Nejm 94% of Family Members Would Attend Resuscitation Again
Special Commodity
A Prospective Report of Advance Directives for Life-Sustaining Intendance
Listing of authors.Abstruse
Background
The use of accelerate directives is recommended so that people tin determine the medical care they will receive when they are no longer competent, merely the effectiveness of such directives is not clear.
Methods.
In a prospective report conducted over a two-year period, 126 competent residents of a nursing home and 49 family members of incompetent patients were interviewed to determine their preferences with respect to hospitalization, intensive intendance, cardiopulmonary resuscitation, bogus ventilation, surgery, and tube feeding in the outcome of disquisitional illness, last illness, or permanent unconsciousness. Accelerate directives, consisting of signed statements of treatment preferences, were placed in the medical record to aid in care in the nursing home and to exist forwarded to the hospital if necessary.
Results.
In an analysis of 96 outcome events (hospitalization or death in the nursing dwelling), care was con
Methods
Study Subjects
All patients residing in a 120-bed skilled-care and intermediatecare nursing home in central Due north Carolina for at least one week between Apr 1, 1986, and July 31, 1987, were eligible to partici-
sistent with previously expressed wishes 75 per centum of the time; however, the presence of the written advance directive in the medical record did non facilitate consistency. Amongst the 24 events in which inconsistencies occurred, care was provided more aggressively than had been requested in six cases, largely considering of unanticipated surgery or artificial ventilation, and less aggressively than requested in 18, largely because hospitalization or cardiopulmonary resuscitation was withheld. Inconsistencies were more likely in the nursing abode than in the hospital.
Conclusions. The effectiveness of written advance directives is limited by inattention to them and by decisions to place priority on considerations other than the patient'due south autonomy. Since our study was performed in only i nursing abode and one hospital, other studies are necessary to determine the generalizability of our findings. (Northward Engl J Med 1991; 324:882–8.)
pate. The nursing habitation is licensed in North Carolina and certified for participation in the Medicaid and Medicare programs.
Patients were included in the study if they gave consent, and those incompetent to do then were included if their family members consented to the patient's participation. A patient was considered competent to give informed consent if, after being read the introductory explanation of the projection, the patient (1) stated, on being asked, that he or she understood the project, (2) could paraphrase the introductory explanation, and (iii) could sign or marker the consent form. These same criteria were used to approximate the patient's competence to create an accelerate directive.
For each patient in the written report, a family fellow member or another surrogate also participated whenever possible. If the patient was competent to exist interviewed, he or she designated the surrogate conclusion maker. If the patient was not competent to be interviewed, the selected surrogate was the person identified in the nursing home tape as being financially responsible for the patient.
Questionnaires
The survey instrument included demographic questions about the patient's age, race, sexual activity, educational activity, and marital status. To define their full general preferences regarding life-sustaining handling, the patients were asked which of the following statements they agreed with: "I want my doctor to keep me live no matter how ill I am" or "There will exist a fourth dimension when I want my md to stop keeping me alive."
The patients were then asked about their specific preferences with respect to hospitalization, intensive care, surgery, cardiopulmonary resuscitation, and artificial ventilation under each of 3 circumstances: critical illness, terminal disease, and permanent unconsciousness. In addition, they were asked about their wishes with regard to tube feeding in the consequence of permanent unconsciousness. The surrogates were asked a parallel serial of questions in order to determine their general preferences and specific treatment choices on behalf of the patient. Before being questioned virtually specific preferences, the patients and surrogates were read descriptions of intensive care, cardiopulmonary resuscitation, and artificial ventilation.
Critical illness was divers equally a status of extreme sickness involving a disease that could improve with medical handling. Terminal disease was defined as a condition in which a person is dying with a disease that cannot get better no matter what the doctor does. Permanent unconsciousness was defined as a condition from which the person will never awaken. In the case of treatment, the respondents could cull (i) to have the treatment, (two) not to accept the handling, (iii) to allow their doctors to make up one's mind, (4) to allow their families to make up one's mind, or (five) to make some other choice of their own. Cue cards labeled with each of the medical atmospheric condition, treatments, and possible choices were used during the interview. (The questionnaire is available on request.)
