Advance directives in skilled nursing facility residents transferred to emergency departments

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Abstract

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.

Original languageEnglish (US)
Pages (from-to)1158-1162
Number of pages5
JournalAcademic Emergency Medicine
Volume8
Issue number12
StatePublished - 2001

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Skilled Nursing Facilities
Advance Directives
Hospital Emergency Service
Cardiopulmonary Resuscitation
Intubation
Confidence Intervals
Resuscitation Orders
Patient Self-Determination Act
Emergency Medical Services
Legislation
Hispanic Americans
African Americans
Demography
Interviews
Physicians

Keywords

  • Advance directives
  • Cardiopulmonary resuscitation
  • Emergency treatment
  • Living wills
  • Nursing homes
  • Resuscitation orders

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

@article{e25831e6610a4134b11fc950d8e4d995,
title = "Advance directives in skilled nursing facility residents transferred to emergency departments",
abstract = "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.",
keywords = "Advance directives, Cardiopulmonary resuscitation, Emergency treatment, Living wills, Nursing homes, Resuscitation orders",
author = "M. Lahn and Friedman, {Benjamin W.} and Bijur, {Polly E.} and M. Haughey and Gallagher, {E. John}",
year = "2001",
language = "English (US)",
volume = "8",
pages = "1158--1162",
journal = "Academic Emergency Medicine",
issn = "1069-6563",
publisher = "Wiley-Blackwell",
number = "12",

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TY - JOUR

T1 - Advance directives in skilled nursing facility residents transferred to emergency departments

AU - Lahn, M.

AU - Friedman, Benjamin W.

AU - Bijur, Polly E.

AU - Haughey, M.

AU - Gallagher, E. John

PY - 2001

Y1 - 2001

N2 - 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.

AB - 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.

KW - Advance directives

KW - Cardiopulmonary resuscitation

KW - Emergency treatment

KW - Living wills

KW - Nursing homes

KW - Resuscitation orders

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