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Many Chronically Critically Ill Patients Do Not Have an Advance Directive

Kelley CG, Lipson AR, Daly BJ, Douglas SL. Use of advance directives in the chronically critically ill. JONAS Healthcare Law, Ethics, and Regulation. 2006;8:42-47.
Improved medical treatment and healthcare technology have allowed more patients to survive for prolonged periods with a critical illness. Before these chronically critically ill patients enter a crisis period in which they may lose the capacity to communicate, it would be beneficial for them to have an advance directive (AD) in place expressing their wishes for end-of-life care. From a secondary analysis of 2 long-term care studies, researchers examined the frequency of documentation of AD choices in the medical charts of 1128 patients hospitalized with a chronic critical illness. Most of the patients were over 60 years of age, had been living independently at home before their illness, and were hospitalized longer than 3 weeks, with an average of 15-19 days spent in the intensive care unit. In the first study, involving 530 patients who required long-term ventilator support, 37% of the patients had an AD in their charts, and 82% of the charts specifically documented either the presence or the absence of an AD.
In the second study, involving 598 patients enrolled in a disease management program for those with chronic critical illnesses, 36% of patients had an AD, but only 57% of the charts contained any AD documentation. For both studies, patients who were white, older, and/or had more preexisting and comorbid conditions were more likely to have an AD in place. Roughly 40% of the patients died during their hospitalization, and there were no differences in the patterns of these deaths or the use of mechanical ventilation between decedents who had an AD in place and those who did not. As most of these patients had been living independently before their illness, they might not have anticipated the need to have an AD. However, given the high rate of in-hospital mortality found in this study, nurses working with any critically ill patients may need to initiate or encourage discussions about end-of-life care and ADs with patients, families, and the healthcare team.
Abstract URL: www.medscape.com/medline/abstract/16755231

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Jan Grossberg, RN, BSN
Editorial Team