• advanced directives;
  • end-of-life care;
  • health status

Aims and objectives.  To examine the use of advanced directives (ADs) in patients actively using health services in the USA.

Background.  Since 1991, USA law (PSDA 1991) has required hospitals, skilled nursing facilities (SNFs) and home health services to inquire, at admission, if patients have in place ADs, to provide patients with a written summary of their rights in regard to health-related decision-making and to provide education to staff and the community about ADs.

Design.  Via chart review and observation, the AD status of patients residing in three SNFs during a six-week period was ascertained (n = 272). Those with ADs were further evaluated to examine the timing of the directive in regards to their health status.

Methods.  Patients residing at SNFs were selected for study because SNF patients are admitted from the hospital; therefore, there are at least two opportunities – at hospital admission and at SNF admission – to inquire and educate about advance directives.

Results.  Residents ranged in age from 35 to 100 years and included patients admitted for short-term rehabilitation after hospitalisation, as well as residents who were initially admitted after a hospitalisation but required long-term care. A full 90·44% (n = 246) entered skilled care without an AD, and 69·11% (n = 188) remained without an AD. The most likely reason for the development of an AD was lengthy decline in health status associated with multiple hospitalisations.

Conclusions.  Current law appears ineffective. A more appropriate approach is to encourage open dialogue about treatment options and quality of life.

Relevance to clinical practice.  Given the rapidity with which populations are ageing in countries worldwide, ADs would appear to be a phenomenon that should be embraced. However, experience in the USA has called into question their usefulness.