Documentation of Preferences
A argument was prepared for each patient that was based on the preferences expressed during the interview. The statement included the specific choices of treatment, the names of the surrogate decision makers chosen by the patient, and the statement of the patient's general preference (see the Appendix for a sample preference statement).
Later on the statements had been read to the patients, they were asked whether they still agreed with them and were asked to sign them. If they did not concord with the statements, changes were made before they gave their final signatures. The document was and then placed in each patient's nursing home chart, in the department designated for handling orders, to be used as an advance directive. A copy was also placed in a sealed envelope in the forepart of the nautical chart, stamped boldly in cherry ink as follows: "Statement of Patient's Preferences for Intendance: To Be Transferred with Patient If Discharged to Hospital." In the case of an incompetent patient, the statement of the surrogate's preferences for the patient's care was prepared, signed, and placed in the patient'due south nursing habitation chart to be used to straight the patient'southward futurity care.
Before inserting the statement in the patient's chart, a research banana reviewed the chart to verify that the orders it contained were consistent with the wishes expressed in the statement. In particular, if a tape included a practice-not-resuscitate order that was inconsistent with the patient's or surrogate's stated wishes, this inconsistency was brought to the attention of the attending medico. In these cases, at the doc'southward discretion, either the preference statement was withheld from the nautical chart considering the physician disagreed with the investigator's evaluation of the patient's competence, or the orders in the nautical chart were changed before the insertion of the certificate.
If a patient returned to the nursing dwelling after a hospitalization, he or she was again presented with the document and asked whether there should exist whatever changes before it was reinserted into the nursing home chart. When a preference statement was reviewed, the patient's competence to make decisions was reevaluated according to the criteria used initially. If the patient was subsequently evaluated as incompetent, the original document was inserted without modification.
Follow-upward Data
The nursing home census was reviewed every weekday to identify deaths in the nursing home or hospitalizations. When either of these outcome events occurred, a research banana reviewed either the hospital discharge summary or the nursing habitation chart to determine ( i ) the use of hospitalization, intensive care, cardiopulmonary resuscitation, artificial ventilation, surgery, or tube feeding, (2) the presence of critical illness, final illness (incurable illness with a prognosis of less than half-dozen months' survival), or irreversible unconsciousness, (iii) the presence or absence of the advance directive in the medical record, and (4) the patient's competence to brand choices at the time of the event event, equally judged on the ground of mental status and level of consciousness as recorded past medical or nursing staff at the time of the effect.
All attention physicians in the nursing home who cared for the patients included in the study and all attention physicians who cared for these patients during an outcome result in the hospital were interviewed to decide why there had been any inconsistencies betwixt the advance directive and the actual care provided to the patient. All registered nurses who had worked in the nursing home for at to the lowest degree six months during the study period were interviewed to make up one's mind whether they considered the interview and written directive helpful and how the procedure could exist improved.
Statistical Assay
The demographic characteristics of the patients and the responses of the interviewees were analyzed with utilise of summary statistics. The effectiveness of the written advance directives was measured in terms of how frequently the directives were available at the time of an outcome event and how oftentimes the patient's care was consistent with the previously expressed wishes. The unit of measurement of analysis was the outcome event, not the individual patient. Because multiple events involving the same patient were not necessarily contained of each other, we performed all analyses twice — one time using only the beginning outcome consequence for each patient, and a 2nd time using all outcome events. The results of the two analyses were essentially identical and are therefore reported just for the analysis of all outcome events.
