ED clinicians may feel these conversations are best held in a nonchaotic setting with qualified personnel may also hinder early prognostication/goals-of-care discussions. 2,4,18 Admittedly, it is a challenge to predict which ED crisis presentation is a patient's terminal event. ...
... Although the majority of our dying patients were on known recognizable accelerated dying trajectories on ED presentation, only 11% had preexisting advance directives, similar to prior studies. 16,17 The rapid decision making required for the acute terminal crisis event leaves limited time for dialogue and adds to the challenge of having conversations with family with whom there is no prior established rapport. 8,18 This time may be optimal for PC clinician support to the ED and hence a major role of the PC in early, real-time, determinative decision making, but prompt availability will be essential. ...
... 7. Successful management of child deaths requires supportive, compassionate and tactful measures. Although there has been an increase in advance care planning since then, in many cases advance directives are still lacking when patients are transferred to emergency departments (EDs) [17][18][19][20]. One study found that many ED patients have never thought about advance directives or prefer that families make the decisions at the time of an event [21]. ...
EMS physicians and providers should provide high-quality, compassionate, and medically appropriate end-of-life care. This includes protocols and education that guide when and when not to provide resuscitation and other life-sustaining treatments, as well as direction for support of the grieving survivors left behind. Patient preferences for end-of-life care in the form of advance directives, do not resuscitate (DNR) orders, and Physician Orders for Life-Sustaining Treatment (POLST) are increasingly common and must be accurately interpreted by EMS professionals.
... Whether they believe it or not, young adults act as if they are immortal, too healthy or too young to need such a reminder of death as an advance directive (hereinafter at times referred to as AD) [4]. Yet Death's scythe for younger people is still often sudden and unexpected precisely when an advance directive would be especially helpful [5]. ...
... These forms can be cumbersome to complete and calls have been made for states to simplify the process [7]. One study found that many emergency department patients have never thought about an advance directive or prefer that families make the decision at the time of an event [8]. ...
... Health care systems may register and add completed advance directives to the patient's chart, but one study found that only 27% of ED patients have completed these documents. 15 Some experts question the effectiveness of these documents in achieving the patient's preference, since they are often difficult to find, ignored by medical personnel, or overridden by a surrogate. 16 However, recent research shows that completed advance directives do make it more likely that clinicians will follow patient wishes than if patients had no completed documents. ...
ACADEMIC EMERGENCY MEDICINE 2012; 19: 1068–1072; © 2012 by the Society for Academic Emergency Medicine
Abstract
Making decisions for a patient affected by sudden devastating illness or injury traumatizes a patient’s family and loved ones. Even in the absence of an emergency, surrogates making end‐of‐life treatment decisions may experience negative emotional effects. Helping surrogates with these end‐of‐life decisions under emergent conditions requires the emergency physician (EP) to be clear, making medical recommendations with sensitivity. This model for emergency department (ED) end‐of‐life communications after acute devastating events comprises the following steps: 1) determine the patient’s decision‐making capacity; 2) identify the legal surrogate; 3) elicit patient values as expressed in completed advance directives; 4) determine patient/surrogate understanding of the life‐limiting event and expectant treatment goals; 5) convey physician understanding of the event, including prognosis, treatment options, and recommendation; 6) share decisions regarding withdrawing or withholding of resuscitative efforts, using available resources and considering options for organ donation; and 7) revise treatment goals as needed.
Emergency physicians should break bad news compassionately, yet sufficiently, so that surrogate and family understand both the gravity of the situation and the lack of long‐term benefit of continued life‐sustaining interventions. EPs should also help the surrogate and family understand that palliative care addresses comfort needs of the patient including adequate treatment for pain, dyspnea, or anxiety. Part I of this communications model reviews determination of decision‐making capacity, surrogacy laws, and advance directives, including legal definitions and application of these steps; Part II (which will appear in a future issue of AEM ) covers communication moving from resuscitative to end‐of‐life and palliative treatment. EPs should recognize acute devastating illness or injuries, when appropriate, as opportunities to initiate end‐of‐life discussions and to implement shared decisions.
... Because other ED-based studies were not restricted to elder or institutionalized patients, the prevalence of ADs in our study is nearly double that reported by previous investigators (22%, 27%, and 23%). [7][8][9] This higher prevalence is still disturbingly low when one considers that the Congressional Patient Self-Determination Act of 1991 clearly requires all hospitals and other institutions receiving Medicare or Medicaid funding to promote the use of ADs. We found variability among the different types of ADs used in our patients. ...
Objective:
Ten years have passed since Congress enacted the Patient Self-Determination Act to promote the use of advance directives (ADs). This study was performed to determine the frequency, type, demographic distribution, and utility of ADs that accompany residents of skilled nursing facilities (SNFs) transferred to emergency departments (EDs).
Methods:
This was an observational, cross-sectional cohort of SNF residents, transferred to two urban, academic EDs. Chart review and physician interviews were conducted on consecutive patients arriving during 12-hour data collection shifts.
Results:
Among 715 patients entered, 315 [44%, 95% confidence interval (95% CI) = 40% to 48%] had an AD. Advance directives were significantly more prevalent among white (50%) than African American (34%) or Hispanic (39%) patients (p < 0.001), and varied from 0% to 94% among SNFs. Of the 315 patients with ADs, do-not-resuscitate (DNR) orders were the most prevalent (65%, 95% CI = 58% to 69%). Although 75% (95% CI = 69% to 81%) of the DNR orders addressed cardiopulmonary resuscitation (CPR), only 12% (95% CI = 8% to 16%) addressed intubation. Among 39 patients who required intubation or CPR, 44% had ADs, 82% (95% CI = 57% to 96%) of which were deemed useful.
Conclusions:
Despite a decade of legislation promoting their use, ADs are lacking in most SNF residents transferred to EDs for evaluation and in most settings in which a clinical indication exists for intubation or CPR. Variation in their prevalence appears to be associated with both ethnicity and SNF origin. Although about three-fourths of DNR ADs addressed CPR, only about one in ten offered guidance regarding intubation. When available, ADs are used in most instances to guide emergency care.
... Availability of these documents assists the intensivist in guiding families through the intensive care experience. However, only few patients complete such directives, [60][61][62][63][64] and few understand what they are actually authorizing physicians to do. [65][66][67][68] In an Oregon study, a large proportion of patients in the university clinics did not understand end-of-life options. ...
The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.
... This prospective study was conducted through direct, face-to-face interviews with hospitalized patients, nursing home residents, and community-dwelling seniors with regard to their wishes for end-of-life care. The survey questionnaire was modeled after Mezey et al.'s comprehensive Patient Survey Instrument (PSI), originally developed for the purpose of studying reasons for execution of ADs in the hospital setting, and Llovera's study of barriers to AD completion in the emergency room setting (Llovera et al., 1999;Mezey et al., 2000). In addition, questions were added with regard to the patient's previous exposure to end-of-life information, individual beliefs, and factual experience with the healthcare system. ...
The purpose of this study was to determine the factors which influence advance directive (AD) completion among older adults.
