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Abstract. Objectives:In 1997 the authors determined that only 27% of their adult ED patients had advance directives (ADs). The purpose of this followup 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. 3 The purpose of the current study was to determine the reasons why adult ED patients and the chronically ill, in particular, do not have ADs. We believed that such information could help determine where an impact could be made to increase the number of patients with ADs. We also wanted to determine whether patients were discussing their ADs with their physicians. METHODSStudy Design. This was a prospective, cross-sectional study performed on a convenience sample of adult patients presenting to our ED during representative shifts. This study was approved by the institutional review board of the participating institution.

Objectives: 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. Methods: This was a cross-sectional patient survey performed at a community teaching hospital ED. Surveys were completed by 5 11 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 patientgenerated 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. Results: 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. Conclusion: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. Key words: advance directives; do not attempt resuscitation; legal; law; ethics; emergency department. care in the scenario of a deteriorating mental and physical state. When no formal documentation exists, it is often the emergency physician (EP) who is required to make difficult decisions with significant ramifications in a sometimes humed and underinformed fashion.One recent study evaluated the prevalence of ADS in ED patients who were elder or critically ill.' The purpose of our study was to determine the prevalence of ADS [health care proxies, do-not-attempt-resuscitation (DNAR) orders, living wills] in the adult ED population, as a whole, and how factors such as age, sex, and the patient's perception of health status are related to the likelihood of having an AD.

Of the 878 subjects in the study group, 96% were interested in obtaining information about one or more preventive health issues. An opportunity exists to respond to this interest by providing material for public health education in the waiting area of EDs.

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