The Inaccessibility of Advance Directives on Transfer From Ambulatory to Acute Care Settings

Objective. —To investigate the accessibility of patients' previously executed advance directives during an acute hospitalization. Design. —Retrospective chart review. Setting. —A large metropolitan teaching hospital, a 514-bed skilled nursing facility, a geriatrics ambulatory care clinic, and a geriatrics group practice office. Patients. —One hundred fourteen geriatric patients who had previously executed an advance directive. Main Outcome Measures. —The medical records of 180 admissions over 3 years, 1991 through 1993, were reviewed for documentation of patients' advance directive status. Results. —Twenty-six percent of patients who had previously executed advance directives had their directives recognized during their hospitalization. Of the subgroup of patients who were judged not to have the capacity to make medical decisions during their admissions, 26% (14/53) had their directives recognized. When the advance directive was recognized, it appeared to influence treatment decisions in 12 (86%) of 14 cases. Conclusions. —Previously executed advance directives are not accessible when patients are admitted to hospitals for acute illness. When such directives are recognized, they are used to influence medical treatment decisions. Further research is needed to define and overcome barriers to this inaccessibility. (JAMA. 1995;274:478-482)