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Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.
J Am Geriatr Soc. 1997 Apr; 45(4):508-12.JA

Abstract

OBJECTIVE

To evaluate whether the lack of effect of advance directives (ADs) on decision-making in SUPPORT might arise, in part, from the content of the actual documents.

DESIGN

Advance directives placed in the medical records were abstracted for date of completion and content of additional written instructions. We examined directives with instructions to forgo life-sustaining treatment in the current state of health to determine whether care given was consistent with preferences noted in those directives.

SETTINGS

Five teaching hospitals in the United States.

PATIENTS

A total of 4804 patients with at least one of nine serious illnesses were admitted to five teaching hospitals in the 2 years following implementation of the Patient Self-Determination Act. Patients were part of a randomized controlled trial to improve decision-making and outcomes.

RESULTS

From the medical records of 4804 patients, a total of 688 directives were collected from 569 patients. The majority of these directives (66%) were durable powers of attorney; in addition, 31% were standard living wills or other forms of written instructions (3%). Only 90 documents (13%) provided additional instructions for medical care beyond naming a proxy or stating the preferences of a standard living will. Only 36 contained specific instructions about the use of life-sustaining medical treatment, and only 22 of these directed forgoing life-sustaining treatment in the patient's current situation. For these, the treatment course was consistent with the instruction for nine patients. In two cases, patients may have changed an inconsistent directive after discussion with hospital staff.

CONCLUSION

Advance directives placed in the medical records of seriously ill patients often did not guide medical decision-making beyond naming a healthcare proxy or documenting general preferences in a standard living will format. Even when specific instructions were present, care was potentially inconsistent in half of the cases.

Authors+Show Affiliations

Center to Improve Care of the Dying, George Washington University Medical Center, Washington, DC 20037, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Clinical Trial
Journal Article
Randomized Controlled Trial
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

9100722

Citation

Teno, J M., et al. "Do Advance Directives Provide Instructions That Direct Care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment." Journal of the American Geriatrics Society, vol. 45, no. 4, 1997, pp. 508-12.
Teno JM, Licks S, Lynn J, et al. Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. J Am Geriatr Soc. 1997;45(4):508-12.
Teno, J. M., Licks, S., Lynn, J., Wenger, N., Connors, A. F., Phillips, R. S., O'Connor, M. A., Murphy, D. P., Fulkerson, W. J., Desbiens, N., & Knaus, W. A. (1997). Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. Journal of the American Geriatrics Society, 45(4), 508-12.
Teno JM, et al. Do Advance Directives Provide Instructions That Direct Care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. J Am Geriatr Soc. 1997;45(4):508-12. PubMed PMID: 9100722.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Do advance directives provide instructions that direct care? SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. AU - Teno,J M, AU - Licks,S, AU - Lynn,J, AU - Wenger,N, AU - Connors,A F,Jr AU - Phillips,R S, AU - O'Connor,M A, AU - Murphy,D P, AU - Fulkerson,W J, AU - Desbiens,N, AU - Knaus,W A, PY - 1997/4/1/pubmed PY - 2001/3/28/medline PY - 1997/4/1/entrez KW - Death and Euthanasia KW - Empirical Approach KW - Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) SP - 508 EP - 12 JF - Journal of the American Geriatrics Society JO - J Am Geriatr Soc VL - 45 IS - 4 N2 - OBJECTIVE: To evaluate whether the lack of effect of advance directives (ADs) on decision-making in SUPPORT might arise, in part, from the content of the actual documents. DESIGN: Advance directives placed in the medical records were abstracted for date of completion and content of additional written instructions. We examined directives with instructions to forgo life-sustaining treatment in the current state of health to determine whether care given was consistent with preferences noted in those directives. SETTINGS: Five teaching hospitals in the United States. PATIENTS: A total of 4804 patients with at least one of nine serious illnesses were admitted to five teaching hospitals in the 2 years following implementation of the Patient Self-Determination Act. Patients were part of a randomized controlled trial to improve decision-making and outcomes. RESULTS: From the medical records of 4804 patients, a total of 688 directives were collected from 569 patients. The majority of these directives (66%) were durable powers of attorney; in addition, 31% were standard living wills or other forms of written instructions (3%). Only 90 documents (13%) provided additional instructions for medical care beyond naming a proxy or stating the preferences of a standard living will. Only 36 contained specific instructions about the use of life-sustaining medical treatment, and only 22 of these directed forgoing life-sustaining treatment in the patient's current situation. For these, the treatment course was consistent with the instruction for nine patients. In two cases, patients may have changed an inconsistent directive after discussion with hospital staff. CONCLUSION: Advance directives placed in the medical records of seriously ill patients often did not guide medical decision-making beyond naming a healthcare proxy or documenting general preferences in a standard living will format. Even when specific instructions were present, care was potentially inconsistent in half of the cases. SN - 0002-8614 UR - https://www.unboundmedicine.com/medline/citation/9100722/Do_advance_directives_provide_instructions_that_direct_care_SUPPORT_Investigators__Study_to_Understand_Prognoses_and_Preferences_for_Outcomes_and_Risks_of_Treatment_ L2 - https://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0002-8614&date=1997&volume=45&issue=4&spage=508 DB - PRIME DP - Unbound Medicine ER -