 |
 |
 |
|
|
|
|
|
 |
 Advance Directives: The Emerging Body of Research Barbara B. Ott, RN, PhD, CCRN American Journal of Critical Care January 1999 - Volume 8 - Number 1wew www.aacn.org According to published information, about 2% to 15% of the adults in the United States have an advance directive document, compared with about 57% of primary care patients who have an estate will. In a study of terminal cancer patients, only 55.7% had completed advance directives. Notably, Brunetti et al found that few healthcare providers had completed advance directives. In a study of 200 outpatients, 92% had heard of advance directives primarily through the popular press. Eighteen percent of the outpatients had already completed an advance directive, and only 5% had received information about advance directives from their physicians, even though 65% said they would like to have received this information from their physician. Eighty-seven percent of these outpatients stated that they would not be offended if, on admission to the hospital, they were asked whether they had completed a living will, and 88% viewed such a policy as showing evidence of positive concern by the hospital on their behalf. Interestingly, of the subjects in this study who had completed an advance directive, 50% had placed the only copy in a safety deposit box, where it is inaccessible to healthcare providers. Patients do not seem to mind discussing issues related to their terminal care. In one investigation, 94% of the subjects said that they would be comfortable discussing advance directives with their attending physician, and 78% said they would be comfortable discussing advance directives with a nurse; 61% reported that they would be uncomfortable discussing advance directives with admitting clerks. Other results suggest that the largest barriers to the discussion of advance directives are (1) physicians' erroneous beliefs that advance directives are unnecessary for young, healthy patients and (2) physicians' lack of knowledge about how to formulate advance directives. The demographic characteristics of the samples examined indicated that persons with higher levels of education and higher socioeconomic status are more likely to have completed an advance directive. Hispanics are significantly less likely to have completed an advance directive or a durable power of attorney. Patients who are black, have lower levels of education, are underinsured, or are cognitively impaired are least likely to have living wills. only about 10% of healthy adults complete an advance directive after counseling strategies are used. In one investigation, the completion rate after the primary care provider (either a nurse or a physician) discussed advance directives with the patient was 45%. Patients' Understanding of Advance Directives Patients have been evaluated for their understanding of advance directives. In one study 11 of 96 patients, 77% of patients had heard of a living will, and 25% had heard of a durable power of attorney. Also, a correct definition of the purpose of a living will was given by 52% of the subjects, whereas only 24% correctly defined a durable power of attorney for healthcare. In another study, statistically significant differences between ethnic groups were found. Hispanics were less likely than non-Hispanics to correctly define a living will and a durable power of attorney. Much more study is needed in this area. Treatment Choices Ethnicity and age influence treatment decisions. In one study, Hispanics were statistically more likely than non-Hispanics to choose life-sustaining measures. The probability of surviving a treatment influences choices and stability of choices. Elderly patients opted for CPR 41% of the time before learning the probability of survival to discharge. Elderly patients have a 39% chance of survival to discharge after CPR is performed in the hospital, and ill elderly patients have a 5% to 17% chance of survival to discharge. The wording of the descriptions of life-sustaining interventions affects the advance directive choices of elderly patients. In one study, elderly subjects opted for the intervention 12% of the time when it was presented negatively, 18% of the time when it was phrased as in an advance directive already in use, and 30% of the time when it was phrased positively. Chambers et al found that the mean hospital charges for patients with documentation of advance directives were 68% less than those of patients without advance directives. Additionally, within each set of patients with a common admitting diagnosis, mean inpatient charges were lower for the group with documentation of advance directives. For example, the mean charge for patients with malignant neoplasms who had advance directives was $22,396, whereas the mean charge for such patients without an advance directive was $76,096. Patients with cardiopulmonary diseases with advance directives had a mean charge of $28,856, whereas such patients without advance directives had a mean charge of $85,648.  |
|
 |
