Advance directives in the medical intensive care unit of a community teaching hospital.
OBJECTIVE
To evaluate the frequency with which advance directives (ADs) are available at the time of admission and their impact on subsequent care in a medical intensive care unit (MICU) setting before and 9 months after the implementation of the Patient Self-Determination Act (PSDA).


METHODS
Prospective nonrandomized cohort data collection and analysis.


METHODS
Thirteen-bed MICU of community teaching hospital providing primary and referred care.


METHODS
Consecutive admissions during 2-month periods separated by 1 year: August-September 1991 (91) and August-September 1992 (92).


METHODS
The following were assessed: the presence and type or absence of AD at the time of admission; the presence or absence of a written order to limit resuscitation (WO-R) during the MICU stay; duration of MICU stay in hours; outcome; and combined duration of use or administration of seven selected interventions.


RESULTS
Fifteen of 133 patients (11.3%) in the 91 group and 15 of 171 patients (8.8%) in the 92 group presented with an AD. This difference was not significant (p = 0.578). Most patients in both groups (75.9% in 91 and 80.1% in 92) presented without an AD and did not have a WO-R during their MICU course. In addition, most patients who did present with an AD, 11 of 15 (73.3%) in the 91 group and 14 of 15 (93.3%) in the 92 group, did not have a WO-R. A subgroup of older and more severely ill patients in both cohorts was identified; they did not present with an AD but subsequently a WO-R was established. These patients had the highest mortality, about 40%, when compared with the overall mortality of 8.2%.


CONCLUSIONS
Advanced directives were infrequently available and had little impact on the pattern of care.
Johnson
R F
RF
Medical Intensive Care Unit, Blodgett Memorial Medical Center, Grand Rapids, MI.
Baranowski-Birkmeier
T
T
O'Donnell
J B
JB
D016223:Advance Directives / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D003657:Decision Making; D035082:Federal Government; D033161:Government Regulation; D006745:Hospital Bed Capacity, 300 to 499; D006764:Hospitals, Community / Q000331:legislation & jurisprudence / Q000592:standards; D006784:Hospitals, Teaching / Q000331:legislation & jurisprudence / Q000592:standards; D006801:Humans; D007362:Intensive Care Units / Q000331:legislation & jurisprudence / Q000592:standards* / Q000706:statistics & numerical data; D008824:Michigan; D011446:Prospective Studies