Advance directives in the medical intensive care unit of a community teaching hospital

Abstract

Study objective: To evaluate the frequency with which advance directives (ADs) are available at the time of admission and their impact on subsequent care in a medical intensive care unit (MICU) setting before and 9 months after the implementation of the Patient Self-Determination Act (PSDA).

Design: Prospective nonrandomized cohort data collection and analysis.

Setting: Thirteen-bed MICU of community teaching hospital providing primary and referred care.

Patients: Consecutive admissions during 2-month periods separated by 1 year: August-September 1991 (91) and August-September 1992 (92).

Measurements: The following were assessed: the presence and type or absence of AD at the time of admission; the presence or absence of a written order to limit resuscitation (WO-R) during the MICU stay; duration of MICU stay in hours; outcome; and combined duration of use or administration of seven selected interventions.

Main results: Fifteen of 133 patients (11.3%) in the 91 group and 15 of 171 patients (8.8%) in the 92 group presented with an AD. This difference was not significant (p = 0.578). Most patients in both groups (75.9% in 91 and 80.1% in 92) presented without an AD and did not have a WO-R during their MICU course. In addition, most patients who did present with an AD, 11 of 15 (73.3%) in the 91 group and 14 of 15 (93.3%) in the 92 group, did not have a WO-R. A subgroup of older and more severely ill patients in both cohorts was identified; they did not present with an AD but subsequently a WO-R was established. These patients had the highest mortality, about 40%, when compared with the overall mortality of 8.2%.

Conclusion: Advanced directives were infrequently available and had little impact on the pattern of care.