Hawaii medical journal
-
A review of medical charts of all deaths for one year at a general acute care hospital reveals that 135/602 (22%) charts indicate that the patient had an advance directive. In 68/135 (50%) of the cases, the patients were unable to participate in decisions and met the conditions of the advance directive. In 33/68 (49%) of those cases the records indicate that the advance directive influenced care. In 63 of the 135 charts the advance directive was present and chart notations indicate an additional 25 advance directives were located at the physician's office. Eighteen of a total of 44 physicians listed as attending accounted for the 33 cases in which the record indicates that the advance directive was recognized. Twelve of these 135 patients were coded during their hospitalization. Three of the 12 were coded in the ER upon admission, the remaining 9 were coded in the course of their care in the acute care hospital. Regarding code status a three tiered (Cat I, II, III) classification system was in place. Initial classification of the 135 patients upon admission was: 64 "full code" (I), 56 were "all but CPR" (II), 15 were "No code" (III). Code classification at the time of death (or discharge) was: I = 45, II = 53, III = 36. ⋯ In 50% or 68/135 of the cases the patient met the conditions for invocation of the advance directive and in 33 or 49% of those cases the advance directive was invoked. Another way to state the impact of advance directives in the population studied is that in 22% of the 602 deaths there was indication of an advance directive and in 50% of those cases the directive became relevant and in 49% of those cases it had a bearing on the care (or in 5% of the 602 death studied). More research is needed to determine why advance directives are not utilized more and why they to do not have greater effect on clinical care decisions in terminal patients. But problems with making them available to relevant parties, hospital record keeping, and physician recognition of their significance are evident.