Direct interviews of hospitalized and community-dwelling cognitively intact patients > 65 years of age were conducted in three tertiary teaching settings in New York. Analysis of AD completion focused on its correlation with demographics, personal beliefs, knowledge, attitudes, and exposure to educational media initiatives. We identified five variables with loadings of at least 0.30 in absolute value, along with five demographic variables (significant in the univariate analyses) for multiple logistic regression. The backward elimination method was used to select the final set of jointly significant predictor variables.
Of the 200 subjects consenting to an interview, 125 subjects (63%) had completed ADs. In comparing groups with and without ADs, gender (p < 0.0002), age (p < 0.0161), race (p < 0.0001), education (p < 0.0039), and religion (p < 0.0104) were significantly associated with having an AD. Factors predicting AD completion are: thinking an AD will help in the relief of suffering at the end of life, (OR 76.3, p < 0.0001), being asked to complete ADs/ or receiving explanation about ADs (OR 55.2, p < 0.0001), having undergone major surgery (OR 6.3, p < 0.0017), female gender (OR 11.1, p < 0.0001) and increasing age (76-85 vs. 59-75: OR 3.4, p < 0.0543; < 85 vs. 59-75: OR 6.3, p < 0.0263).
This study suggests that among older adults, the probability of completing ADs is related to personal requests by health care providers, educational level, and exposure to advance care planning media campaigns.
... Only a minority of patients (estimated 10-30%) have completed advance directives [70][71][72][73][74]. and even fewer present to the ED with the appropriate documentation [75]. ...
The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.
... These forms can be cumbersome to complete and calls have been made for states to simplify the process [7]. One study found that many emergency department patients have never thought about an advance directive or prefer that families make the decision at the time of an event [8]. ...
Decision making near the end of life can be complex and laden with emotion for families and health care providers. Families and patients can prepare themselves for these difficult moments by thinking ahead about the patient's wishes and preparing clear documents that express those wishes. Health care providers can prepare themselves by being familiar with those documents, considering the goals of treatment, remembering the principles on which health care ethics are founded and knowing decision-making models that will help them to think through treatment plans and the best options for patient taking into consideration the goals of treatment.
Background
Providing individualised healthcare in line with patient wishes is a particular challenge for emergency healthcare professionals. Documentation of patient wishes (DPW), e.g., in the form of advance directives, can guide clinicians in making end-of-life decisions that respect the patient’s wishes and autonomy. However, these are hindered by limited availability in emergency settings.
Objective
This systematic review aims to congregate existing data on DPW possesion and availability in the emergency department (ED) as well as contributing factors.
Methods
We searched the MEDLINE database (PubMed) in October 2021. All publications that provided primary quantitative data on DPW in the ED were assessed, culminating in a total of 16 studies included in the analysis. Most (n = 9) were from the US, followed by Australia (4), Germany (1), Canada (1) and Switzerland (1). Publication dates ranged from 1996 to 2020.
Results
In the general adult population presenting to the ED, 19.9–27.0% of patients possessed some variation of DPW, fewer than 3.2% had it available on presentation. In older people, possession rates (7.9–51.9%) as well as availability (1.7–48.8%) varied widely. The following variables were identified as positive predictors for DPW possession: older age, poorer overall health and presence of comorbidities, as well as several sociodemographic factors, such as female gender, having children, being in a relationship and higher level of education.
Conclusion
Possession and availability of DPW among ED patients was low in general and even in the older population mostly below 50%. While we were able to gather data on prevalence and predictors, we believe that further research is needed to explore the quality of DPW and possible public health measures to encourage patients to document their healthcare wishes.
This chapter presents a case of 84-year-old woman with a complaint of shortness of breath and fever. Emergency medicine presents a challenge in that emergency physicians (EPs) frequently have no preexisting relationship with the patient and are unfamiliar with patient's medical history and baseline level of health. Traditionally, the EP has focused on identification and management of acute and life-threatening illnesses with the primary goal of prolonging life. However, in ill geriatric patients who likely have multiple medical problems, this approach may not be ideal, and perhaps will be inconsistent with the patient's wishes. Patient-centered goals and patient-directed decision-making should be a key focus whenever caring for a geriatric patient in the emergency department (ED). However, given geriatric patients high burden of disease and potential cognitive impairment, especially near the end of life, EPs should, if possible, complete proper evaluation of a patient's decisional capacity.
This chapter discusses the issues surrounding advance directives, focusing specifically on the impact these documents may have on the care of the acute care surgical patient. At first, it may seem somewhat unusual to include a chapter on this topic in a text devoted to the care of the acute care surgical patient. However, it is important to remember that acute surgical illness, whether from injury, sepsis, or shock, may render the patient incapable of participating in decision making at the time of presentation. Furthermore, the nature of acute surgical illness not infrequently results in postoperative complications, organ failure, and prolonged intensive care unit stays, requiring invasive and expensive treatment modalities that, for some patients, may be life saving but, for others, may simply be death delaying. Thus, some understanding of the history of advance directives, the types of documents that currently exist, and their relative advantages and disadvantages is necessary to ensure optimal outcomes for this patient population.
Introduction: Death in the emergency department (ED) occurs frequently. Approximately 249,000 patients die in EDs annually (0.2% of ED visits). Emergency care of dying patients and survivors presents numerous unique challenges to emergency physicians and other front line providers. Management of end-of-life (EOL) symptoms, communication, cultural sensitivity, attention to spiritual needs, and psychosocial support for grieving survivors are essential skills for emergency physicians. Caring for dying patients is challenging. The American College of Emergency Physicians (ACEP) acknowledged this and provided some guidance when they issued a Policy on Ethical Issues at the End-of-life, in 2008. Within that policy, the college succinctly summarized the importance of compassionate end-of-life care by stating, “Emergency physicians should respect the dying patient’s needs for care, comfort, and compassion.” In this chapter, we review the basic issues of death and dying in the ED and provide some strategies for management.
It has been more than two decades since the passage of the Patient Self-Determination Act (PSDA) of 1991, an act that requires many medical points of care, including emergency departments (EDs), to provide information to patients about advance directives (ADs).
The study objective was to determine the prevalence of ADs among ED patients with a focus on older adults and factors associated with rates of completion.
We searched PubMed, Embase, PsycINFO, CINAHL, Web of Science, Medline, and the Cochrane Library. Articles were selected according to the following criteria: (1) population: adult ED patients; (2) outcome measures: quantitative prevalence data pertaining to ADs and factors associated with completion of an AD; (3) location: EDs in the United States; and (4) date: published 1991 or later.
Of the 258 references retrieved as a result of our search, six studies met inclusion criteria. Rates of patient-reported AD completion ranged from 21% to 53%, while ADs were available to ED personnel for 1% to 44% of patients. Patients aged ≥65 years had ADs 21% to 46% of the time. Sociodemographics (e.g., older age, specific religion, white or African American race, being widowed, or having children) and health status related variables (e.g., poor health, institutionalization, and having a primary care provider) were associated with greater likelihood of having an AD.
Published rates of AD completion vary widely among patients presenting to U.S. EDs. Patient sociodemographic and health status factors are associated with increased rates of AD completion, though rates are low for all populations.