To examine which independent variables were associated with treatment that was consistent with accelerate directives, the Pearson chi-square statistic was used. A logistic regression model was then fitted to make up one's mind the joint effect of the factors of interest, with adjustment for any significant demographic variables. Consistency betwixt previous wishes and subsequent treatment was the dichotomous outcome (one = inconsistent, 0 = consequent). Four main factors were included in the concluding model: the presence of the accelerate directive in the medical record at the institution where the effect event occurred (nowadays or absent), the origin of the advance directive (patient or family), the competence of the patient at the time of the outcome event (incompetent or competent), and the location of the result effect (nursing abode or hospital). Potential confounding variables examined were the circumstances of the event (disquisitional disease, terminal affliction, or permanent unconsciousness), sex, race, age, and marital status. A astern elimination procedure was used to remove from the model whatever potential confounders that did not significantly impact the results of the analysis.
Results
Patients' Characteristics
Two hundred ten eligible patients or their surrogates were asked to participate in the study; 175 (83 percent) did so. The patients who did non participate did not differ significantly in age, race, or sex from those who did participate.
Table one.
Table ane. Characteristics of the Patients. Seventy-two percent of the patients (126) were judged competent to give informed consent. The competent and the incompetent patients had similar demographic characteristics, except that the incompetent patients were slightly older and more ofttimes white and female (Table i).
One hundred forty-2 family members or other surrogates participated in the study. 90-three persons were related to competent patients, and 49 were related to incompetent patients. The participating surrogates included children (63 percent), spouses (14 pct), siblings (2 percent), other relatives (16 percent), and friends or others (4 percent).
Treatment Preferences
Table ii.
Table 2. Preferences of 126 Nursing Home Residents Regarding Life-Sustaining Treatment. The majority of the competent patients thought that there would come a time when they would want their md to terminate keeping them live (72 patients, or 57 percent). Forty-one (33 percent) wanted their doctor to go along them live as long as possible. The remaining 13 patients (10 percent) did not know how they felt about these statements. As for specific treatment choices, the patients were most willing to receive life-sustaining treatment during a disquisitional illness and to the lowest degree willing to receive such treatment during permanent unconsciousness (Table 2).
Table 3.
Tabular array 3. Preferences of 49 Family Members of Incompetent Nursing Dwelling Residents Regarding Life-Sustaining Treatment.* The family members of the incompetent patients consistently preferred to have life-sustaining treatments withheld from the patients more frequently than the competent patients did for themselves. Thirty-six family members (73 percent) agreed that there would be a fourth dimension when they would want the patient's doctor to terminate keeping the patient live; 6 family members (12 pct) disagreed; seven (14 percent) did not know how they felt about this statement. When they were asked about specific treatments, their choices paralleled those of the competent patients, with the inclination to choose life-sustaining treatments diminishing every bit the condition became less reversible (Table iii).
Iii preference statements were withheld from the charts because of inconsistencies between the wishes expressed and the orders in the chart, or because of inconsistencies within the preference statement.
Outcome Events
Tabular array four.
Table four. Treatments Received by Patients during Outcome Events. During the two-year study period there were 35 deaths in the nursing dwelling and 71 hospitalizations, for a total of 106 effect events, involving 76 patients. During these events, 134 relevant treatments were provided (Tabular array iv). Ninety pct of the hospitalizations involved a state-funded, university-affiliated hospital. The remainder occurred in either a Veterans Affairs hospital or a canton hospital.
Effectiveness of the Written Advance Directive
An accelerate directive remained in the nursing home chart for 74 percent of the 106 outcome events, but it was successfully delivered to the hospital and incorporated into the hospital record for but 25 of the 71 hospitalizations. During their interviews, nurses commented that staff turnover was the crusade of unfamiliarity with the document and its infrequent transfer to the hospital.
The consistency between the advance directive and the intendance provided during the outcome event was analyzed for 96 of the 106 events. The remaining 10 events were not analyzed, because they involved circumstances to which the advance directive did not employ — i.e., unwitnessed deaths, illnesses that were not considered disquisitional or terminal, or those that did non involve permanent unconsciousness.
