title: Advance directives in skilled nursing facility residents transferred to emergency departments.
abstract: OBJECTIVE
  Ten years have passed since Congress enacted the Patient Self-Determination Act to promote the use of advance directives (ADs). This study was performed to determine the frequency, type, demographic distribution, and utility of ADs that accompany residents of skilled nursing facilities (SNFs) transferred to emergency departments (EDs).
  
  
  METHODS
  This was an observational, cross-sectional cohort of SNF residents, transferred to two urban, academic EDs. Chart review and physician interviews were conducted on consecutive 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 among 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 ADs, do-not-resuscitate (DNR) orders were the most prevalent (65%, 95% CI = 58% to 69%). Although 75% (95% CI = 69% to 81%) of the DNR orders addressed cardiopulmonary resuscitation (CPR), only 12% (95% CI = 8% to 16%) addressed intubation. Among 39 patients who required intubation or CPR, 44% had ADs, 82% (95% CI = 57% to 96%) of which were deemed useful.
  
  
  CONCLUSIONS
  Despite a decade of legislation promoting their use, ADs are lacking in most SNF residents transferred to EDs for evaluation and in most settings in which a clinical indication exists for intubation or CPR. Variation in their prevalence appears to be associated with both ethnicity and SNF origin. Although about three-fourths of DNR ADs addressed CPR, only about one in ten offered guidance regarding intubation. When available, ADs are used in most instances to guide emergency care.
authors.affiliation: Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
authors.forename: M
authors.initials: M
authors.lastname: Lahn
authors.forename: B
authors.initials: B
authors.lastname: Friedman
authors.forename: P
authors.initials: P
authors.lastname: Bijur
authors.forename: M
authors.initials: M
authors.lastname: Haughey
authors.forename: E J
authors.initials: EJ
authors.lastname: Gallagher
mesh_terms: D016223:Advance Directives / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003142:Communication; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D006707:Homes for the Aged / Q000458:organization & administration*; D006801:Humans; D007373:Interinstitutional Relations; D008297:Male; D008875:Middle Aged; D009735:Nursing Homes / Q000458:organization & administration*; D010360:Patient Transfer / Q000458:organization & administration*; D014481:United States