Reasons for noncompletion of advance directives in a cardiac intensive care unit.

BACKGROUND: The Patient Self-Determination Act of 1990 mandates that hospitals reimbursed by Medicare and Medicaid inform each patient about the patient's right to a natural death. OBJECTIVE: To describe and explore implementation of the Patient Self-Determination Act in a critical care setting. The goal was to assess patients' understanding of advance directives. METHODS: In a semistructured cross-sectional study, all eligible patients 18 years or older admitted to the cardiac intensive care unit at Duke University Medical Center, Durham, North Carolina, were assessed. Each patient was asked the standard question required by the Patient Self-Determination Act-Do you have an advance directive?-and 3 open-ended questions to ascertain the patient's understanding of advance directives. RESULTS: The sample consisted of 505 patients with a mean age of 61.9 years (SD, 14.8), 37.8% (n = 191) were women, and 68.5% (n = 346) were white. Most patients (64.4%; n = 325) did not have an advance directive before admission to the unit. Of the patients who initially declined the opportunity to complete an advance directive (n = 213), 33.8% (n = 72) said they did not understand the question when initially asked and therefore just said no. CONCLUSIONS: Current practice meets the requirement of the Patient Self-Determination Act for documentation of patients' right to a natural death. However, simply asking Do you have an advance directive? does not elicit an accurate reflection of a patient's understanding of advance directives.

Differences in level of care at the end of life according to race.

BACKGROUND: Tailoring care for patients and their families at the end of life is important. PURPOSE: To examine factors associated with patients' choices for level of care at the end of life. METHODS: Data on demographics and level of care (full code, do not resuscitate, or withdrawal of life support) were collected on 1072 patients who died between January 1998 and June 2006 on a cardiac care unit. Logistic regression was used to identify factors associated with level of care. RESULTS: Median (interquartile range) age of blacks was 64 (50-74) years and of whites was 70 (62-78) years. At the time of death, the level of care differed significantly between blacks and whites: 41.8% (n = 112) of blacks versus 26.7% (n = 194) of whites chose full code (P <.001), 37.3% (n = 96) of blacks versus 43.9% (n = 317) of whites chose do not resuscitate (P = .03), and 20.9% (n = 54) of blacks versus 29.3% (n = 210) of whites chose withdrawal of life support (P = .005). After age, sex, diagnosis, and lengths of stay in intensive care unit and hospital were controlled for, blacks were more likely than whites to choose full code status at the time of death (odds ratio 1.91 [95% confidence interval, 2.63-1.39], P < .001). CONCLUSIONS: Blacks are 1.9 times as likely as others to choose full code at time of death. Cultural differences should be acknowledged when providing end-of-life care.