• Laura A Hill, Christine J Waller, Andrew J Borgert, Kara J Kallies, and Thomas H Cogbill.
• General Surgery Residency, Department of Medical Education, Gundersen Medical Foundation, La Crosse, Wisconsin, USA.
• J Palliat Med. 2020 Jul 1; 23 (7): 944-949.

Abstract Background: As the number of geriatric trauma patients rises, end-of-life planning is of increased importance. A community-wide initiative to increase advance care planning was undertaken in the 1990s, resulting in a high rate (85%) of completed advance directives (ADs). Objectives: To assess the impact of ADs on quality measures of care and outcomes for elderly trauma patients. To determine if the historically high rate of completed ADs in the community applied to the trauma patient population. Design: A single trauma center's registry was retrospectively reviewed. Patients with versus without an AD were compared. A case-control analysis was completed. Statistical analysis included chi-square test, Wilcoxon rank sum, and multivariate linear regression modeling. Setting: American College of Surgeons-verified level II trauma center with a 325-bed teaching hospital. Subjects: Patients ≥55 years admitted as level I or II activations from January 2007 through April 2017. Measurements: Hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and 30-day mortality. Results: Nine hundred thirty-six patients were identified; 173 (18%) had an AD and 763 (82%) did not. ADs were more common among older, female patients. The majority of patients with ADs lived within the medical center's service area (99% vs. 1%) and had a primary care provider within the health care system (72% vs. 28%). Although 30-day mortality was higher in patients with ADs versus without (21% vs. 15%; p = 0.03), this difference was not significant on case-control analysis (20% vs. 15%, p = 0.31). No difference was identified in LOS, ICU days, ventilator days, or charges. Conclusions: Presence of an AD was not associated with any difference in 30-day mortality, LOS, or hospital charges. More widespread efforts at AD education and documentation are necessary, particularly in the setting of trauma.

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