Medical treatment was consistent with the accelerate directives in 72 of the 96 events (75 per centum). 20-four events occurred in which care was inconsistent with previous wishes. (A detailed tabular array of all cases of inconsistent intendance has been deposited with the National Auxiliary Publications Service.*) In six cases intendance was more than aggressive than had been requested, and consisted of ventilation (ii cases), surgery (ii), cardiopulmonary resuscitation (one), and tube feeding (one). For instance, 1 patient declined artificial ventilation in the directive but had a reversible episode of
Run across NAPS document no. 04847 for 7 pages of supplementary textile. Guild from NAPS c/o Microfiche Publications, P.O. Box 3513, Grand Primal Station, New York, NY 10163–3513. Remit in advance (in U.Southward. funds only) $7.75 for photocopies or $4 for microfiche. Outside the U.S. and Canada add postage of $4.50 ($ane.50 for microfiche postage). There is an invoicing accuse of $xv on orders non prepaid. This charge includes buy gild. respiratory failure during treatment for a seizure. This patient was consequently given artificial ventilation for a cursory flow. In another example, the family of an incompetent patient had declined surgery in its directive, only later agreed to amputation of the patient'south leg because of an open up, infected femoral fracture.
Care was less aggressive than had been requested in 18 cases, largely considering hospitalization or cardiopulmonary resuscitation was withheld. For case, a patient with stop-phase congestive heart failure had requested hospitalization in the directive, but at a time when the patient was no longer competent, the family unit and md believed there was no do good to be gained from ambitious care, and the patient died in the nursing home. A patient with severe embolic illness requested cardiopulmonary resuscitation in the directive, but afterward in that location had been repeated hospitalizations, the family, who had been directed by the patient to make up one's mind about hospitalization, refused hospitalization; this patient died in the nursing home without cardiopulmonary resuscitation.
Table five.
Table 5. Consistency betwixt Accelerate Directives and Actual Provision of Care, Co-ordinate to the Presence of the Directive in the Medical Tape, the Originator of the Directive, and the Patient's Competence and Location at the Time of the Upshot Event. Consistency betwixt previous wishes and patient care occurred less frequently when the advance directive was present in the medical tape than when it was absent-minded (P = 0.045) (Table 5). Advance directives that originated with patients were every bit constructive as those that originated with families in leading to intendance consistent with previous wishes (Table 5). If a patient was incompetent at the fourth dimension of an upshot event, care was less likely to be consistent with previous wishes than if the patient was competent (P = 0.014) (Tabular array v). Finally, care in the hospital was more consistent with patients' previous wishes than care received in the nursing home (P = 0.00003) (Tabular array five).
Table half dozen.
Tabular array half-dozen. Adapted Pct of Instances of Care Inconsistent with Advance Directives.* The results of the logistic regression analysis are summarized in Table 6. A backward emptying of the potential confounders found only marital status to be associated with the consequence, also as with the four main effects of interest. Therefore, the concluding model included the presence of the accelerate directive in the tape, the origin of the directive, the patient'south competence at the time of the outcome consequence, the location of the event, and marital condition.
The risk of receiving a treatment at the time of an event that was inconsistent with the advance directive is given for the four chief effects (Table 6). If the accelerate directive was present in the chart at the time of an event, treatment was inconsistent well-nigh 2.3 times more often than when the directive was absent. When the accelerate directive originated with the patient rather than the family, the treatment for an consequence was about 3.2 times as probable to exist inconsistent. Patients who were incompetent at the time of an result were about four times as likely to receive treatment inconsistent with their directives. Finally, subjects treated at the nursing home at the time of an event rather than in the infirmary were almost 4 times every bit likely to receive a handling that was inconsistent with their accelerate directives. But this last difference reached statistical significance.
Word
The results of this study indicate that the treatments that patients received during outcome events were consistent with their previously expressed wishes most of the fourth dimension. The presence of the written advance directive in the medical record did not facilitate this consistency, however. Inconsistent intendance occurred more often in the nursing abode, when patients were incompetent, and when the advance directive was available.
