ADVANCE DIRECTIVES IN THE MEDICAL INTENSIVE-CARE UNIT OF A COMMUNITY TEACHING HOSPITAL

Study objective: To evaluate the frequency with which advance directiv es (ADs) are available at the time of admission and their impact on su bsequent care in a medical intensive care unit (MICU) setting before a nd 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 hospita l providing primary and referred care. Patients: Consecutive admission s during e-month periods separated by 1 year: August-September 1991(91 ) and August-September 1992 (92). Measurements: The following were ass essed: the presence and type or absence of AD at the time of admission ; the presence or absence of a written order to limit resuscitation (W O-R) during the MICU stay; duration of MICU stay in hours; outcome; an d combined duration of use or administration of seven selected interve ntions. 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. Th is difference was not significant (p=0.578). Most patients in both gro ups (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 d id 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 m ore severely ill patients in both cohorts was identified; they did not present with an AD but subsequently a WO-R was established. These pat ients had the highest mortality, about 40%, when compared with the ove rall mortality of 8.2%. Conclusion: Advanced directives were infrequen tly available and had little impact on the pattern of care.