BACKGROUND: The use of advance directives is recommended so that people can determine the medical care they will receive when they are no longer competent, but the effectiveness of such directives is not clear. METHODS: In a prospective study conducted over a two-year period, 126 competent residents of a nursing home and 49 family members of incompetent patients were interviewed to determine their preferences with respect to hospitalization, intensive care, cardiopulmonary resuscitation, artificial ventilation, surgery, and tube feeding in the event of critical illness, terminal illness, or permanent unconsciousness. Advance directives, consisting of signed statements of treatment preferences, were placed in the medical record to assist in care in the nursing home and to be forwarded to the hospital if necessary. RESULTS: In an analysis of 96 outcome events (hospitalization or death in the nursing home), care was consistent with previously expressed wishes 75 percent of the time; however, the presence of the written advance directive in the medical record did not facilitate consistency. Among the 24 events in which inconsistencies occurred, care was provided more aggressively than had been requested in 6 cases, largely because of unanticipated surgery or artificial ventilation, and less aggressively than requested in 18, largely because hospitalization or cardiopulmonary resuscitation was withheld. Inconsistencies were more likely in the nursing home than in the hospital. CONCLUSIONS. The effectiveness of written advance directives is limited by inattention to them and by decisions to place priority on considerations other than the patient's autonomy. Since our study was performed in only one nursing home and one hospital, other studies are necessary to determine the generalizability of our findings.
Source Information
Department of Medicine, University of North Carolina, Chapel Hill 27599-7110.
This article has been cited by other articles:
Pautex, S, Herrmann, F., Zulian, G.
(2008). Role of advance directives in palliative care units: a prospective study. Palliat Med
22: 835-841
[Abstract]
Curtis, J. R.
(2008). Palliative and end-of-life care for patients with severe COPD. Eur Respir J
32: 796-803
[Abstract][Full Text]
Walling, A., Lorenz, K. A., Dy, S. M., Naeim, A., Sanati, H., Asch, S. M., Wenger, N. S.
(2008). Evidence-Based Recommendations for Information and Care Planning in Cancer Care. JCO
26: 3896-3902
[Abstract][Full Text]
Berger, J. T., DeRenzo, E. G., Schwartz, J.
(2008). Surrogate Decision Making: Reconciling Ethical Theory and Clinical Practice. ANN INTERN MED
149: 48-53
[Abstract][Full Text]
Alderman, J. S., Nair, B., Fox, M. D.
(2008). Residency Training in Advance Care Planning: Can It Be Done in the Outpatient Clinic?. AM J HOSP PALLIAT CARE
25: 190-194
[Abstract]
Wilson, J
(2008). To what extent should older patients be included in decisions regarding their resuscitation status?. J. Med. Ethics
34: 353-356
[Abstract][Full Text]
Lanken, P. N., Terry, P. B., DeLisser, H. M., Fahy, B. F., Hansen-Flaschen, J., Heffner, J. E., Levy, M., Mularski, R. A., Osborne, M. L., Prendergast, T. J., Rocker, G., Sibbald, W. J., Wilfond, B., Yankaskas, J. R., on behalf of the ATS End-of-Life Care Task Force,
(2008). An Official American Thoracic Society Clinical Policy Statement: Palliative Care for Patients with Respiratory Diseases and Critical Illnesses. Am. J. Respir. Crit. Care Med.
177: 912-927
[Full Text]
Shanawani, H., Wenrich, M. D., Tonelli, M. R., Curtis, J. R.
(2008). Meeting Physicians' Responsibilities in Providing End-of-Life Care. Chest
133: 775-786
[Abstract][Full Text]
Cohen-Mansfield, J., Lipson, S.
(2008). Which Advance Directive Matters? An Analysis of End-of-Life Decisions Made in Nursing Homes. Research on Aging
30: 74-92
[Abstract]
Collins, L. G., Parks, S. M., Winter, L.
(2006). The State of Advance Care Planning: One Decade After SUPPORT. AM J HOSP PALLIAT CARE
23: 378-384
[Abstract]
Swanson, J. W., McCrary, S. V., Swartz, M. S., Elbogen, E. B., Van Dorn, R. A.
