Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments
Article first published online: 28 JUN 2008
Academic Emergency Medicine
Volume 8, Issue 12, pages 1158–1162, December 2001
How to Cite
Lahn, M., Friedman, B., Bijur, P., Haughey, M. and Gallagher, E. J. (2001), Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments. Academic Emergency Medicine, 8: 1158–1162. doi: 10.1111/j.1553-2712.2001.tb01133.x
- Issue published online: 28 JUN 2008
- Article first published online: 28 JUN 2008
- Received April 3, 2001; revision received August 2, 2001; accepted August 14, 2001
- advance directives;
- nursing homes;
- resuscitation orders;
- living wills;
- emergency treatment;
- cardiopulmonary resuscitation
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.