PROMOTING INPATIENT DIRECTIVES ABOUT LIFE-SUSTAINING TREATMENTS IN A COMMUNITY-HOSPITAL - RESULTS OF A 3-YEAR TIME-SERIES INTERVENTION TRIAL

Background: Hospitalization presents an opportunity for physicians to discuss advance directives with patients and to encourage completion o f health care proxies. Objective: To prospectively promote discussion and documentation of treatment-specific directives about life-sustaini ng interventions (cardiopulmonary resuscitation, admission to critical care units, mechanical ventilation, electrical cardioversion, and vas opressor therapy) among unselected medical inpatients in a community t eaching hospital. Methods: We conducted a time-series intervention tri al from January 1, 1991, through June 30 1993, divided into three phas es. During the education phase, eve provided reminders, education, and feedback to attending physicians; during the intervention phase, we p romoted a new documentation form for directives to be used by attendin g physicians; during the control phase, no interventions occurred. We studied consecutive patients (N = 1780) admitted to the hospital acute medical service in each of the following 10 periods: three in the edu cation phase (n = 598), three in the intervention phase (n = 826), and four in the control phase (n = 356). The primary outcome measures wer e the frequency and content of directives documented by attending phys icians in their patients' hospital charts. Secondary outcome measures included physicians' and patients' attitudes about directives, surveye d repeatedly. Results: The proportion of inpatients with directives in creased significantly during the intervention phase (62.5% vs 23.6% du ring the education phase and 25.3% during the control period, P < .001 , Pearson chi(2) test). During the final intervention phase, 227 (83.2 %) of 273 inpatients had directives documented in the hospital chart. Increases in clinically important (''impact'') directives usually invo lved intensive care, not do-not-resuscitate status. Overall, 366 (86.7 %) of 422 physician-attested directives agreed with the treatment pref erences of interviewed patients (kappa ranges, 0.53 to 0.79). Physicia ns' attitudes about and interest in directives improved. Conclusions: Institutional interventions can facilitate attending physicians' docum entation of treatment-specific directives about life-sustaining care f or most medical inpatients. More research is needed to confirm the eff ect of these efforts on quality and cost of hospital care, patients' a utonomy, and their eventual execution of durable directives and proxie s.