Advance directives and intensity of care delivered to hospitalized older adults at the end-of-life.
Marsha H Tyacke, Jill L Guttormson, Mauricio Garnier-Villarreal and 2 others
PMID 31492522WHAT IT FOUND
Having an advance directive on file did not reduce aggressive treatments like CPR or dialysis in dying older adults.
It did increase referrals to palliative care and hospice, but those referrals happened late, often just days before death.
Key findings
01Advance directives were not associated with receiving new dialysis, invasive procedures, mechanical ventilation, artificial nutrition, cardiovascular supports, ICU care, ICU length of stay, or CPR.
02Advance directives were associated with increased referrals to palliative care and hospice, but there was no difference in how many days before death those referrals occurred.
03The overwhelming majority of advance directives identified were power of attorney for healthcare documents, rather than living wills that specify treatment preferences.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The study was retrospective, so it could not capture the context of decision-making or whether the care received actually matched the patient's preferences. Patients who died in hospice or outside the hospital were excluded, which may have skewed the results toward those who received more aggressive hospital care. The sample was not representative of the local population, with Caucasian patients overrepresented. Some patients coded as having no advance directive may have had one stored in a different healthcare system that the researchers could not access.
Declared interests
The study was supported by the National Institutes of Health (N.I.H., Extramural). The authors declared no conflicts of interest.
The easy way to misread this
Do not conclude that advance directives are useless because they did not reduce aggressive care in this study. The majority of directives were only power of attorney documents, which name a decision-maker but do not specify treatment limits. This suggests the problem is often the lack of detailed preferences, not the concept of advance planning itself.