Volume 45, Issue 4 p. 508-512

Do Advance Directives Provide Instructions That Direct Care?

Joan M Teno MD, MS

Corresponding Author

Joan M Teno MD, MS

Center to Improve Care of the Dying, The George Washington University Medical Center, Washington, DC

The Center to Improve Care of the Dying, 1001 22nd St. NW, Ste. 820, Washington, DC 20037.Search for more papers by this author
Sandra Licks

Sandra Licks

Center for the Evaluative Clinical Sciences, Dartmouth College, Hanover, NH

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Joanne Lynn MD, MA

Joanne Lynn MD, MA

Center to Improve Care of the Dying, The George Washington University Medical Center, Washington, DC

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Neil Wenger MD

Neil Wenger MD

UCLA Medical Center, Los Angeles, CA

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Alfred F. Connors Jr. MD

Alfred F. Connors Jr. MD

MetroHealth Medical Center, Cleveland, OH

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Russell S. Phillips MD

Russell S. Phillips MD

Beth Israel Hospital, Boston, MA

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Mary Ann O'Connor MA

Mary Ann O'Connor MA

Center for the Evaluative Clinical Sciences, Dartmouth College, Hanover, NH

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Donald P. Murphy MD

Donald P. Murphy MD

St Luke's Presbyterian Hospital, Denver, CO

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William J. Fulkerson MD

William J. Fulkerson MD

Duke University Hospital, Durham, NC

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Norman Desbiens MD

Norman Desbiens MD

Marshfield Clinic, Marshfield, WI

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William A. Knaus MD

William A. Knaus MD

The Department of Health Evaluation Sciences, The University of Virginia School of Medicine.

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First published: 27 April 2015
Citations: 268

This research was made possible by funding from the Robert Wood Johnson Foundation's Program on the Care of Critically Ill Hospitalized Adults: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) and by the Agency for Health Care Policy and Research, Grant no. 1 R01 HS070 75. The opinions and findings in this manuscript are those of the authors and do not necessarily represent the views of the sponsors.

Abstract

OBJECTIVE: To evaluate whether the lack of effect of advance directives (ADs) on decision-making in SUPPORT might arise, in part, from the content of the actual documents.

DESIGN: Advance directives placed in the medical records were abstracted for date of completion and content of additional written instructions. We examined directives with instructions to forgo life-sustaining treatment in the current state of health to determine whether care given was consistent with preferences noted in those directives.

SETTINGS: Five teaching hospitals in the United States.

PATIENTS: A total of 4804 patients with at least one of nine serious illnesses were admitted to five teaching hospitals in the 2 years following implementation of the Patient Self-Determination Act. Patients were part of a randomized controlled trial to improve decision-making and outcomes.

RESULTS: From the medical records of 4804 patients, a total of 688 directives were collected from 569 patients. The majority of these directives (66%) were durable powers of attorney; in addition, 31% were standard living wills or other forms of written instructions (3%). Only 90 documents (13%) provided additional instructions for medical care beyond naming a proxy or stating the preferences of a standard living will. Only 36 contained specific instructions about the use of life-sustaining medical treatment, and only 22 of these directed forgoing life-sustaining treatment in the patient's current situation. For these, the treatment course was consistent with the instruction for nine patients. In two cases, patients may have changed an inconsistent directive after discussion with hospital staff.

CONCLUSION: Advance directives placed in the medical records of seriously ill patients often did not guide medical decision-making beyond naming a healthcare proxy or documenting general preferences in a standard living will format. Even when specific instructions were present, care was potentially inconsistent in half of the cases.