Presentation Date
19-10-2021 12:00 AM
Description
BACKGROUND: Patients admitted to the Intensive Care Unit (ICU) may choose to provide an advanced directive (AD) or delegate a health care proxy (HCP) to make decisions for them if they were to become incapacitated or unable to make decisions for themselves. Although universally recommended for patients to make end of life decisions, there is no consensus on whether these directives are specific enough to guide treatment decisions. The objectives of this study are to examine the presence and specificity of an AD or HCP documented in patients' medical records as well as the demographics and outcomes associated with the presence or absence of AD or HCP. METHODS: A retrospective chart review was completed on 2,363 patients aged 18 or older treated in the ICU between August 2015 and May 2017 after admission to a Level 1 Trauma Center. Patients were followed up to March 2019 for subsequent ICU admissions. Patients with an AD or HCP had the format (typed, verbal, or handwritten) and specificity of the document recorded. Treatments, procedures, escalation events and palliative care that patients received after a change in DNR status or delegation of HCP were assessed for alignment with wishes. Futile events were defined as those procedures that did not align with patient wishes. Demographic information, procedures performed during the admission, and patient outcomes were recorded. Patient characteristics were examined with descriptive statistics. We assessed the associations between presence of ADs and potential sociodemographic factors such as age, gender, race, and religion using Firth’s logistic regression while HCPs and their association with sociodemographic factors were analyzed with logistic regression modeling. RESULTS: Analysis showed that older patients were significantly more likely to have an AD (95% CI: 1.043-1.080) and HCP (95% CI: 1.031-1.051). There was no statistical relationship between the presence of an AD or HCP and race, religion, and gender. The analysis further revealed that 3.38% of ICU admissions had an AD while 12.4% had an HCP. The verbal format was most common at a rate of 81% for ADs and 89.72% for HCPs. Futile procedures were carried out on 13.75% of patients with an AD with that percentage increasing to 46.60% of patient with an HCP. Even when an AD or HCP was present, 41.43% of these patients still received some futile procedure. CONCLUSION: The majority of ICU patients did not have an AD or HCP present and may be receiving care that does not align with their wishes. Specific interventions like educational programs targeting HCP could be initiated, since our study reveals that more futile procedures are performed on these patients. Findings from this study can also guide the hospital’s quality improvement and patient safety programs aimed at increasing the number of ADs among ICU patients.
Recommended Citation
Benes, Gregory; Roth, Maya; Fontenot, Bailli; Rhodes, Stacey; Oral, Evrim; Wheeler, Carolyn; Fox, Jessica; and Moreno Walton, Lisa, "Adequacy of Health Care Advance Directives in Patients Admitted to the Intensive Care Unit" (2021). Medical Research Day. 8.
https://digitalscholar.lsuhsc.edu/sommrd/2021MRD/Posters/8
Included in
Adequacy of Health Care Advance Directives in Patients Admitted to the Intensive Care Unit
BACKGROUND: Patients admitted to the Intensive Care Unit (ICU) may choose to provide an advanced directive (AD) or delegate a health care proxy (HCP) to make decisions for them if they were to become incapacitated or unable to make decisions for themselves. Although universally recommended for patients to make end of life decisions, there is no consensus on whether these directives are specific enough to guide treatment decisions. The objectives of this study are to examine the presence and specificity of an AD or HCP documented in patients' medical records as well as the demographics and outcomes associated with the presence or absence of AD or HCP. METHODS: A retrospective chart review was completed on 2,363 patients aged 18 or older treated in the ICU between August 2015 and May 2017 after admission to a Level 1 Trauma Center. Patients were followed up to March 2019 for subsequent ICU admissions. Patients with an AD or HCP had the format (typed, verbal, or handwritten) and specificity of the document recorded. Treatments, procedures, escalation events and palliative care that patients received after a change in DNR status or delegation of HCP were assessed for alignment with wishes. Futile events were defined as those procedures that did not align with patient wishes. Demographic information, procedures performed during the admission, and patient outcomes were recorded. Patient characteristics were examined with descriptive statistics. We assessed the associations between presence of ADs and potential sociodemographic factors such as age, gender, race, and religion using Firth’s logistic regression while HCPs and their association with sociodemographic factors were analyzed with logistic regression modeling. RESULTS: Analysis showed that older patients were significantly more likely to have an AD (95% CI: 1.043-1.080) and HCP (95% CI: 1.031-1.051). There was no statistical relationship between the presence of an AD or HCP and race, religion, and gender. The analysis further revealed that 3.38% of ICU admissions had an AD while 12.4% had an HCP. The verbal format was most common at a rate of 81% for ADs and 89.72% for HCPs. Futile procedures were carried out on 13.75% of patients with an AD with that percentage increasing to 46.60% of patient with an HCP. Even when an AD or HCP was present, 41.43% of these patients still received some futile procedure. CONCLUSION: The majority of ICU patients did not have an AD or HCP present and may be receiving care that does not align with their wishes. Specific interventions like educational programs targeting HCP could be initiated, since our study reveals that more futile procedures are performed on these patients. Findings from this study can also guide the hospital’s quality improvement and patient safety programs aimed at increasing the number of ADs among ICU patients.