HOSPITAL POLICIES ON LIFE-SUSTAINING TREATMENTS AND ADVANCE DIRECTIVES IN CANADA

Objective: To determine the prevalence and content of hospital policie s on life-sustaining treatments (cardiopulmonary resuscitation CPR, mechanical ventilation, dialysis, artificial nutrition and hydration, and antibiotic therapy for life-threatening infections) and advance di rectives in Canada. Design: Cross-sectional mailed survey. Setting: Ca nada. Participants: Chief executive officers or their designates at pu blic general hospitals. Main outcome measures: Information regarding t he existence of policies on life-sustaining treatments or advance dire ctives and the content of the policies. Results: Questionnaires were c ompleted for 697 (79.2%) of the 880 hospitals surveyed. Of the 697 res pondents 362 (51.9%) sent 388 policies; 355 (50.9%%) sent do-not-resus citate (DNR) policies (i.e., policies that addressed CPR alone or in c ombination with other life-sustaining treatments). Of the 388 policies 327 (84.3%) addressed CPR alone, 28 (7.2%) addressed CPR plus other l ife-sustaining treatments, 10 (2.6%) addressed advance directives, and the remaining 23 (5.9%) addressed other life-sustaining treatments. O f the 355 DNR policies 1 (0.3%) stated that routine discussion with pa tients is required, 315 (88.7%) restricted their scope to terminally o r hopelessly ill patients, 187 (52.7%) mentioned futility, 29 (8.2%) m entioned conflict resolution, 9 (2.5%) and 13 (3.7%) required explicit communication of the decision to the competent patient or family of t he incompetent patient respectively, 110 (31.0%) authorized the family of an incompetent patient to rescind the DNR order, 224 (63.1%) autho rized the nursing staff to do so, and 217 (61.1%) authorized physician s to do so. Conclusions: Although about half of the public general hos pitals surveyed had DNR policies few had policies regarding other life -sustaining treatments or advance directives. Existing policies could be improved if hospitals encouraged routine advance discussions, remov ed the restriction to terminally or hopelessly ill patients, scrutiniz ed the use of the futility standard, stipulated procedures for conflic t resolution, explicitly required communication of the decision to com petent patients or substitute decision-makers of incompetent patients and scrutinized the provision allowing families and health care profes sionals to rescind the wishes of now incompetent patients.