Advance directives in the intensive care unit: An eight-year vanguard cohort study

This is the authors' abstract. We don't add key points for this paper.

To investigate the frequency, content, and clinical translation of advance directives in intensive care units (ICUs). Retrospective 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. Of 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). Advance 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. • In this Swiss study investigating advance directives in intensive care patients, only 2.7 % of patients had directives. • Up to 19 % of directives had subjective/contradictory wording, and 9 % were violated, which was associated with worse outcomes. • Unawareness or violation of directives may have serious consequences with unfavorable patients' in-hospital outcomes.