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.