Assessing knowledge gaps regarding end-of-life issues in patients admitted to the hospital through the emergency department

Abstract

Introduction: United States law requires hospitals to document advanced directives for patients on admission with no provision for assessment of their understanding. Aim: We sought to assess patients' knowledge gaps regarding end-of-life care, including do-not-resuscitate and do-not-intubate orders, physician orders for life-sustaining treatment, outcomes after cardiopulmonary resuscitation, and preferences regarding end-of-life care Methods: This is a cross-sectional survey-based study of adult patients aged 55 and older who were being admitted to a large community hospital from the emergency department (ED). Patients were not excluded based on acuity or reason for admission. The survey questioned patients regarding age, primary care provider status, ED visits and hospitalization within the prior year, prior discussions with family, primary care, or inpatient care physicians regarding advanced medical directives, prior completion of advanced medical directives paperwork, knowledge of outcomes after cardiac arrest, and general attitudes regarding priorities related to a “good death”. Results: Although 98% of patients had primary care physicians, only one-fourth recalled discussing advanced directives with their doctors. About half of patients had discussed their wishes with their families, and 52% had signed advanced directive paperwork. Patients overestimated survival after cardiac arrest. The most common elements reported by patients as being important to a “good death” were the absence of pain (26%), the presence of family (24%), and death at home (16%). Conclusion: Patients have clear ideas for what makes a good death but have inadequate knowledge regarding resuscitative outcomes and do not make use of advanced directives. Physicians miss opportunities to educate patients and assist with these difficult decisions. Closing the gap between providers' understanding of patients' desires, and patients' understanding of end-of-life care is an opportunity for improvement. The following core competencies are addressed in this article: Patient care and procedural skills and Systems-based practice.