Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments

Abstract

Abstract. 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.

152: Epidemiology of Advance Directives in Extended Care Facility Patients Presenting to the Emergency Department

“…Some authors have shown a relationship with race, which was not found in this study, possibly due to the inclusion of confounders in past analyses. 8,9,11,12 In the multivariate analysis, patients of increasing age were significantly more likely to present with a DNR order. Previous studies have consistently demonstrated similar associations with age.…”

“…Previous studies have consistently demonstrated similar associations with age. 8,9,14,22 Age was broken out further in Table 2, and demonstrated significant associations with the presence of DNR orders, living wills, and healthcare POAs. While the oldest of the geriatric population has a high prevalence of POA (59.5%), living will (40.5%) and DNR orders (40.5%), the younger geriatric population has a significantly lower prevalence of these documents.…”

“…ADs 8 has been demonstrated in patients transferred from ECFs to EDs. The most recent national survey of nursing homes demonstrated that 65.3% of residents had some kind of AD, of which 55.9% were do-not-resuscitate orders.…”

“…We felt this necessary, as age has been treated variably in previous studies. For example age has been broken into greater than and less than 65 or 75, 8,11 or into decades or larger categories 9,12-14 when relating it to DNR status in the nursing home. For this secondary analysis, we hypothesized that documentation of DNR status would become more prevalent with increasing age.…”

Part 2: Ethical Issues

“…Quality of life should never be used as a criterion to withhold CPR, because conditions such as irreversible brain damage or brain death cannot be reliably assessed or predicted. [22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37] Out-of-hospital DNAR protocols must be clear to all involved (eg, physicians, patients, family members, loved ones, and out-of-hospital healthcare providers). Advance directives can take many forms (eg, written bedside orders from physicians, wallet identification cards, identification bracelets, and other mechanisms approved by the local emergency medical services [EMS] authority).…”