Advance directives in an intensive care unit: experiences and recommendations of critical care nurses and physicians

This study explored the experiences of critical care nurses and physicians with advance directives (ADs) in an intensive care unit (ICU) to identify the benefits and limitations of ADs and recommendations for improvement.

This descriptive study, obtained by ethnographic means, was implemented in a 22-bed adult medical-surgical ICU in a large community hospital in the Midwestern United States. Subjects included 14 critical care nurses, 7 attending, and 3 fellow critical care physicians. Subjects were interviewed informally and formally. Patient medical records were reviewed for ADs.

Results supported numerous problems with ADs described previously and identified additional problems, including inability of ADs to prevent unwanted aggressive treatments outside of health care facilities, and patient reluctance to share ADs for fear of physicians "throwing in the towel" too early. Although most subjects described ADs as "useless," one helpful aspect was using ADs to shift perceptions of responsibility for end-of-life decision making and outcomes from the family/providers to the patient by reframing "pulling the plug" to "honoring patient wishes." Recommendations are described, including evolving the current emphasis of increasing completion of ADs to encourage patient-family discussions focused on quality of life to increase the likelihood of discussions occurring.