Availability of advance directives in the emergency department
Emergency departments (EDs) are crowded with critically ill patients, many of whom are no longer able to communicate with the emergency staff. Substitute decision makers are often unknown or not reachable in time. The availability of advance directives (ADs) among Swiss ED patients has not yet been evaluated. The purpose of this prospective survey was to investigate the prevalence of ADs among ED patients and to identify factors associated with the existence or absence of ADs.
In a prospective survey, we enrolled consecutive patients from 10–30 July 2017 who visited a tertiary care ED. Patients completed a written, standardised and self-administrated questionnaire during the waiting time. The primary endpoint was the prevalence of ADs in ED patients. Secondarily, we defined predictors associated with the existence or absence of ADs. Two months after the first survey, there was a written follow-up survey asking patients without ADs whether they had completed an AD in the meantime.
Fifty-eight of 292 enrolled ED patients (19.9%) had a completed AD. Overall, 49.3% of the survey population was female. Patients having an AD were older (69.5 years, interquartile range [IQR] 57–81 vs 39 years, IQR 27–56) and had more comorbidities (67.2% vs 38.9%) compared with patients without ADs. The four leading reasons given for not having an AD were: 33.6% never considered completing one, 26% did not know about ADs, 14% preferred family to make decisions, 11.6% felt it was too early to make such a decision. Predictors for having an AD were older age (p <0.001), being in long-term medical treatment by a specialist (p = 0.050), being Swiss (p = 0.021) and living with nursing care (p = 0.043). Of the ED patients with ADs, 46.6% discussed their AD with the family and 31% with their general practitioner. Results of the follow-up survey showed that eight participants had completed an AD in the meantime. The prevalence of ADs increased from 19.9% to 22.6%.
During the last 20 years, the percentage of patients having an AD has not changed. Even today, only every fifth ED patient has a completed AD. Nearly two thirds of ED patients never considered completing one or did not know about ADs. Therefore, there is an urgent need to better inform and sensitise the public, so that they will define in a timely manner legally valid and specifically defined decisions about future medical treatments and wishes by completing individual directives.
- Clemency B, Cordes CC, Lindstrom HA, Basior JM, Waldrop DP. Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care. J Am Med Dir Assoc. 2017;18(1):35–9. doi:.https://doi.org/10.1016/j.jamda.2016.07.032
- Fagerlin A, Schneider CE. Enough. The failure of the living will. Hastings Cent Rep. 2004;34(2):30–42. doi:.https://doi.org/10.2307/3527683
- Llovera I, Ward MF, Ryan JG, Lesser M, Sama AE, Crough D, et al. Why don’t emergency department patients have advance directives? Acad Emerg Med. 1999;6(10):1054–60. doi:.https://doi.org/10.1111/j.1553-2712.1999.tb01192.x
- Silveira MJ, Kim SYH, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. 2010;362(13):1211–8. doi:.https://doi.org/10.1056/NEJMsa0907901
- Stelter KL, Elliott BA, Bruno CA. Living will completion in older adults. Arch Intern Med. 1992;152(5):954–9. doi:.https://doi.org/10.1001/archinte.1992.00400170044008
- Cugliari AM, Miller T, Sobal J. Factors promoting completion of advance directives in the hospital. Arch Intern Med. 1995;155(17):1893–8. doi:.https://doi.org/10.1001/archinte.1995.00430170089011
- Emanuel LL, Barry MJ, Stoeckle JD, Ettelson LM, Emanuel EJ. Advance directives for medical care--a case for greater use. N Engl J Med. 1991;324(13):889–95. doi:.https://doi.org/10.1056/NEJM199103283241305
- Wissow LS, Belote A, Kramer W, Compton-Phillips A, Kritzler R, Weiner JP. Promoting advance directives among elderly primary care patients. J Gen Intern Med. 2004;19(9):944–51. doi:.https://doi.org/10.1111/j.1525-1497.2004.30117.x
- Ramsaroop SD, Reid MC, Adelman RD. Completing an advance directive in the primary care setting: what do we need for success? J Am Geriatr Soc. 2007;55(2):277–83. doi:.https://doi.org/10.1111/j.1532-5415.2007.01065.x
- O’Sullivan R, Mailo K, Angeles R, Agarwal G. Advance directives: survey of primary care patients. Can Fam Physician. 2015;61(4):353–6.