The study was designed to maximize the possibility of examining the effectiveness of advance directives. A nursing home setting was used because the patient population was considered likely to experience a large number of observable life-threatening events during the study period. The advance directives were placed directly in the patients' charts at the nursing home to minimize difficulty with access to the document. Once an advance directive was placed in the chart, information technology was not interfered with by the investigators. Thus, the effect of nursing habitation routine and emergency events on the disposition of the directive could be determined. As other authors have suggested, the directives included both specific and general statements most treatment preferences so that the preferences of patients could be interpreted as clearly every bit possible.11
The generalizability of the study may be limited by the fact that it was conducted in a unmarried nursing domicile and almost exclusively in a single astute care hospital. The institutional setting, at least in the nursing dwelling house, would tend to brand the advance directive more readily available than a noninstitutional setting, whereas compliance with the document might have varied had the written report been conducted in several settings.
Why were the advance directives not followed in all cases? Although they may not accept been followed in some cases because they were non available at the fourth dimension of the outcome event, a review of the medical records and interviews with physicians suggest that in many cases in that location were other compelling reasons. In four cases, the initial preference expressed may have been too restrictive to let care that was strongly believed to be appropriate at the time of the upshot consequence, equally in the cases in which surgery or brief bogus ventilation afforded the patient substantial do good. In four other cases the handling chosen in the directive was not administered because it was not likely to afford benefit. In two cases the patients changed their minds, and in 1 the family changed its mind. 3 families fabricated choices at the time of an effect outcome that contradicted the patients' previously expressed wishes. Finally, in 2 cases the advance directives were not followed because providers were unaware of them.
The logistic regression analysis pointed out that the presence of the written directive in the medical tape did not increase the consistency between stated wishes and subsequent care. It should be noted that in that location was a loftier rate of consistency betwixt preferences and actual care for all study patients. The failure to amend consistency cannot be explained by this high rate, however, since at that place was actually a trend toward less consequent care when the directive was present. I might speculate that the high rate of consistency overall was achieved because the interview procedure itself, in which all study participants engaged, facilitated forethought and advice among patients, families, and care givers. This possibility is supported past the nurses' comments to the effect that the interviews often stimulated patients and families to discuss their treatment preferences with the staff.
The analysis pointed out further that the occurrence of an outcome event in the nursing dwelling rather than the hospital was an independent predictor of inconsistency between the accelerate directive and subsequent care. One might speculate that the arroyo to medical care in a long-term care facility is naturally less aggressive than it is in an acute care hospital, and well-nigh of the inconsistencies were in the direction of undertreatment. Physicians may decide non to use life-sustaining treatment in the nursing dwelling house and may feel less pressure to do then, despite patients' wishes, because of the pocket-size likelihood of benefit from such treatments, particularly cardiopulmonary resuscitation, in this setting.12 In addition, it may exist much more than difficult, even with some effort, to maintain a vigilant concern for autonomy when caring for a population of patients who are often unable to exercise choice.
These report findings imply that at that place are limits to the ability of written accelerate directives to enhance the autonomy of incapacitated patients. To improve the effectiveness of such directives, they must be applicable and accessible, and they must be carefully heeded. To make them more applicative, patients might exist brash to be cautious about refusing time to come treatments, such equally surgery or ventilatory support, for treatable weather condition and to anticipate that there volition come up a time when cardiopulmonary resuscitation will not prevent decease. For advance directives to be heeded adequately, all personnel in a variety of institutional settings must exist alerted to them and be concerned nearly their proper transfer, particularly in emergencies. If a written document alone is ineffective, mayhap discussions of treatment preferences during conferences on patient care would increase its effectiveness.
Beyond this, the results suggest that regardless of how specific and accessible they are, written directives cannot be expected to anticipate all situations or all changes in attitude. These findings imply that the durable power of attorney should be given much more serious consideration as a mechanism for facilitating the autonomy of incapacitated patients.
Finally, some of the intendance decisions that were inconsistent with advance directives appeared to be based on principles of beneficence and proportionality. Thus, the data suggest that in caring for incapacitated patients, physicians balance respect for autonomy with other competing ethical principles in guild to make what they believe are the wisest decisions. This raises the possibility that advance directives may on rare occasions pose an upstanding and legal dilemma, because strict adherence to them precludes the opportunity to residue autonomy against other valuable ethical principles.