Die Notaufnahme des Basler Universitätsspitals wird interdisziplinär als ,,Notfallstation“ geführt. Das dort praktizierte ,,Basler Modell“ wird schlaglichtartig beleuchtet. Ethische Fragestellungen, insbesondere die Frage nach dem Sistieren einer Behandlung, sollten frühzeitig und interdisziplinär besprochen werden. Da das Ziel der Versorgung in der präklinischen Phase zumeist der möglichst rasche Transport in ein geeignetes Zielkrankenhaus ist, bietet sich oft erst im Reanimationsraum der Notfallstation erstmals die Chance, diese Fragen überhaupt auszusprechen. Hier können entscheidungsrelevante Zusatzinformationen berücksichtigt werden wie etwa der mutmaßliche Wille des Patienten, aber auch die Prognose. Die unterschiedlichen Standards der präklinischen und der klinischen Phase können an der Schnittstelle Notfallstation zu Konflikten führen. Hier ist die Kommunikation des Teamleaders mit dem Rettungsteam, aber auch mit den Kollegen der anderen Disziplinen von entscheidender Bedeutung.
Background: In accord with the rapid growth of the nonagenarian population, their emergency departments (ED) visits are increasing. The aim of our study was to examine ED use by nonagenarian patients and their dispositions.
Method: We analyzed 275 consecutive ED visits of nonagenarian patients in Japan during 1 year. Demographic data, chief complaint, diagnosis, categories of urgency, and disposition following the ED visit were recorded. A 1‐year follow up was conducted on all discharged nonagenarian patients.
Results: A total of 199 patients made 275 visits. Of these patients, 56.4% were transferred by ambulance, 15.6% were classified as emergency, and 65.1% led to hospitalization. Fever, fall, altered mental status, anorexia, focal neurological deficits and general fatigue accounted for 72% of the reasons for ED visits, and 43% of their ED visits resulted in a diagnosis of pneumonia, stroke, head trauma or hip fracture. In hospitalized patients, the mean length of stay was 23.4 days. Most of the patients had geriatric problems such as disability (78%), comorbidity (86%) and polypharmacy (82%). The in‐hospital mortality of the 179 hospitalized patients was 19.6% (35/179). Eighty‐six percent of alive patients were discharged to long‐term care facilities (124/144). The total 1‐year mortality of the 199 patients who visited the ED accounted for 49.2% (98/199).
Conclusion: Nonagenarians’ ED visits were associated with prolonged admissions, postdischarge institutionalizations, and high risk of in‐hospital and postdischarge death. Their ED visits seemed to be a major transition in their own life.
When patients cannot make their own treatment decisions, surrogates typically step in to do it for them. Surrogate decision-making is far from ideal, of course, as the surrogate may not know what the patient prefers or what best promotes her interests. One way to improve it would be to arm surrogates with information about what patients in similar circumstances tend to prefer, allowing them to make empirically grounded predictions about what their patient would want.
To assess the prevalence of advance care directives in the residential aged care facilities within the catchment for a single ED and to assess the systems in place for development of those advance care directives with focus on documentation and communication.
A de-identified, paper-based, mail-out survey of all 30 residential aged care facilities potentially referring to the Wollongong Hospital ED.
A total of 24 of 30 surveys were returned. Thirteen facilities reported at least some proportion of their residents having documented advance care directives. The median prevalence of advance care directives was 5% of residents (interquartile range 0-10%). Discussions with residents over advance care directives were reported in 9 of 24 survey returns. Not all facilities that reported documenting advance care directives had processes for regular review or 24 h access to the documentation for carers. Ten of the survey returns reported general practitioner involvement in advance care directive development.
The facilities surveyed reported that advance care directives are the exception rather than the rule. Where they were developed some facilities did not ensure regular review, dissemination of the information nor consistent involvement of the GP. This demonstrates low utilization and poor application, which has implications for care appropriate to patients' wishes and for resource use within the ED.
Informed patient choice is central to modern clinical care but there is a paucity of data about how patients respond to information regarding complex therapies. This qualitative study aimed to understand the attitudes of patients with chronic obstructive pulmonary disease (COPD) toward acute ventilatory support and assess how aids to decision making regarding ventilation affect patients' views of therapy.
A standardized five-stage interview process was used to explore attitudes toward noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) in 50 stable COPD patients.
Eighty-six percent found demonstration of NIV helpful in decision making compared to 24% with the photographic aid (p < 00.001). Although 96% were willing to receive NIV after a verbal description of the technique, only 76% consented when a photographic aid was shown. When NIV was demonstrated, willingness rose to 84%. While 60% were willing to receive IMV following a verbal description, this decreased to 58% following explanation of alternative treatments to IMV. Patients willing to receive IMV were younger (67 versus 76 years p = 0.016) and had a better functional status (NEADL index 20 versus 15 units p = 0.03). Only 34% had heard of advanced directives of care (ADCs), none had ever issued one but 48% expressed an interest in doing so following explanation of this process.
COPD patients would find both explanation and demonstration of NIV useful in an outpatient setting. Worsening functional status along with advanced age was associated with reduced willingness to receive invasive ventilatory support. Awareness of ADCs was found to be low although almost half of the patients expressed interest in the uptake of ADCs following explanation of the process.
Palliative care is the physical, psychological, social, and spiritual care provided to patients from diagnosis to death or resolution of a life-threatening illness. Hospice care is a comprehensive program of care that is appropriate when patients with chronic, progressive, and eventually fatal illness are determined to have a prognosis of 6 months or fewer. Hospice and palliative medicine has now been recognized by the American Board of Medical Subspecialties as a field with a unique body of knowledge and practice. With 9 other specialty boards, the American Board of Emergency Medicine has cosponsored hospice and palliative medicine as an official subspecialty. As a result, board-certified emergency physicians may now pursue certification in hospice and palliative medicine through either fellowship training or, for a limited time, completing practice track requirements, followed by a written examination in the subspecialty. As the practice of palliative medicine grows in hospitals, emergency physicians can develop a core of generalist palliative medicine skills for use with adults and children. These would include assessing and communicating prognoses, managing the relief of pain and other distressing symptoms, helping articulate goals of patient care, understanding ethical and legal requirements; and ensuring the provision of culturally appropriate spiritual care in the last hours of living. Front-line emergency physicians possessing these basic palliative medicine skills will be able to work collaboratively with subspecialty physicians who are dually certified in emergency medicine and hospice and palliative medicine. Together, generalist and specialist emergency physicians can advance research, education, and policy in this new field to reach the common goals of high-quality, efficient, evidence-based palliative care in the emergency department.
Many residents of long-term care (LTC) facilities are transferred to Emergency Departments without advance directives (AD). The goal of this study was to describe an ideal model for the transfer of AD from LTC facilities to Emergency Departments. Health care providers were asked to describe their ideal model for the completion and transfer of the ADs of LTC residents. A grounded theory methodology was used to identify significant themes. The model we present as a result of this analysis acknowledges the importance of simplifying and standardizing ADs, but focuses more attention on the process of completing and transferring the AD. A key feature of this model is an emphasis on the education of LTC residents and their relatives about ADs and advance-care planning. This education should involve a variety of resources used in creative ways; it should begin as soon as LTC placement is being considered, and the emphasis should be on providing information and discussing options rather than pressuring residents to make a decision.