(2006). Superseding Psychiatric Advance Directives: Ethical and Legal Considerations. J Am Acad Psychiatry Law
34: 385-394
[Abstract][Full Text]
Heyland, D. K., Frank, C., Groll, D., Pichora, D., Dodek, P., Rocker, G., Gafni, A., for the Canadian Researchers at the End of Life Ne,
(2006). Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and family members.. Chest
130: 419-428
[Abstract][Full Text]
McAuley, W. J., Buchanan, R. J., Travis, S. S., Wang, S., Kim, M.
(2006). Recent Trends in Advance Directives at Nursing Home Admission and One Year After Admission.. Gerontologist
46: 377-381
[Abstract][Full Text]
Schiff, R., Sacares, P., Snook, J., Rajkumar, C., Bulpitt, C. J.
(2006). Living wills and the Mental Capacity Act: a postal questionnaire survey of UK geriatricians. Age Ageing
35: 116-121
[Abstract][Full Text]
(2005). Part 2: Ethical Issues. Circulation
112: IV-6-IV-11
[Full Text]
Temkin-Greener, H., Gross, D. L., Mukamel, D. B.
(2005). Advance Care Planning in a Frail Older Population: Patient Versus Program Influences. Research on Aging
27: 659-691
[Abstract]
McMahon, M. M., Hurley, D. L., Kamath, P. S., Mueller, P. S.
(2005). Medical and Ethical Aspects of Long-term Enteral Tube Feeding. Mayo Clin Proc.
80: 1461-1476
[Abstract]
Stapleton, R. D., Wang, B. M., Hudson, L. D., Rubenfeld, G. D., Caldwell, E. S., Steinberg, K. P.
(2005). Causes and Timing of Death in Patients With ARDS. Chest
128: 525-532
[Abstract][Full Text]
Tulsky, J. A.
(2005). Beyond Advance Directives: Importance of Communication Skills at the End of Life. JAMA
294: 359-365
[Abstract][Full Text]
Hampson, L. A., Emanuel, E. J.
(2005). The Prognosis For Changes In End-Of-Life Care After The Schiavo Case. Health Aff (Millwood)
24: 972-975
[Abstract][Full Text]
Rose, J. H., O'Toole, E. E., Dawson, N. V., Lawrence, R., Gurley, D., Thomas, C., Hamel, M. B., Cohen, H. J.
(2004). Perspectives, Preferences, Care Practices, and Outcomes Among Older and Middle-Aged Patients With Late-Stage Cancer. JCO
22: 4907-4917
[Abstract][Full Text]
Hilden, H-M, Louhiala, P, Palo, J
(2004). End of life decisions: attitudes of Finnish physicians. J. Med. Ethics
30: 362-365
[Abstract][Full Text]
Hirschman, K. B., Xie, S. X., Feudtner, C., Karlawish, J. H. T.
(2004). How Does an Alzheimer's Disease Patient's Role in Medical Decision Making Change Over Time?. J Geriatr Psychiatry Neurol
17: 55-60
[Abstract]
Dobalian, A.
(2004). Nursing Facility Compliance With Do-Not-Hospitalize Orders. Gerontologist
44: 159-165
[Abstract][Full Text]
Mueller, P. S., Hook, C. C., Fleming, K. C.
(2004). Ethical Issues in Geriatrics: A Guide for Clinicians. Mayo Clin Proc.
79: 554-562
[Abstract]
Hilden, H.-M., Louhiala, P., Honkasalo, M.-L., Palo, J.
(2004). Finnish Nurses' Views on End-of-Life Discussions and a Comparison with Physicians' Views. Nurs Ethics
11: 165-178
[Abstract]
Rabow, M. W., Hauser, J. M., Adams, J.
(2004). Supporting Family Caregivers at the End of Life: "They Don't Know What They Don't Know". JAMA
291: 483-491
[Abstract][Full Text]
Thompson, T., Barbour, R., Schwartz, L.
(2003). Adherence to advance directives in critical care decision making: vignette study. BMJ
327: 1011-
[Abstract][Full Text]
Lynn, J., Goldstein, N. E.
