Why don't emergency department patients have advance directives?

Objectives: In 1997 the authors determined that only 27% of their adult ED patients had advance directives (ADs), The purpose of this followup study w as to determine the reasons why their adult ED patients do not have ADs. Me thods: This prospective study enrolled patients from a convenience sample o f representative shifts in the ED selected over a three-month period. Surve y questions included demographic information, whether the patients had a li fe-threatening medical problem, whether they had an AD, with whom they had discussed their ADs, and the reasons why they did not have an AD. We exclud ed those who refused participation or who were incapacitated (i.e., any pat ient with a condition that precluded him or her from answering the question naire himself or herself, such as an altered level of consciousness, dement ia, mental retardation, or inability to understand English). Results: Four hundred seventy-six subjects were enrolled during the study period from an ED census of 816 adult patients. Three hundred forty patients were not incl uded in the study for the following reasons: inability to complete the surv ey, refusal to participate, or not being approached by the interviewers. Of those enrolled, 77% of the patients did not have an AD (females, 73%; male s, 80%). The most frequent reasons given for not having an AD were: 40% nev er thought about it, 24% preferred family to make the decision, and 23% wer e procrastinating. Factors jointly predictive of having an AD were older ag e, having a specialist, having a life-threatening medical problem, and not being Catholic. Patients who had ADs were discussing their ADs with their p rimary care physicians (PCPs) only 5% of the time. Conclusion: Many patient s, even when they have life-threatening medical problems, do not have an AD , and several reasons for this have been identified. Few of these ED patien ts who had ADs had discussed them with their physicians. Further studies sh ould assess whether more physician intervention would increase the percenta ge of patients who have ADs.