Little has been written in the medical literature concerning the ethics of treatment of the elderly demented patient with bowel obstruction. It is one example of the issues with which we are becoming increasingly involved. We conducted a survey of our colleagues' opinions to determine current practice.
A postal questionnaire study (62% response rate). Questions were posed that related to a case scenario of an elderly demented patient presenting with a presumed sigmoid volvulus.
The northern region of England.
Thirty seven surgical members of the Association of Coloproctology of Great Britain and Ireland, Northern Chapter.
Sixty five per cent of respondents felt that surgery would be inappropriate, and 26% that any intervention at all upon the subject in the case scenario would be inappropriate. More would operate, however, at the request of relatives. An advance directive not to treat would be respected by 70% despite a relative's wishes.
Overall there was a wide variation in the approach of the surgeons to a demented patient with bowel obstruction. In an era of clinical governance, and an increased awareness of the ethics of consent, this study presents one example of the difficult decisions with which we are increasingly faced. The greater use of advance directives may provide one possible solution.
The objective of this study was to determine the knowledge, utilization, and experience of primary care physicians (PCPs) with nonhospital do-not-resuscitate (NH-DNR) orders. An anonymous survey was sent to all PCPs in a single northeastern county. Up to two surveys were mailed to each PCP. Descriptive statistics were used to report provider responses. The main variable of interest was issuance of NH-DNR orders. Surveys were mailed to 820 PCPs; 348 (42%) were returned. Respondents had practiced an average 17 +/- 11 years, and cared for an average of 720 patients per month, 7 of whom were terminally ill. Seventy percent issued NH-DNR orders. Twenty-five percent reported resuscitation had been attempted for at least one patient with a NH-DNR order; 64% reported this had happened more than once. Of respondents who had a NH-DNR order ignored, 14% had instructed family members to call police, fire, or EMS following death of the patient. Of the PCPs who did not issue NH-DNR orders, 71% reported not caring for any appropriate patients, yet 41% reported caring for at least 1 terminally ill patient per month. Seventy-nine percent disagreed that intubation and mechanical ventilation were appropriate treatment for DNR patients in severe respiratory distress, and 71% disagreed that cardioversion was appropriate treatment for an unconscious DNR patient with unstable ventricular tachycardia. In conclusion, a majority of respondents issued NH-DNR orders and one quarter reported these orders had not been followed. A majority felt intubation, mechanical ventilation, and cardioversion should not be performed for noncardiac arrest DNR patients with an indication, but not in cardiac arrest.
The author writes about various alternatives once decisional capacity is lost. So-called advance directives come in two forms: the living will and an appointed proxy for health care. The US--were these have been legally binding for over 20 years in all states--is a useful laboratory for studying the effect. Advantages and disadvantages are discussed. In some civilizations decisions about all such matters are made in different ways--these are not superior or inferior but simply different. In the US with its shameful social conditions for a large part of the population more important problems need to be addressed. In civilizations which have at least basic medical care for all, discussing such documents becomes far more important. The EU is likely to make some form of advance directive have legal standing. The last 20 or more years that they have been utilized in the US may provide experience important for the time when the EU also makes such documents legally binding.
Ethical issues can be more difficult to address in the emergency department than in other settings. We present two cases, with the goal of stimulating moral reflection and encouraging emergency physicians to gain a better understanding of two important ethical issues: advance directives and resource allocation decisions.
Understanding the legal and ethical basis for advance directives allows emergency physicians to determine when the directives should be followed and when they should be questioned. Resource allocation decisions are among the toughest decisions emergency physicians make. Although patients or substitute decision-makers define the value of a treatment goal, emergency physicians must ensure that this goal does indeed represent the patient’s wishes, that it is achievable, and that competing claims for the same resource are considered.
Learning from others’ experiences and preparing for ethical problems in advance will help physicians feel more comfortable in dealing with ethical issues.
We performed a two-site prospective, controlled interventional study of patients enrolled in pulmonary rehabilitation to assess effects of advance directive education on completion of (1) living wills, (2) durable powers of attorney for health care (DPAHC), (3) patient-physician discussions about advance directives, and (4) discussions about life support, in addition to (5) patient impressions that their physicians understood their end-of-life preferences. The educational group had an increase (p < 0.05) in all five study outcomes compared with baseline values; the control group had an increase in three of five outcomes. The effect strength was greater in the educational compared with the control group for completion of DPAHC (odds ratio [OR] = 3.6, 95% confidence interval [CI] 1.1 to 12.9), advance directive discussions (OR = 2.9, 95% CI 1.1 to 8.3), initiation of life-support discussions (OR = 2.7, 95% CI 1.0 to 7.7), and development of patient assurance that their physicians understand their preferences (OR = 3.7, 95% CI 1.3 to 13.4). The educational intervention was an independent explanatory factor by multivariate analysis. We conclude that patients enrolled in pulmonary rehabilitation are receptive to advance care planning, which is promoted by education on end-of-life issues.
Background: Physicians are frequently unaware of patient preferences for end-of-life care. Identifying and exploring barriers to patient-physician communication about end-of-life issues may help guide physicians and their patients toward more effective discussions. Objective: To examine correlates and associated outcomes of patient communication and patient preferences for communication with physicians about cardiopulmonary resuscitation and prolonged mechanical ventilation. Design: Prospective cohort study. Setting: Five tertiary care hospitals. Patients: 1832 (85%) of 2162 eligible patients completed interviews. Measurements: Surveys of patient characteristics and preferences for end-of-life care; perceptions of prognosis, decision making, and quality of life; and patient preferences for communication with physicians about end-of-life decisions. Results: Fewer than one fourth (23%) of seriously ill patients had discussed preferences for cardiopulmonary resuscitation with their physicians. Of patients who had not discussed their preferences for resuscitation, 58% were not interested in doing so. Of patients who had not discussed and did not want to discuss their preferences, 25% did not want resuscitation. In multivariable analyses, patient factors independently associated with not wanting to discuss preferences for cardiopulmonary resuscitation included being of an ethnicity other than black (adjusted odds ratio [OR], 1.48 [95% CI, 1.10 to 1.99), not having an advance directive (OR, 1.35 [CI, 1.04 to 1.76]), estimating an excellent prognosis (OR, 1.72 [CI, 1.32 to 2.59]), reporting fair to excellent quality of life (OR, 1.36 [CI, 1.05 to 1.76]), and not desiring active involvement in medical decisions (OR, 1.33 [CI, 1.07 to 1.65]). Factors independently associated with wanting to discuss preferences for resuscitation but not doing so included being black (OR, 1.53 [CI, 1.11 to 2.11]) and being younger (OR, 1,14 per 10-year interval younger [CI, 1.04 to 1.25]). Conclusions: Among seriously ill hospitalized adults, communication about preferences for cardiopulmonary resuscitation is uncommon. A majority of patients who have not discussed preferences for end-of-life care do not want to do so. For patients who do not want to discuss their preferences, as well as patients with an unmet need for such discussions, failure to discuss preferences for cardiopulmonary resuscitation and mechanical ventilation may result in unwanted interventions.
