Why Don't Emergency Department Patients Have Advance Directives?

Abstract

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.

Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments

“…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.…”

Early Identification of Dying Trajectories in Emergency Department Patients: Potential Impact on Hospital Care

“…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.…”

“…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.…”

Prevalence of advance directives among elderly patients attending an urban Canadian emergency department

“…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.…”

“…[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.…”