(2003). Advance Care Planning for Fatal Chronic Illness: Avoiding Commonplace Errors and Unwarranted Suffering. ANN INTERN MED
138: 812-818
[Abstract][Full Text]
Pfeifer, M. P., Mitchell, C. K., Chamberlain, L.
(2003). The Value of Disease Severity in Predicting Patient Readiness to Address End-of-Life Issues. Arch Intern Med
163: 609-612
[Abstract][Full Text]
Prendergast, T. J., Puntillo, K. A.
(2002). Withdrawal of Life Support: Intensive Caring at the End of Life. JAMA
288: 2732-2740
[Abstract][Full Text]
Upadya, A., Muralidharan, V., Thorevska, N., Amoateng-Adjepong, Y., Manthous, C. A.
(2002). Patient, Physician, and Family Member Understanding of Living Wills. Am. J. Respir. Crit. Care Med.
166: 1430-1435
[Abstract][Full Text]
Cherniack, E P
(2002). Increasing use of DNR orders in the elderly worldwide: whose choice is it?. J. Med. Ethics
28: 303-307
[Abstract][Full Text]
Curtis, J. R., Wenrich, M. D., Carline, J. D., Shannon, S. E., Ambrozy, D. M., Ramsey, P. G.
(2002). Patients' Perspectives on Physician Skill in End-of-Life Care* : Differences Between Patients With COPD, Cancer, and AIDS. Chest
122: 356-362
[Abstract][Full Text]
Larson, J. S., Larson, K. K.
(2002). Evaluating End-of-Life Care from the Perspective of the Patient's Family. Eval Health Prof
25: 143-151
[Abstract]
Hinkka, H, Kosunen, E, Metsanoja, R, Lammi, U-K, Kellokumpu-Lehtinen, P
(2002). Factors affecting physicians' decisions to forgo life-sustaining treatments in terminal care. J. Med. Ethics
28: 109-114
[Abstract][Full Text]
Houts, R. M., Smucker, W. D., Jacobson, J. A., Ditto, P. H., Danks, J. H.
(2002). Predicting Elderly Outpatients' Life-Sustaining Treatment Preferences over Time: The Majority Rules. Med Decis Making
22: 39-52
[Abstract]
Wenger, N. S., Rosenfeld, K.
(2001). Quality Indicators for End-of-Life Care in Vulnerable Elders. ANN INTERN MED
135: 677-685
[Full Text]
Ditto, P. H., Danks, J. H., Smucker, W. D., Bookwala, J., Coppola, K. M., Dresser, R., Fagerlin, A., Gready, R. M., Houts, R. M., Lockhart, L. K., Zyzanski, S.
(2001). Advance Directives as Acts of Communication: A Randomized Controlled Trial. Arch Intern Med
161: 421-430
[Abstract][Full Text]
Coppola, K. M., Ditto, P. H., Danks, J. H., Smucker, W. D.
(2001). Accuracy of Primary Care and Hospital-Based Physicians' Predictions of Elderly Outpatients' Treatment Preferences With and Without Advance Directives. Arch Intern Med
161: 431-440
[Abstract][Full Text]
Smucker, W. D., Houts, R. M., Danks, J. H., Ditto, P. H., Fagerlin, A., Coppola, K. M.
(2000). Modal Preferences Predict Elderly Patients' Life-sustaining Treatment Choices as Well as Patients' Chosen Surrogates Do. Med Decis Making
20: 271-280
[Abstract]
Curtis, J. R., Patrick, D. L., Caldwell, E. S., Collier, A. C.
(2000). Why Don't Patients and Physicians Talk About End-of-Life Care?: Barriers to Communication for Patients With Acquired Immunodeficiency Syndrome and Their Primary Care Clinicians. Arch Intern Med
160: 1690-1696
[Abstract][Full Text]
Orentlicher, D.
(2000). Euthanasia and Law in the Netherlands. Journal of Health Politics, Policy and Law
25: 387-391
Molloy, D. W., Russo, R., Pedlar, D., Bédard, M.