The year 1996 marks the fifth anniversary of the federal Patient Self-Determination Act. The Patient Self-Determination Act required hospitals, nursing homes, and health plans to ask whether patients have advance directives and to incorporate them into the medical record. A living will is an advance directive by which a person tells caregivers the circumstances in which life-sustaining treatment is to be provided or forgone if the patient is unable to communicate. A durable power of attorney for health care enables one to designate a person to speak on his or her behalf if the author loses decision-making capacity. Advance planning is the process of reflection, discussion, and communication of treatment preferences for end-of-life care that precedes and may lead to an advance directive.
Background:
The wider use of written advance directives is popular but problematic. We have shown previously that acute hospitalization in the era of the Patient Self-Determination Act can facilitate directive discussions and documentation. We investigated whether a simple educational intervention following hospitalization would increase patients' execution of durable health care proxies.Methods:
We studied a consecutive series of patients (n=162) recently discharged from the acute care medical service of a community hospital where they had been interviewed about advance directives. The intervention group was randomized to receive an educational brochure and encouragement to execute durable health care proxies. The primary outcome was the proportion of patients in each group with completed durable health care proxies on file in their primary physicians' offices.Results:
Overall, only 20 (12.3%) of 162 patients had documented proxies, 17 of whom (85%) were 65 years of age or older, with no difference between the intervention and control groups (11 [13.3%] of 83 vs nine [11.4%] of 79, respectively). Subgroup analysis of elderly patients also revealed no intervention effect. Univariate analysis revealed three significant predictors of patients' proxy completion: patient age, whether patients had discussed directives in hospital with their physicians, and whether patients' physicians completed proxies for themselves. Multiple logistic regression analysis showed that these three variables interact to predict the probability of patients' executing proxies.Conclusions:
Simple educational interventions, like those mandated by the Patient Self-Determination Act, are unlikely to increase patients' completion of durable healthcare proxies. Multidimensional interventions that target both elderly patients and their personal physicians should be tested in the future. Discussion in hospital about advance directives can be a useful component of such efforts.(Arch Intern Med. 1995;155:2202-2206)
Background:
The Patient Self-Determination Act aims to enhance patient awareness of advance directives by requiring health-care institutions to ask patients whether they have advance directives and to inform patients of their rights to prepare these documents. We investigated the following: (1) compliance of the hospital staff with implementing this act, (2) the effects of this act on the extent to which patients discuss and prepare advance directives, and (3) variables that might influence patient discussions on advance planning and preparation of advance directives.Methods:
We surveyed 219 patients from a university hospital that implemented a nurse-dependent advance directive program. We also conducted a telephone interview with 57% of these patients at least 6 months after hospital discharge.Results:
Nurses asked 70% of the patients about the existence of an advance directive and of these patients, only 57% remembered the inquiry. Only 57% of the patients received the brochure on advance directives and of these patients, only 55% read the brochure. Only 2% of the patients requested to receive additional information on advance directives. Less than one quarter of the patients had discussions on advance planning while in the hospital and of those patients who were contacted within 6 months after hospital discharge, 39% had discussions on advance planning and 15% prepared an advance directive. Race was an independent predictor for hospital discussions, and educational level was an independent predictor for discussions and preparation of advance directives after hospital discharge.Conclusions:
To enhance the effectiveness of a nurse-dependent advance directive program, hospitals may need (1) to strengthen the quality of the patient-nurse encounter in which the issue of advance directives is raised to more effectively promote patient interest, discussions, and preparation of advance directives and (2) to account for the social diversity of their patient population.(Arch Intern Med. 1995;155:502-510)
Objective:To determine: 1) the number of patients arriving at the ED who had executed an advance directive (AD), 2) how many of the patients who had an AD brought the AD with them, and 3) whether those patients who did not have an AD had ever discussed ADs with their primary care providers (PCPs) or had ever heard of an AD.
Methods: A cross-sectional, observational survey of a convenience sample of high-risk patients presenting to the ED of a university hospital was performed. Patients presenting to the ED for acute complaints who were elderly or had an underlying disease that suggested a risk of death in the near future were considered high risk.
Results: Of the 238 patients surveyed, 90% had PCPs. However, only 22% had ADs. Of these, only 23% brought the AD to the ED. Of the patients who did not have ADs, 95% had never discussed ADs with their PCPs, and 42% did not know what an AD was. Blacks were less likely than whites to have ADs (p < 0.0002) or to know about them (p < 0.004).
Conclusion: The majority of high-risk patients presenting to this ED do not have ADs. Among those high-risk patients who did have ADs, fewer than 25% brought the ADs with them. The development of ADs for high-risk patients and the availability of ADs in the ED are woefully inadequate. Emergency physicians need to collaborate with PCPs to remedy these deficiencies.
To evaluate the nature of the decision to write a do-not-resuscitate (DNR) order in the Emergency Department (ED).
This is a prospective evaluation of 37 consecutive patients for whom a DNR order was written by personnel assigned to the ED of a large inner-city teaching hospital. For each patient, information was collected including who was involved in the decision, the difficulty the family or patient had in agreeing to the DNR order, acute and chronic problems, how often the patient could enter into the process, and the ultimate outcome.
DNR orders were usually initiated by house officers assigned to the ED (65%), and the family was usually involved (89%, mean of 1.4 family members per patient). There were no cases where significant resistance to the DNR order was exhibited by the family. The patients were generally elderly, demented, and debilitated with multiple chronic medical problems or young with malignancy or the acquired immunodeficiency syndrome and had become critically ill and unstable. Only five patients were able to enter into the decision. Discussion of DNR status had occurred previously in only 14% of patients.
Because there remains considerable reluctance on the part of physicians to discuss the DNR issue before patients become critically ill, it is often necessary for ED physicians to write a DNR order. Although the ED is not an ideal setting for discussion of DNR orders and patients and families do not generally initiate this discussion, DNR orders can be written by ED physicians after consultation with the family.
The wider use of written advance directives is popular but problematic. We have shown previously that acute hospitalization in the era of the Patient Self-Determination Act can facilitate directive discussions and documentation. We investigated whether a simple educational intervention following hospitalization would increase patients' execution of durable health care proxies.
We studied a consecutive series of patients (n = 162) recently discharged from the acute care medical service of a community hospital where they had been interviewed about advance directives. The intervention group was randomized to receive an educational brochure and encouragement to execute durable health care proxies. The primary outcome was the proportion of patients in each group with completed durable health care proxies on file in their primary physicians' offices.
Overall, only 20 (12.3%) of 162 patients had documented proxies, 17 of whom (85%) were 65 years of age or older, with no difference between the intervention and control groups (11 [13.3%] of 83 vs nine [11.4%] of 79, respectively). Subgroup analysis of elderly patients also revealed no intervention effect. Univariate analysis revealed three significant predictors of patients' proxy completion: patient age, whether patients had discussed directives in hospital with their physicians, and whether patients' physicians completed proxies for themselves. Multiple logistic regression analysis showed that these three variables interact to predict the probability of patients' executing proxies.
