120 Advance Directives: Applications to Clinical Scenarios

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Study Objective

To assess emergency department (ED) patients’ perspectives regarding advance directives and their application to various clinical scenarios.

Advance directives provide patients with a means to communicate end of life preferences if they are unable to communicate their own wishes. Examples of advance directives include do not resuscitate (DNR) orders, living will, durable power of attorney for health care and physician orders for life-sustaining treatment (POLST). These orders are commonly applied in the setting of severe disease or terminal conditions. However, the application of advance directives to unanticipated clinical scenarios is not well understood.


In this prospective survey study, eligible participants included any ED patient age 18 years or older. Participants received written education regarding advance directives and state law regarding advance directives. Participants were asked to assess their personal opinions regarding whether an advance directive would apply to 14 hypothetical clinical scenarios.


The survey was completed by 271 patients (mean age 50.3 + 18.5 years, age range 18-90+). Participants were 56% female (n=151), and 66% Caucasian (n=176). Only 21 patients (7.8%) currently had a DNR order in place for themselves. The clinical scenario for which the greatest proportion of patients thought a DNR should apply was a severe car accident with critical injuries (N =123/271; 45.6%), followed by surgery for aortic aneurysm rupture (N =121/271; 44.8%), cancer causing a collapsed lung (N =119/271; 44.1%) and suicide attempt (N = 111/271; 41.3%). Of note, only 36.5% of patients (N=99) believed that a pre-existing DNR order should apply in the case of cardiac arrest.


These results demonstrate wide variability in patient opinion and insight regarding the clinical application of advance directives. The majority of participants had little understanding of the advanced directive concept or end-of-life decisionmaking. These results underscore the importance of recognizing the complexity of end-of-life care decisions and individual communication with patients regarding personal preferences for end-of-life care.



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