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Advance directives lessen the decisional burden of surrogate decision-making for the chronically critically ill

Authors

  • Ronald L Hickman Jr PhD, RN, ACNP-BC,

    Assistant Professor, Acute Care Nurse Practitoner, Corresponding author
    1. Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
    2. Department of Anesthesiology and Perioperative Medicine, University Hospitals Case Medical Center, Cleveland, OH, USA
    • Correspondence: Ronald L Hickman Jr, Assistant Professor, Case Western Reserve University, School of Nursing, 2120 Cornell Road, Cleveland, OH 44106-4904, USA. Telephone: +1 216 368 2147.

      E-mail: rlh4@case.edu

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  • Melissa D Pinto PhD, RN

    Assistant Professor
    1. School of Nursing, Emory University, Atlanta, GA, USA
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Abstract

Aims and objectives

To identify the relationships between advance directive status, demographic characteristics and decisional burden (role stress and depressive symptoms) of surrogate decision-makers (SDMs) of patients with chronic critical illness.

Background

Although the prevalence of advance directives among Americans has increased, SDMs are ultimately responsible for complex medical decisions of the chronically critically ill patient. Decisional burden has lasting psychological effects on SDMs. There is insufficient evidence on the influence of advance directives on the decisional burden of surrogate decision-makers of patients with chronic critical illness.

Design

The study was a secondary data analysis of cross-sectional data. Data were obtained from 489 surrogate decision-makers of chronically critically ill patients at two academic medical centres in Northeast Ohio, United States, between September 2005–May 2008.

Methods

Data were collected using demographic forms and questionnaires. A single-item measure of role stress and the Center for Epidemiological Studies Depression (CESD) scale were used to capture the SDM's decisional burden. Descriptive statistics, t-tests, chi-square and path analyses were performed.

Results

Surrogate decision-makers who were nonwhite, with low socioeconomic status and low education level were less likely to have advance directive documentation for their chronically critically ill patient. The presence of an advance directive mitigates the decisional burden by directly reducing the SDM's role stress and indirectly lessening the severity of depressive symptoms.

Conclusions

Most SDMs of chronically critically ill patients will not have the benefit of knowing the patient's preferences for life-sustaining therapies and consequently be at risk of increased decisional burden.

Relevance to clinical practice

Study results are clinically useful for patient education on the influence of advance directives. Patients may be informed that SDMs without advance directives are at risk of increased decisional burden and will require decisional support to facilitate patient-centred decision-making.

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