An advance directive (AD) is a legal document that becomes effective if a patient cannot speak for themselves, or expresses their wishes for medical care. An advance directive is important not only for patients at older ages but also for any patient who is undergoing elective surgery, in case of complications during the procedure. This document can specify the patient’s wishes regarding life-prolonging treatments, such as mechanical ventilation and cardiopulmonary resuscitation (CPR), in addition to appointing someone to make decisions on behalf of the patient.
In medical practice, frequently, patients who undergo planned surgery do not have an advance directive in case of surgical complications. As a result, doctors are obligated to reach family members and force them to make a hard decision regarding their loved one’s medical care. Sometimes the choice of the family is different from the care that the patient would actually like to receive.
Researchers from the Regenstrief Institute, Indiana University Health and Indiana University School of Medicine conducted a study to find out how often patients who underwent preoperative assessment completed an advance directive, and its availability in the electronic medical record (EMR). The results were published in the Journal of General Internal Medicine.
The lead researcher, Shilpee Sinha, M.D., with her colleagues analyzed 400 patients who had been seen in a preoperative clinic for assessment before surgery at two high-volume hospitals over a period of 1.5 months. They reported that 30% of the patients in the study had some form of AD, with a higher number for patients aged 65 and older, and with chronic heart disease such as congestive heart failure. However, only 16% had a file scanned into the EMR. Having the document available through the EMR is an advantage, as a doctor can reach the document at any time during surgery when needed.
This study was conducted at a single hospital site, which may not represent all hospitals, however, the investigators hope that their findings will bring a significant opportunity for advanced care planning. “One of my goals for doing this study is to drive clinical change,” said Dr. Sinha. “The discussion of advance care planning is not part of the established routine. I think we’ve achieved buy-in on the idea of having these conversations. Now we need actual logistical application.”