Simple educational interventions, like those mandated by the Patient Self-Determination Act, are unlikely to increase patients' completion of durable healthcare proxies. Multidimensional interventions that target both elderly patients and their personal physicians should be tested in the future. Discussion in hospital about advance directives can be a useful component of such efforts.
To examine the effects of a practical method to increase patient completion and filing of advance directives.
Randomized controlled trial to examine the effects of structured discussions, information, and mailed reminders on completion of advance directives by internal medicine outpatients.
Presence of advance directives in patients' medical files. Secondary analyses include (1) participant satisfaction with procedures, (2) data on delayed effects of discussion, and (3) data on discrepancies in patients' completion of forms.
Six months following the intervention, 23% of patients in the experimental group and 3% of patients in the control group had directives on file. The findings were statistically significant. Patients, nurses, and physicians were satisfied with intervention procedures. Chart reviews at 6 weeks and 6 months indicated that intervention effects were delayed.
Structured discussions and follow-up mailings substantially increased use of advance directives and were time effective and cost-effective.
Advance planning for future illness should be broadened from medical care in the event of incompetence to all medical care for the elderly. To plan effectively, patients need an assessment of their overall medical condition: whether they are robust, frail, demented, or dying. They need to understand the kinds of complications often engendered by aggressive treatment, given their underlying status. Given information about their circumstances and their capacity to withstand medical interventions, patients, together with their physicians, need to formulate broad goals for medical care. There are significant barriers to implementing this scheme, but pressure from patients, structural changes in the practice of medicine that create incentives for planning, and educational strategies, including videotaped interviews and role-playing exercises, can facilitate this form of preventive medicine.
The 1991 Patient Self-Determination Act required health care providers to give patients information about advance directives.
To investigate whether the requirement to distribute information to hospital patients increased completion of the health care proxy. To also explore factors that might influence use of advance directives, including demographic variables and methods of informing patients about the directives.
We interviewed 419 randomly selected patients who were admitted for a planned admission to two tertiary care, teaching hospitals. Patients at one hospital received proxy information before the day of admission, at a pretesting visit, or by mail. The other hospital distributed the proxy information only on the day of admission.
Before receiving hospital materials, 17% of all patients had completed proxies. After receiving hospital proxy forms, an additional 40% completed proxies at the hospital that distributed forms before the day of admission. Only 4% of the patients completed proxies at the hospital that distributed information only on the day of admission. The most frequently cited barrier to completion of a proxy was not seeing the form. Few patients said they did not want to think about the subject.
Completion rates for advance directives may be markedly improved by altering the time for distributing information to patients admitted to the hospital for a planned admission. Patients were more likely to complete a proxy in the hospital that distributed the form in advance of the day of admission, a result that was unexplained by other variables in the study. Although many patients would prefer to receive information about advance directives during an office visit with a physician, hospitalization can provide a valuable opportunity for many patients to complete directives.
Widely publicized court cases have focused national attention on the importance of advance directives. In spite of initiatives such as the Patient Self-Determination Act of 1991, fewer than 10% of Americans have prepared advance directives. One way to increase the preparation of advance directives may be to increase the frequency and quality of discussions about them between individual patients and their physicians. We performed a multicenter observational study to assess the opinions of primary care patients and physicians regarding these discussions.
This was a cross-sectional descriptive survey of randomly selected primary care patients and physicians in eight primary care internal medicine clinics in the eastern and midwestern United States. Quantitative questionnaires were used to elicit subjects' demographic characteristics, and their opinions regarding the timing, content, and location of discussions about advance directives.
The 883 subjects included 329 adult outpatients, 282 resident physicians, and 272 practicing physicians. Physician and patient response rates were 75% and 76%, respectively. Patients felt that the discussion should occur earlier than did the physicians: at an earlier age, earlier in the natural history of disease, and earlier in the patient-physician relationship. Most subjects agreed it was the physician's responsibility to initiate the discussion.
We defined a discrepancy between the preferences of primary care patients and physicians regarding the timing of the discussion about advance directives. We propose physician education regarding patient preferences as the most effective way to accomplish the goal of improving the frequency and quality of discussions about advance directives.
To describe the attitudes toward and practice of health prevention and advance planning measures by a group of community-dwelling older adults and to examine the effect of age on these practices.
A descriptive study performed by mail survey.
Members of a research registry who were 65 years of age or older.
By means of a written questionnaire, we asked about knowledge of various health prevention and advance planning topics, including exercise, cholesterol screening, rectal examination, influenza vaccination, sigmoidoscopy, mammography, prostate cancer screening, organ donation, autopsy, health care proxy, and advance directives. Of those who knew about the topic, we asked if the respondent had discussed it with a physician, who initiated the conversation, and if the respondent participated in the activity. We also asked how important the topic was to the respondent.
We received 598 completed surveys, a response rate of 83%. Respondents had a mean age of 74 years, were predominately white (96%), and were well educated, with 44% having completed college. The respondents were all knowledgeable about the topics, and, with the exception of sigmoidoscopy, organ donation, and autopsy, more than 70% thought these topics were important. In the case of health screening and prevention activities, a large percentage of respondents reported having discussed the topic with a physician, and a slightly smaller percentage reported regular participation. In the case of health care proxies and advance directives, however, only about one-half of those who had made these arrangements said they had discussed them with a physician. When discussion did occur, it was much more likely to have been initiated by the respondent. Controlling for level of education, age was inversely associated with the likelihood of a woman reporting she had undergone mammography (P < .05). Age, however, was not associated with decreased frequency of undergoing other screening tests.
Among a group of well educated older adults, reported interest in and compliance with health screening, health promotion, and advance planning activities were high. However, sigmoidoscopy, a relatively more invasive procedure that is generally recommended as a screening tool, is reported less likely to be practiced than prostate cancer screening, a less invasive procedure without such recommendation. Older adults state they are pursuing health care proxies and advance directives, often without the involvement of their physicians. Of the screening tests about which we asked, age was associated only with less frequent practice of mammography.
Advance directives have been widely endorsed, and empiric work has taken place that can aid clinicians in the appropriate use of validated documents. This report reviews philosophic and methodologic issues and offers practical illustrations. Despite the evidence that advance directives can work, there are serious barriers to their actual use. Therefore, these barriers are evaluated and potential solutions suggested.
Patients on chronic dialysis were surveyed to determine the degree to which completion of advance directives (ADs) was influenced by personal factors that patients bring to their dialysis situation (eg, demographic characteristics or personal preferences) and by environmental factors that are not under their control (eg, interaction with dialysis staff or hospital system). Of the 113 questionnaires distributed to the population of 40 hemodialysis and 73 peritoneal dialysis patients, 90 (80%) were completed. Although only 17% of the respondents had actually completed written ADs previously, respondents seemed to have a good general understanding of ADs, as evidenced by the 80% overall accuracy on a 19-question portion of the survey that tested knowledge regarding ADs. While a few personal factors, such as gender, dialysis, modality, perceived quality of life, and attitude toward death, were associated with completion of ADs, most other demographic variables, including age, marital status, religion, work status, number of years of education, disability status, locus of control, renal diagnosis, and number of years on dialysis, were not correlated. More prominently correlated with completion of ADs were environmental factors, such as having dialysis staff discuss ADs with patients, patients being asked to complete ADs at the time of hospitalization, and perception of staff as being comfortable discussing ADs with patients. The overall results of the survey suggest that discussing ADs as an ongoing activity may have been positively influenced by the Federal Patient Self-Determination Act of 1991.(ABSTRACT TRUNCATED AT 250 WORDS)
In their article, published in the April 15, 1994, issue of the Archives, Brooks et al state that their finding of limited availability of advance directives is "further evidence of a low level of physician involvement in this area."