(2000). Implementation of Advance Directives Among Community-Dwelling Veterans. Gerontologist
40: 213-217
[Abstract][Full Text]
Brickner, L., Drought, T., Pantilat, S. Z., Alpers, A., Wachter, R. M.
(2000). The Hospitalist's Role in Advance-Care Directives. JAMA
283: 336-337
[Full Text]
Waldron, D., O'Boyle, C. A., Kearney, M., Moriarty, M., Carney, D.
(1999). Quality-of-Life Measurement in Advanced Cancer: Assessing the Individual. JCO
17: 3603-3611
[Abstract][Full Text]
Pantilat, S. Z., Alpers, A., Wachter, R. M.
(1999). A New Doctor in the House: Ethical Issues in Hospitalist Systems. JAMA
282: 171-174
[Abstract][Full Text]
Srebnik, D. S., Fond, J. Q. L.
(1999). Advance Directives for Mental Health Treatment. Psychiatr. Serv.
50: 919-925
[Abstract][Full Text]
Hanson, L. C., Earp, J. A., Garrett, J., Menon, M., Danis, M.
(1999). Community Physicians Who Provide Terminal Care. Arch Intern Med
159: 1133-1138
[Abstract][Full Text]
Nelson, J. E., Meier, D. E.
(1999). Palliative Care in the Intensive Care Unit: Part I: Nelson JE, Meier DE Palliative care in the intensive care unit part I J Intensive Care Med 1999,14 130-139. J Intensive Care Med
14: 130-139
Perry, A. R., Rivlin, M. M., Goldstone, A. H.
(1999). Bone Marrow Transplant Patients With Life-Threatening Organ Failure: When Should Treatment Stop?. JCO
17: 298-298
[Abstract][Full Text]
Bradley, E. H., Rizzo, J. A.
(1999). Public Information and Private Search: Evaluating the Patient Self-Determination Act. Journal of Health Politics, Policy and Law
24: 239-273
[Abstract]
Murphy, D. J., Santilli, S.
(1998). Elderly Patients' Preferences for Long-term Life Support. Arch Fam Med
7: 484-488
[Abstract][Full Text]
Weeks, J. C., Cook, E. F., O'Day, S. J., Peterson, L. M., Wenger, N., Reding, D., Harrell, F. E., Kussin, P., Dawson, N. V., Connors, A. F. Jr, Lynn, J., Phillips, R. S.
(1998). Relationship Between Cancer Patients' Predictions of Prognosis and Their Treatment Preferences. JAMA
279: 1709-1714
[Abstract][Full Text]
Baldyga, A. P.
(1998). Ethical Issues in the Postoperative Intensive Care Unit. SEMIN CARDIOTHORAC VASC ANESTH
2: 90-98
[Abstract]
Curtis, J. R., Rubenfeld, G. D.
(1997). Aggressive Medical Care at the End of Life: Does Capitated Reimbursement Encourage the Right Care for the Wrong Reason?. JAMA
278: 1025-1026
[Abstract]
Zweig, S. C.
(1997). Cardiopulmonary Resuscitation and Do-Not-Resuscitate Orders in the Nursing Home. Arch Fam Med
6: 424-429
[Abstract]
Mouton, C., Teno, J. M., Mor, V., Piette, J.
(1997). Communication of Preferences for Care Among Human Immunodeficiency Virus--Infected Patients: Barriers to Informed Decisions?. Arch Fam Med
6: 342-347
[Abstract]
Wilson, I. B., Green, M. L., Goldman, L., Tsevat, J., Cook, E. F., Phillips, R. S.
(1997). Is Experience a Good Teacher?: How Interns and Attending Physicians Understand Patients' Choices for End-of-life Care. Med Decis Making
17: 217-227
[Abstract]
Faber-Langendoen, K.
(1996). A Multi-institutional Study of Care Given to Patients Dying in Hospitals: Ethical and Practice Implications. Arch Intern Med
156: 2130-2136
[Abstract]
Jacobson, J. A., Kasworm, E., Battin, M. P., Francis, L. P., Green, D., Botkin, J.
