Availability of advance directives in the emergency department: a prospective survey
K. Slankamenac1, N. Rütsche1, D. I. Keller1 (1Zürich)
Emergency departments (ED) are crowded with critically ill patients, many of whom are not able to communicate with the emergency staff anymore. Substitute decision makers are often not known or reachable in time. Therefore, advance directives (AD) clearly defining patients’ values and beliefs regarding end-of-life decisions are urgently required, especially in life-threatening situations. To our knowledge, the prevalence of ADs among Swiss ED patients has not been evaluated yet.
The purpose of this prospective survey was to investigate the prevalence of ADs among patients visiting a tertiary care Swiss ED and to identify factors associated with the existence or absence of an AD.
In a prospective survey, we enrolled consecutively patients between July 10th to August 6th 2016 who visited a Swiss tertiary care ED one week from 8 am to 6 pm, two weeks from 2 pm to 11 pm and one week from 11 pm to 8 am. The patients completed a written, standardized and self-administrated questionnaire during the waiting time in the ED. The primary endpoint assessed the prevalence of ADs in ED patients. Secondary, we defined predictors associated with the existence or absence of an AD. Descriptive, univariate and multivariable logistic regression models were used.
Fifty-eight of 292 enrolled ED patients (19.9%) had a completed AD. About half of the survey population (49.3%) was female. Patients having an AD were older (69.5 vs. 39 yrs) and had more co-morbidities (67.2% vs. 38.9%) comparing to patients without ADs. The five leading reasons given for not having an AD were: 33.6% never thought about it, 26% did not know about AD, 14% preferred family to make the decision, and 11.6% too early to make such a decision. Predictors having an AD were older age (p<0.001), having a medical specialist (p=0.050), being Swiss (p=0.021) and with nursing care (p=0.043). Almost half of the ED patients (46.6%) who had ADs discussed their AD with the family and in 31% with the general practitioner. Only one patient took the AD along to the ED, whereas 19% would take it along when needing hospital admission.
Comparing our data with the literature, during the last 20 to 30 years the percentage of patients having an AD did not change. Only every fifth ED patient has a completed AD. Nearly two-thirds of ED patients never thought or did not know about ADs.
Therefore, there is an urgent need to better inform and sensitize the public to timely define legally valid decisions about future medical treatments and wishes by completing ADs.