title: Advance directives in an intensive care unit: experiences and recommendations of critical care nurses and physicians.
abstract: OBJECTIVE
  This study explored the experiences of critical care nurses and physicians with advance directives (ADs) in an intensive care unit (ICU) to identify the benefits and limitations of ADs and recommendations for improvement.
  This descriptive study, obtained by ethnographic means, was implemented in a 22-bed adult medical-surgical ICU in a large community hospital in the Midwestern United States. Subjects included 14 critical care nurses, 7 attending, and 3 fellow critical care physicians. Subjects were interviewed informally and formally. Patient medical records were reviewed for ADs.
  
  
  CONCLUSIONS
  Results supported numerous problems with ADs described previously and identified additional problems, including inability of ADs to prevent unwanted aggressive treatments outside of health care facilities, and patient reluctance to share ADs for fear of physicians "throwing in the towel" too early. Although most subjects described ADs as "useless," one helpful aspect was using ADs to shift perceptions of responsibility for end-of-life decision making and outcomes from the family/providers to the patient by reframing "pulling the plug" to "honoring patient wishes." Recommendations are described, including evolving the current emphasis of increasing completion of ADs to encourage patient-family discussions focused on quality of life to increase the likelihood of discussions occurring.
authors.affiliation: Department of Nursing and Health Sciences, Metropolitan State University, St Paul, Minnesota 55331, USA. karen.gutierrez@mchsi.com
authors.forename: Karen M
authors.initials: KM
authors.lastname: Gutierrez
mesh_terms: D000328:Adult; D016223:Advance Directives; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D003422:Critical Care / Q000458:organization & administration; D003657:Decision Making; D005260:Female; D006764:Hospitals, Community; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D008297:Male; D008875:Middle Aged; D020380:Needs Assessment; D024802:Nurse's Role; D010348:Patient Care Team / Q000458:organization & administration*; D010819:Physician's Role; D017410:Practice Guidelines as Topic; D013727:Terminal Care / Q000592:standards* / Q000639:trends; D014481:United States; D055815:Young Adult