(1996). Advance Directives in Utah: Information From Death Certificates and Informants. Arch Intern Med
156: 1862-1868
[Abstract]
Meier, D. E., Fuss, B. R., O'Rourke, D., Baskin, S. A., Lewis, M., Morrison, R. S.
(1996). Marked Improvement in Recognition and Completion of Health Care Proxies: A Randomized Controlled Trial of Counseling by Hospital Patient Representatives. Arch Intern Med
156: 1227-1232
[Abstract]
Castle, N. G., Mor, V.
(1996). Hospitalization of Nursing Home Residents: A Review of the Literature, 1980-1995. Med Care Res Rev
53: 123-148
[Abstract]
Miles, S. H., Koepp, R., Weber, E. P.
(1996). Advance End-of-Life Treatment Planning. Arch Intern Med
156: 1062-1068
[Abstract]
Hanson, L. C., Rodgman, E.
(1996). The Use of Living Wills at the End of Life: A National Study. Arch Intern Med
156: 1018-1022
[Abstract]
Hanson, L. C., Danis, M., Garrett, J. M., Mutran, E.
(1996). Who Decides? Physicians' Willingness to Use Life-Sustaining Treatment. Arch Intern Med
156: 785-789
[Abstract]
Siegert, E. A., Clipp, E. C., Mulhausen, P., Kochersberger, G.
(1996). Impact of Advance Directive Videotape on Patient Comprehension and Treatment Preferences. Arch Fam Med
5: 207-212
[Abstract]
O'Brien, L. A., Grisso, J. A., Maislin, G., LaPann, K., Krotki, K. P., Greco, P. J., Siegert, E. A., Evans, L. K.
(1995). Nursing Home Residents' Preferences for Life-Sustaining Treatments. JAMA
274: 1775-1779
[Abstract]
Lo, B.
(1995). Improving Care Near the End of Life: Why Is It So Hard?. JAMA
274: 1634-1636
[Abstract]
Cugliari, A. M., Miller, T., Sobal, J.
(1995). Factors Promoting Completion of Advance Directives in the Hospital. Arch Intern Med
155: 1893-1898
[Abstract]
Morrison, R. S., Olson, E., Mertz, K. R., Meier, D. E.
(1995). The Inaccessibility of Advance Directives on Transfer From Ambulatory to Acute Care Settings. JAMA
274: 478-482
[Abstract]
Emanuel, L.
(1995). Structured Advance Planning: Is It Finally Time for Physician Action and Reimbursement?. JAMA
274: 501-503
[Abstract]
Hesse, K. A.
(1995). Terminal Care of the Very Old: Changes in the Way We Die. Arch Intern Med
155: 1513-1518
[Abstract]
Richter, K. P., Langel, S., Fawcett, S. B., Paine-Andrews, A., Biehler, L., Manning, R.
(1995). Promoting the Use of Advance Directives: An Empirical Study. Arch Fam Med
4: 609-615
[Abstract]
Pijnenborg, L., van der Maas, P. J., Kardaun, J. W. P. F., Glerum, J. J., van Delden, J. J. M., Looman, C. W. N.
(1995). Withdrawal or Withholding of Treatment at the End of Life: Results of a Nationwide Study. Arch Intern Med
155: 286-292
[Abstract]
Markson, L. J., Fanale, J., Steel, K., Kern, D., Annas, G.
(1994). Implementing Advance Directives in the Primary Care Setting. Arch Intern Med
154: 2321-2327
[Abstract]
Virmani, J., Schneiderman, L. J., Kaplan, R. M.
(1994). Relationship of Advance Directives to Physician-Patient Communication. Arch Intern Med
154: 909-913
[Abstract]
Murphy, D. J., Burrows, D., Santilli, S., Kemp, A. W., Tenner, S., Kreling, B., Teno, J.
(1994). The Influence of the Probability of Survival on Patients' Preferences Regarding Cardiopulmonary Resuscitation. NEJM
330: 545-549
[Abstract][Full Text]
Terry, M., Zweig, S.