- Deutscher Hospiz- und PalliativVerband e. V. Wissen und Einstellungen der Menschen in Deutschland zum Sterben – Ergebnisse einer repräsentativen Bevölkerungsbefragung im Auftrag des DHPV. https://wwwdhpvde/tl_files/public/Aktuelles/presseerklaerungen/3_ZentraleErgebnisse_DHPVBevoelkerungsbefragung_06102017pdf. 2017.
- gfs-zürich. Telefonische Omnibus-Befragung zur persönlichen Vorsorge. August 2017.
- de Heer G, Saugel B, Sensen B, Rübsteck C, Pinnschmidt HO, Kluge S. Advance Directives and Powers of Attorney in Intensive Care Patients. Dtsch Arztebl Int. 2017;114(21):363–70. doi:.https://doi.org/10.3238/arztebl.2017.0363
- Oulton J, Rhodes SM, Howe C, Fain MJ, Mohler MJ. Advance directives for older adults in the emergency department: a systematic review. J Palliat Med. 2015;18(6):500–5. doi:.https://doi.org/10.1089/jpm.2014.0368
- Taylor DM, Ugoni AM, Cameron PA, McNeil JJ. Advance directives and emergency department patients: ownership rates and perceptions of use. Intern Med J. 2003;33(12):586–92. doi:.https://doi.org/10.1111/j.1445-5994.2003.00423.x
- Gill GGK, Fukushima E, Abu-Laban RB, Sweet DD. Prevalence of advance directives among elderly patients attending an urban Canadian emergency department. CJEM. 2012;14(2):90–6. doi:.https://doi.org/10.2310/8000.2012.110554
- Davis CP. Emergency department visits: we are not prepared. Am J Emerg Med. 2012;30(8):1364–70. doi:.https://doi.org/10.1016/j.ajem.2011.09.026
- Grudzen CR, Hwang U, Cohen JA, Fischman M, Morrison RS. Characteristics of emergency department patients who receive a palliative care consultation. J Palliat Med. 2012;15(4):396–9. doi:.https://doi.org/10.1089/jpm.2011.0376
- Ishihara KK, Wrenn K, Wright SW, Socha CM, Cross M. Advance directives in the emergency department: too few, too late. Acad Emerg Med. 1996;3(1):50–3. doi:.https://doi.org/10.1111/j.1553-2712.1996.tb03303.x
- Lahn M, Friedman B, Bijur P, Haughey M, Gallagher EJ. Advance directives in skilled nursing facility residents transferred to emergency departments. Acad Emerg Med. 2001;8(12):1158–62. doi:.https://doi.org/10.1111/j.1553-2712.2001.tb01133.x
- Littrell J, Diwan S, Bryant CJ. Negotiating advance directives for persons with AIDS. Soc Work Health Care. 1996;23(2):43–65. doi:.https://doi.org/10.1300/J010v23n02_03
- Miles SH, Koepp R, Weber EP. Advance end-of-life treatment planning. A research review. Arch Intern Med. 1996;156(10):1062–8. doi:.https://doi.org/10.1001/archinte.1996.00040041062003
- Gillick MR. A broader role for advance medical planning. Ann Intern Med. 1995;123(8):621–4. doi:.https://doi.org/10.7326/0003-4819-123-8-199510150-00009
- Weinryb J. Why no advance directive? Arch Intern Med. 1995;155(5):547. doi:.https://doi.org/10.1001/archinte.1995.00430050127018
- Scholten G, Bourguignon S, Delanote A, Vermeulen B, Van Boxem G, Schoenmakers B. Advance directive: does the GP know and address what the patient wants? Advance directive in primary care. BMC Med Ethics. 2018;19(1):58. doi:.https://doi.org/10.1186/s12910-018-0305-2
- Messinger-Rapport BJ, Baum EE, Smith ML. Advance care planning: Beyond the living will. Cleve Clin J Med. 2009;76(5):276–85. doi:.https://doi.org/10.3949/ccjm.76a.07002
- Kelley K, Clark B, Brown V, Sitzia J. Good practice in the conduct and reporting of survey research. Int J Qual Health Care. 2003;15(3):261–6. doi:.https://doi.org/10.1093/intqhc/mzg031