• Cameron I Knott, Alex J Psirides, Paul J Young, and Dalice Sim.
• Wellington Regional Hospital, Wellington, New Zealand. cknott1@fastmail.fm
• Crit Care Resusc. 2011 Sep 1;13(3):167-74.

ObjectiveTo describe the longitudinal changes in documentation of advance care directives (ACDs), including limitation of medical therapy (LMT) and not-for-resuscitation (NFR) directives among patients reviewed by a medical emergency team (MET).Design And SettingSingle-centre, retrospective cohort study at a tertiary teaching hospital in Wellington, New Zealand, from 1 October 2009 to 30 September 2010.ParticipantsAdult surgical and medical inpatients attended by the hospital's MET, which attends medical emergency calls and cardiac arrest calls.Main Outcome MeasuresChronology of LMT and NFR documentation rates in relation to hospital admission and MET attendance. Medical compliance with hospital NFR documentation policy. Differences in characteristics and outcomes of patients with and without documented ACDs.ResultsDocumentation of LMT and NFR directives at admission was low (18%) in the 71 patient files included in the study. The LMT and NFR directive documentation rate before MET review (32%) doubled after MET involvement (62%). Universal NFR directive documentation was not achieved (66% NFR rate). Presence of pre-MET ACDs were associated with increased age, but this group had similar comorbidities and mortality rates to the group without directives. Presence of ACD documentation after MET review was associated with increased age, comorbidity burden and in hospital mortality.ConclusionsCompliance with hospital policy of universal documentation was low despite MET involvement. There was a strong association between ACDs and death, suggesting an opt-out culture. Further investigation is needed into the interaction between hospital systems, medical culture, human factors, and patient-centred clinical decision making.

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