(1994). Prevalence of Advance Directives and Do-Not-Resuscitate Orders in Community Nursing Facilities. Arch Fam Med
3: 141-145
[Abstract]
Rubin, S. M., Strull, W. M., Fialkow, M. F., Weiss, S. J., Lo, B.
(1994). Increasing the Completion of the Durable Power of Attorney for Health Care: A Randomized, Controlled Trial. JAMA
271: 209-212
[Abstract]
Jayes, R. L., Zimmerman, J. E., Wagner, D. P., Draper, E. A., Knaus, W. A., Chernow, B., Dantzker, D., Leiken, J., Parrillo, J. E., Sibbald, W. J., Vincent, J.-L.
(1993). Do-Not-Resuscitate Orders in Intensive Care Units: Current Practices and Recent Changes. JAMA
270: 2213-2217
[Abstract]
Ashby, M., Wakefield, M.
(1993). Attitudes to some aspects of death and dying, living wills and substituted health care decision-making in South Australia: public opinion survey for a parliamentary select committee. Palliat Med
7: 273-282
[Abstract]
Richardson, J. P., Keay, T. J.
(1993). Practical Problems in the Withdrawal of Nutrition and Hydration From Two Patients in a Persistent Vegetative State. Arch Fam Med
2: 981-986
[Abstract]
Haas, J. S., Weissman, J. S., Cleary, P. D., Goldberg, J., Gatsonis, C., Seage, G. R. III, Fowler, F. J. Jr, Massagli, M. P., Makadon, H. J., Epstein, A. M.
(1993). Discussion of Preferences for Life-Sustaining Care by Persons With AIDS: Predictors of Failure in Patient-Physician Communication. Arch Intern Med
153: 1241-1248
[Abstract]
Mower, W. R., Baraff, L. J.
(1993). Advance Directives: Effect of Type of Directive on Physicians' Therapeutic Decisions. Arch Intern Med
153: 375-381
[Abstract]
Schneiderman, L. J., Kronick, R., Kaplan, R. M., Anderson, J. P., Langer, R. D.
(1992). Effects of Offering Advance Directives on Medical Treatments and Costs. ANN INTERN MED
117: 599-606
[Abstract]
Schneiderman, L. J., Pearlman, R. A., Kaplan, R. M., Anderson, J. P., Rosenberg, E. M.
(1992). Relationship of General Advance Directive Instructions to Specific Life-Sustaining Treatment Preferences in Patients With Serious Illness. Arch Intern Med
152: 2114-2122
[Abstract]
Stelter, K. L., Elliott, B. A., Bruno, C. A.
(1992). Living Will Completion in Older Adults. Arch Intern Med
152: 954-959
[Abstract]
Emanuel, E. J., Emanuel, L. L.
(1992). Proxy Decision Making for Incompetent Patients: An Ethical and Empirical Analysis. JAMA
267: 2067-2071
[Abstract]
Lynn, J.
(1992). Procedures for Making Medical Decisions for Incompetent Adults. JAMA
267: 2082-2084
[Abstract]
Orentlicher, D.
(1992). The Illusion of Patient Choice in End-of-Life Decisions. JAMA
267: 2101-2104
Singer, P. A., Siegler, M.
(1992). Advancing the Cause of Advance Directives. Arch Intern Med
152: 22-24
[Abstract]
Greco, P. J., Schulman, K. A., Lavizzo-Mourey, R., Hansen-Flaschen, J.
(1991). The Patient Self-Determination Act and the Future of Advance Directives. ANN INTERN MED
115: 639-643
[Abstract]
Byock, I. R.
(1991). Tools for autonomy. AM J HOSP PALLIAT CARE
8: 6-8
Brett, A. S.
(1991). Limitations of Listing Specific Medical Interventions in Advance Directives. JAMA
266: 825-828
[Abstract]
La Puma, J., Orentlicher, D., Moss, R. J.
(1991). Advance Directives on Admission Clinical Implications and Analysis of the Patient Self-Determination Act of 1990. JAMA
266: 402-405
[Abstract]
(1991). ADVANCE CARE DIRECTIVES ARE ACCEPTED AND USEFUL. JWatch General
1991: 4-4
[Full Text]
Previous
