ADVANCE DIRECTIVES FOR SERIOUSLY ILL HOSPITALIZED-PATIENTS - EFFECTIVENESS WITH THE PATIENT SELF-DETERMINATION ACT AND THE SUPPORT INTERVENTION

OBJECTIVE: To assess the effectiveness of written advance directives ( ADs) in the care of seriously ill, hospitalized patients. In particula r, to conduct an assessment after ADs were promoted by the Patient Sel f-Determination Act (PSDA) and enhanced by the effort to improve decis ion-making in the Study to Understand Prognoses and Preferences for Ou tcomes and Risks of Treatments (SUPPORT), focusing upon the impact of ADs on decision-making about resuscitation. DESIGN: Observational coho rt study conducted for 2 years before (PRE) and for 2 years after (POS T) the PSDA, with a randomized, controlled trial of an additional inte rvention to improve decision-making after the PSDA (POSTS-SUPPORT). SE TTING: Five teaching hospitals in the United States PATIENTS: A total of 9105 seriously ill patients treated in five teaching hospitals. INT ERVENTIONS: The PSDA mandated patient education about ADs at hospital entry and documentation of ADs in the medical record. The SUPPORT inte rvention, in addition, provided a nurse to facilitate communication am ong patients, surrogates, and physicians about preferences for and out comes of treatment alternatives and, when clinically appropriate, to e ncourage completion and utilization of ADs. MEASUREMENTS: Interviews w ere conducted with patients, surrogates, and attending physicians abou t awareness, completion, and impact of ADs. Medical records were revie wed for discussion about preferences concerning resuscitation, timing and writing of ''Do Not Resuscitate'' (DNR) orders, evidence of ADs, a nd the use or forgoing of resuscitation at the time of death. RESULTS: In the three cohorts, PRE, POST, and POST+SUPPORT, average age was 63 . One-quarter of patients died during the initial hospitalization, one -half were dead within 6 months, and one-half were unconscious far the ir last 3 days. Before the PSDA (PRE), 62% were familiar with a living will, and 21% had an AD. These rates were similar for the POST and PO ST+SUPPORT cohorts. Just 36 (6%) of these directives were mentioned in the medical records for PRE, but a stable 35% were documented for POS T, and POST+SUPPORT had an increasing rate averaging 78% (P<.001). As previously reported for PRE patients, the POST patients with and witho ut ADs had no significant differences in the rates of medical record d ocumentation of discussions about resuscitation (33% vs 38%, POST with out AD vs POST with AD), DNR orders among those who wanted to forgo re suscitation (54% vs 58%), and attempted resuscitations at death (17% v s 9%). The POST+SUPPORT patients had similar results, with no evidence that the intervention enhanced the effect of ADs on these three measu res of resuscitation decision-malting. Patients with ADs more often re ported that preferences about resuscitation were discussed with a phys ician (e.g., for POST patients, 30% for those with no AD and 43% for t hose with an AD, P<.05). Only 12% of patients with ADs had talked with a physician when completing the AD. Only 42% reported ever having dis cussed the AD with their physician. By the second study week, only one in four physicians was aware of patients' ADs. CONCLUSIONS: In these seriously ill patients, ADs did not substantially enhance physician-pa tient communication or decision-making about resuscitation. This lack of effect was not altered by the PSDA or by the enhanced efforts in SU PPORT, although these interventions each substantially increased docum entation of existing ADs. Current practice patterns indicate that incr easing the frequency of ADs is unlikely to be a substantial element in improving the care of seriously ill patients. Future work to improve decisionmaking should focus upon improving the current pattern of prac tice through better communication and more comprehensive advance care planning.