I think that this is a gross misstatement and it overlooks the whole host of cultural, religious, and personal reasons that influence elderly nursing home residents (and, indeed, community-dwelling elderly) to forego formal statement of their preferences.
In my experience as a medical director of a nursing facility, a founding member of its ethics committee, and a personal physician to about a third of its residents, I have been repeatedly impressed by how often people do not wish to make formal advance directives. It is my practice to discuss this issue on first acquaintance and then, again, about 3 weeks later. Subsequently, the topic will be reintroduced if there is a
The Patient Self-Determination Act aims to enhance patient awareness of advance directives by requiring health-care institutions to ask patients whether they have advance directives and to inform patients of their rights to prepare these documents. We investigated the following: (1) compliance of the hospital staff with implementing this act, (2) the effects of this act on the extent to which patients discuss and prepare advance directives, and (3) variables that might influence patient discussions on advance planning and preparation of advance directives.
We surveyed 219 patients from a university hospital that implemented a nurse-dependent advance directive program. We also conducted a telephone interview with 57% of these patients at least 6 months after hospital discharge.
Nurses asked 70% of the patients about the existence of an advance directive and of these patients, only 57% remembered the inquiry. Only 57% of the patients received the brochure on advance directives and of these patients, only 55% read the brochure. Only 2% of the patients requested to receive additional information on advance directives. Less than one quarter of the patients had discussions on advance planning while in the hospital and of those patients who were contacted within 6 months after hospital discharge, 39% had discussions on advance planning and 15% prepared an advance directive. Race was an independent predictor for hospital discussions, and educational level was an independent predictor for discussions and preparation of advance directives after hospital discharge.
To enhance the effectiveness of a nurse-dependent advance directive program, hospitals may need (1) to strengthen the quality of the patient-nurse encounter in which the issue of advance directives is raised to more effectively promote patient interest, discussions, and preparation of advance directives and (2) to account for the social diversity of their patient population.
Those who must make health care decisions on behalf of persons who lack decision-making capacity often have too little information. The purpose of this study was to determine whether and to what degree sociodemographic factors, social support, religious involvement, and functional status served as predictors of the health-related values and preferences of geriatric patients.
A retrospective chart review involving 178 cognitively intact patients enrolled at a geriatric clinic at a university medical center was conducted. Patient variables included age, race, sex, marital status, years of education, participation in formal religious activities, self-reported functional status, and adequacy of social and family support. These were compared with responses to a modified version of the Values History questionnaire, an established method of evaluating patient values that includes advance directives.
Patients were likely to value quality (82%) over quantity of life (18%) and the ability to think clearly (64%) over 13 other specific health-related values. They were likely (93%) to want to be taken to a hospital emergency department on losing consciousness or becoming confused. Seventy-eight percent expressed a desire to be resuscitated using cardiopulmonary resuscitation (CPR), and 76% expressed a preference for use of a respirator, if necessary. Most (85%) considered a permanent vegetative state to be worse than death. High functional status predicted a preference for quality of life over length of life and the perception of a persistent vegetative state as worse than death (positive predictive value = 89%). Persons with better social and family support were more likely to accept treatment with CPR or a respirator and less likely to consider a permanent vegetative state to be worse than death. No single patient factor was strong enough to increase the probability of a particular value or preference by more than 17% above baseline.
Sociodemographic and functional status variables are relatively weak predictors of personal values and directives. This reinforces the importance of routinely eliciting patient values and preferences and of updating the information, particularly following changes in functional status or family support. Baseline information regarding the health-related values and preferences of this primary care geriatric clinic population may provide valuable information about the values and preferences of decisionally impaired older patients.
Advance directives support the concepts of patient autonomy and resource allocation. Promotion of advance directives by nurse managers according to the suggested paradigm should be an economic and policy priority.
Per the Patient Self-Determination Act of 1991, hospitals are required to ascertain whether patients have an advance directive (AD). At this point, factors prompting patients to issue ADs have not been studied. The purpose of this study was to describe patients' understanding of ADs as well as the process patients used to arrive at their decisions to implement an AD. A stratified random sample of 26 patients from two intensive care units, one general medical unit, one general cardiac unit, and one acquired immunodeficiency unit were selected for participation. Patients were asked a series of open-ended questions to determine their knowledge and understanding of ADs. The constant comparative method was used to review the transcripts. It was found that only 31 per cent of patients had issued an AD, and 20% had learned of ADs for the first time during their hospitalization. Response analysis showed four phases of AD decision making: evaluation of illness, establishment of priorities, consideration of implications of the directives, and selection or rejection of directives. In conclusion, patients continue to have limited understanding of ADs and their implications. Continued investigation will elucidate the best strategies to educate patients about this topic.
The purpose of this study was to determine whether discussion about and distribution of advance directive forms in a rural, private primary health care office would increase the number of patients who complete and return advance directive forms. This study was also designed to identify individual characteristics of patients who complete advance directives compared with those who do not.
The sample consisted of 195 patients who ranged in age from 21 to 88 years and visited the primary care office during a 1-month period. Patients who met the inclusion criteria were asked to complete a brief questionnaire while waiting to see their primary care provider, either a physician or a nurse practitioner. The survey included questions about education, previous experience with illness, religion, contact with family members, and attitudes concerning death. The primary care provider then briefly discussed with each patient the advance directive and provided an advance directive form to be completed and returned. The form was short and easy to complete.
The discussion about and distribution of advance directive forms in the primary care office results in a 45% return rate. Older patient age (P=.001), longer length of time in the practice (P=.039), less education (P=.025), and physician provider (gamma=.002) were associated with higher completion rates. The variables of provider and level of education were also influenced by older age.
Discussion about and distribution of advance directive forms should be incorporated into primary office care for all adults.
Advance directives provide a means for patients to retain influence on their medical care should decisional capacity be lost. Several studies have now demonstrated that advance directives that are completed in the ambulatory care setting are rarely available and recognized when patients are admitted to the acute care hospital.
To evaluate a generalizable model for improving recognition of previously completed advance directives and for promoting appointment of health care proxies in hospitalized patients.
Hospitalized elderly patients were randomly assigned to receive the intervention or usual care (n = 190). Intervention patients with capacity were counseled by hospital patient representatives about advance directives and encouraged to complete health care proxies. Patients with existing proxies had this information noted in their charts. For patients without capacity, counselors reviewed their charts for proxy documentation and if absent, contacted patients' next of kin and private physicians to determine proxy status. Usual care patients were not contacted by patient representatives.
