Advance directives in skilled nursing facility residents transferred to emergency departments

Objective: Ten years have passed since Congress enacted the Patient Self-De termination Act to promote the use of advance directives (ADs). This study was performed to determine the frequency, type, demographic distribution, a nd utility of ADs that accompany residents of skilled nursing facilities (S NFs) transferred to emergency departments (EDs). Methods: This was an obser vational, cross-sectional cohort of SNF residents, transferred to two urban , academic EDs. Chart review and physician interviews were conducted on con secutive patients arriving during 12-hour data collection shifts. Results: Among 715 patients entered, 315 [44%, 95% confidence interval (95% CI) = 40 % to 48%] had an AD. Advance directives were significantly more prevalent a mong white (50%) than African American (34%) or Hispanic (39%) patients (p < 0.001), and varied from 0% to 94% among SNFs. Of the 315 patients with AD s, do-not-resuscitate (DNR) orders were the most prevalent (65%, 95% CI = 5 8% to 69%). Although 75% (95% Cl = 69% to 81%) of the DNR orders addressed cardiopulmonary resuscitation (CPR), only 12% (95% Cl = 8% to 16%) addresse d intubation. Among 39 patients who required intubation or CPR, 44% had ADs , 82% (95% CI = 57% to 96%) of which were deemed useful. Conclusions: Despi te a decade of legislation promoting their use, ADs are lacking in most SN- F residents transferred to EDs for evaluation and in most settings in which a clinical indication exists for intubation or CPR. Variation in their pre valence appears to be associated with both ethnicity and SNF origin. Althou gh about three-fourths of DNR ADs addressed CPR, only about one in ten offe red guidance regarding intubation. When available, ADs are used in most ins tances to guide emergency care.