Advanced directives in an emergency department nonagenarian population

Abstract

Study objectives: We determine how many persons close to the end of life have actual, formalized advanced directives. Methods: The records of 849 visits of patients aged 90 years and older presenting to the Saint Mary's Hospital emergency department (ED) between January 1, 2002, and December 31, 2002, were reviewed. Data on the presence and details of any advanced directives were abstracted. There is no standard screen for the presence of these on our ED record, so information was gathered by reading the entire ED record, as well as the remainder of the general medical record within the past year (current visit information form). In addition to ascertaining whether advanced directives were in place, the details of these directives were catalogued. Also, for those who did not have advanced directives, information on whether they wished to receive further information on the topic was also collected. Results: A total of 363 (43%) patient encounters had formal advanced directives. Of the 238 that specified their advanced directives, 8 (3%) encounters were do not resuscitate (DNR), 2 (1%) encounters were do not intubate (DNI), and 21 (9%) encounters were DNR and DNI. A small minority (3%) indicated interest in organ donation, whereas 5 (2%) made a request or gave permission for an autopsy. The most common ultimate diagnoses resulting from these ED visits were pneumonia or pneumonitis, acute coronary syndrome, cardiac arrhythmia, congestive heart failure, and extremity fracture. Everyone who was asked whether he or she would like to receive more information about advanced directives answered yes. Conclusion: Less than half of all patients aged 90 years and older who presented to the ED had formal advanced directives in place. In addition to these patients being toward the end of life by virtue of their age, the most common presenting complaints were all of an acute nature with real potential life threat. Furthermore, from the patients' standpoint, there appears to be a clear interest in receiving more information on advanced directives. This study highlights the need to address the issue of advanced directives with elderly patients presenting to the ED; possibly, this may best be achieved by way of a mandatory screen on the ED record.