• Sira M Baumann, Simon A Amacher, Yasmin Erne, Pascale Grzonka, Sebastian Berger, Sabina Hunziker, Caroline E Gebhard, Mathias Nebiker, Luca Cioccari, and Raoul Sutter.
• Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland.
• J Crit Care. 2024 Sep 17; 85: 154918154918.

PurposeTo investigate the frequency, content, and clinical translation of advance directives in intensive care units (ICUs).Material And MethodsRetrospective cohort study in a Swiss tertiary ICU, including patients with advance directives treated in ICUs ≥48 h. The primary endpoint was the violation of directives. Key secondary endpoints were the directives' prevalence and their translation into clinical practice.ResultsOf 5'851 patients treated ≥48 h in ICUs, 2.7 % had documented directives. Despite 92 % using templates, subjective or contradictory wording was found in 19 % and 12 %. Nine percent of directives were violated. Patients with directive violations had worse in-hospital outcomes (p = 0.012). At admission, 64 % of patients experiencing violations could not communicate, and directives were missing/unrecognized in 30 %. Mostly, directives were not followed regarding life-prolonging measures (6 %), ICU admission (5 %), and mechanical ventilation (3 %). Kaplan Meier statistics revealed a lower survival rate with directives recognized at admission (p = 0.04) and when treatment was withheld (p < 0.001).ConclusionsAdvance directives are available in a minority of ICU patients and often contain subjective/contradictory wording. Physicians respected directives in 90 % of patients, with treatment adapted following their wishes. However, violation of directives may have serious consequences with unfavorable in-hospital outcomes and decreased long-term survival with treatment adaption following directives.Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.

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