Forty-eight percent of intervention patients completed a new proxy or had a previously completed proxy identified compared with 6% of controls (P < .001). For patients with capacity, 22% of intervention patients had a previously appointed proxy agent identified compared with 6% of controls (P < .001). Thirty-six percent of intervention patients appointed a proxy decision maker compared with 0% of controls (P < .02). For patients without capacity, 31% of intervention patients had previously appointed proxies identified compared with 6% of controls (P < .001).
Counseling by hospital patient representatives is an effective and generalizable means of improving recognition and execution of advance directives in the acute care hospital.
The year 1996 marks the fifth anniversary of the federal Patient Self-Determination Act. The Patient Self-Determination Act required hospitals, nursing homes, and health plans to ask whether patients have advance directives and to incorporate them into the medical record. A "living will" is an advance directive by which a person tells caregivers the circumstances in which life-sustaining treatment is to be provided or forgone if the patient is unable to communicate. A "durable power of attorney for health care" enables one to designate a person to speak on his or her behalf if the author loses decision-making capacity. "Advance planning" is the process of reflection, discussion, and communication of treatment preferences for end-of-life care that precedes and may lead to an advance directive.
To determine: 1) the number of patients arriving at the ED who had executed an advance directive (AD), 2) how many of the patients who had an AD brought the AD with them, and 3) whether those patients who did not have an AD had ever discussed ADs with their primary care providers (PCPs) or had ever heard of an AD.
A cross-sectional, observational survey of a convenience sample of high-risk patients presenting to the ED of a university hospital was performed. Patients presenting to the ED for acute complaints who were elderly or had an underlying disease that suggested a risk of death in the near future were considered high risk.
Of the 238 patients surveyed, 90% had PCPs. However, only 22% had ADs. Of these, only 23% brought the AD to the ED. Of the patients who did not have ADs, 95% had never discussed ADs with their PCPs, and 42% did not know what an AD was. Blacks were less likely than whites to have ADs (p < 0.0002) or to know about them (p < 0.004).
The majority of high-risk patients presenting to this ED do not have ADs. Among those high-risk patients who did have ADs, fewer than 25% brought the ADs with them. The development of ADs for high-risk patients and the availability of ADs in the ED are woefully inadequate. Emergency physicians need to collaborate with PCPs to remedy these deficiencies.
A focus group was conducted to determine the views of persons with AIDS about how to best conduct the process of establishing advance directives. (Advance directives are instructions regarding future medical care to be implemented should a patient be unable to communicate his/her treatment preferences.) Several hypotheses emerged from this focus group that were then formally tested with a questionnaire. The results of the questionnaire identified (a) predictors of attitudes toward advance directives and (b) predictors of the act of having established a directive. Based upon the findings from the focus group and the questionnaire, recommendations for social workers raising the issue of advance directives can be made. First, time for the client to adjust to seropositive notification should be allowed prior to raising the advance directive issue. Second, the advance directive issue should be raised in the context of empowerment rather than being embedded in other paper work. Third, people who are most likely to be disturbed by the process of establishing advance directives are those who have low health locus of control, low trait optimism, low reliance on active involvement as a coping mechanism, and low reliance on distraction as a coping mechanism. More time should be allotted for people with those characteristics.
Physicians are frequently unaware of patient preferences for end-of-life care. Identifying and exploring barriers to patient-physician communication about end-of-life issues may help guide physicians and their patients toward more effective discussions.
To examine correlates and associated outcomes of patient communication and patient preferences for communication with physicians about cardiopulmonary resuscitation and prolonged mechanical ventilation.
Prospective cohort study.
Five tertiary care hospitals.
1832 (85%) of 2162 eligible patients completed interviews.
Surveys of patient characteristics and preferences for end-of-life care; perceptions of prognosis, decision making, and quality of life; and patient preferences for communication with physicians about end-of-life decisions.
Fewer than one fourth (23%) of seriously ill patients had discussed preferences for cardiopulmonary resuscitation with their physicians. Of patients who had not discussed their preferences for resuscitation, 58% were not interested in doing so. Of patients who had not discussed and did not want to discuss their preferences, 25% did not want resuscitation. In multivariable analyses, patient factors independently associated with not wanting to discuss preferences for cardiopulmonary resuscitation included being of an ethnicity other than black (adjusted odds ratio [OR], 1.48 [95% CI, 1.10 to 1.99), not having an advance directive (OR, 1.35 [CI, 1.04 to 1.76]), estimating an excellent prognosis (OR, 1.72 [CI, 1.32 to 2.59]), reporting fair to excellent quality of life (OR, 1.36 [CI, 1.05 to 1.76]), and not desiring active involvement in medical decisions (OR, 1.33 [CI, 1.07 to 1.65]). Factors independently associated with wanting to discuss preferences for resuscitation but not doing so included being black (OR, 1.53 [CI, 1.11 to 2.11]) and being younger (OR, 1.14 per 10-year interval younger [CI, 1.04 to 1.25]).
Among seriously ill hospitalized adults, communication about preferences for cardiopulmonary resuscitation is uncommon. A majority of patients who have not discussed preferences for end-of-life care do not want to do so. For patients who do not want to discuss their preferences, as well as patients with an unmet need for such discussions, failure to discuss preferences for cardiopulmonary resuscitation and mechanical ventilation may result in unwanted interventions.
Advance directives, which allow a person to record preferences for end-of-life care in case of incapacity, have been underused in home care. In this study, thirty home care clients, who were either elderly or persons with AIDS, were offered the opportunity to execute individualized advance directives and to include issues of specific importance to them. Twenty-three completed and signed their documents; nearly all expressed wishes, fears, and concerns that are both not always adequately addressed and not necessarily capable of "yes" or "no" answers. These are discussed and explained, with guidelines for clinicians.
To assess the percentage of adult patients presenting to an urban ED who have a written advance directive (AD) and to determine whether age, sex, a patient's perception of his or her health status, and having a regular physician are associated with the patient's having an AD.
This was a cross-sectional patient survey performed at a community teaching hospital ED. Surveys were completed by 511 adult ED patients during representative shifts over a 3-month period. The questions included age, sex, "self-reported" health status, whether the patient had a "regular" physician, a patient-generated list of medical problems, and whether the patient had a written AD. For this study, ADs included health care proxies, living wills, and do-not-attempt-resuscitation (DNAR) orders.
Of the patients surveyed, 27% reported having an AD. Males and females were equally likely to have an AD. Factors associated with an increased likelihood of having an AD were older age, having a "regular" physician, and the patient's perception of his or her health status as ill. Most patients who had an AD (82%) discussed it with their families, but only 48% discussed it with their physicians.
Only 27% of the adult patients presenting to the ED had an AD. Older age, the patient's perception of his or her health status as ill, and having a "regular" physician increased the likelihood of having an AD.
An ED resident at Bronx Jacobi Medical Center evaluating a patient brought in by paramedics
- Elsburgh Clarke
- Rehoboth Beach
An ED resident at Bronx Jacobi Medical Center evaluating a patient brought in by paramedics. Photograph by ELSBURGH CLARKE, MD, Rehoboth Beach, Delaware.
The discussion about advance directives: patient and physician opinions regarding when and how it should be conducted
- Johnston SC