It should non be inferred from this discussion that the effort to maintain autonomy through the use of advance directives is futile or valueless. Rather, the utilise of such directives is in its infancy, and we demand to ascertain and grapple with their limitations before we can employ them optimally.
Appendix: Sample Statement of Patient's Preferences
To my Physician:
While I have been at—, I accept discussed my wishes concerning my medical treatment in the upshot that I get extremely ill. I did this in the hope that if I fabricated my wishes known beforehand, it would be easier for my doctors to know my preferences at a time when I am unable to limited them.
If I become critically sick:
I want to be hospitalized.
I want to go into intensive intendance.
I want to accept my heart revived if my center stops.
I want to have surgery.
I want to be put on a breathing machine.
If I become terminally sick:
I desire to be hospitalized.
I want my family members to determine whether I shall go into intensive care afterwards they talk with my doctor.
I want my physician to decide whether to revive me if my center stops.
I desire my family members to determine whether I shall have surgery after they talk with my doc.
I desire my family members to make up one's mind whether I shall be put on a breathing machine after they talk with my doctor.
If I am in an irreversible blackout:
I want to be hospitalized.
I want my family members to decide whether I shall go into intensive care after they talk with my physician.
I want my dr. to decide whether to revive me if my heart stops.
I want my family unit members to determine whether I shall have surgery after they talk with my doctor.
I exercise not want to be put on a animate machine.
I want my family unit members to make up one's mind whether I shall be fed through a tube after they talk with my dr..
If I am unable to make decisions for myself, I would like the post-obit person to make necessary decisions on my behalf:
1. name (human relationship) address
phone: (home) (work)
If y'all cannot accomplish— — — — —, I would similar the following person to brand the necessary decisions on my behalf:
2. name (relationship) address
phone: (dwelling) (piece of work)
There will be a fourth dimension when I desire my doctor to stop keeping me alive.
I take provided this information in the hope that information technology will be easier to respect my wishes about my medical intendance at a time when I am unable to express them.
Patient — — — — —name (printed) (signature) (date)
Witness — — — — — name (printed) (signature) (date)
References (12)
-
ane. Jonsen A, Siegler M, Winslade WJ. Clinical ideals: a practical approach to ethical decisions in clinical medicine. New York: Macmillan, 1982.
-
2. President'due south Commission for the Written report of Ethical Issues in Medicine and Biomedical and Behavioral Research. Making health care decisions. Washington, D.C.: Regime Press Office, 1982. (SUDOC no. 1982 0–383–515/8673.)
-
3. Idem. Deciding to forego life-sustaining treatment: a written report on the ethical, medical, and legal issues in handling decisions. Washington, D.C.: Authorities Printing Role, 1983.
-
4. Kutner L. . Due process of euthanasia: the living will, a proposal . Indiana Police J 1969; 44:537–54.
-
5. Bok S. . Personal directions for care at the terminate of life . Northward Engl J Med 1976; 295:367–9.
-
6. Hackler C, Moseley R, Vawter DE, eds. Advance directives in medicine: studies in wellness and homo value. New York: Praeger, 1989.
-
seven. The Hastings Eye. Guidelines on the termination of life-sustaining treatment and the care of the dying. Bloomington: Indiana Academy Press, 1987.
-
viii. Legal Advisors Committee, Concern for Dying. . The right to turn down handling: a model act . Am J Public Health 1983; 73:918–21.
-
9. Eisendrath SJ, Jonsen AR. . The living will: aid or hindrance? JAMA 1983; 249:2054–viii.
-
10. Redleaf DL, Schmitt SB, Thompson WC. . The California natural death act: an empirical study of physicians practices . Stanford Law Rev 1979; 31:913–45.
-
eleven. Emanuel LL, Emanuel EJ. . The Medical Directive: a new comprehensive advance care document . JAMA 1989; 261:3288–93.
-
12. Murphy DJ, Murray AM, Robinson BE, Campion EW. . Outcomes of cardiopulmonary resuscitation in the elderly . Ann Intern Med 1989; 111:199–205.
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