Advance directives and HIV: a current trend in the inner city

Throughout the 1980's, HIV antiretroviral therapy was non-existent or insufficient, and patients admitted to hospitals were frequently terminal. In 1988 we evaluated the HIV related hospitalizations at the Lutheran Medical Center in Brooklyn, New York, and found that only 1.3 % of the patients had an advanced directive/living will. Fifty percent of the patients expired during their hospitalization. To assist health care professionals during this serious illness, medical decisions were needed from the patients and, at other times, from family members and/or significant others. Subsequently, patients were approached to discuss advance directives (AD). With the introduction of the Highly Active Antiretroviral Therapy, medical management has decreased HIV mortality. Patients may have started having different perceptions on the need for an AD. The study design was submitted to the Institutional Review Board (IRB), and the IRB granted a HIPPA waiver because this was a retrospective study which delinked the study data from any identification of the patient. The chart reviews were conducted to ascertain the existence of an AD for all patients admitted at the Lutheran Medical Center, Brooklyn, NY from 2004 to 2011. One hundred eighty-two patients were identified from their discharge codes for HIV or AIDS. The median age was 47 years (range 22-85 years). Median time since HIV diagnosis was 9.5 years (range 0-28 years). Ninety-two percent lacked an AD on admission. From the thirty patients that were older than 54 years of age, only four of them had an AD prior to admission. During hospitalization only 11 patients out of 187 enacted a new AD, which decreased the overall percentage of patients lacking an AD to 86.3 % (pre and during admission). The majority of HIV infected patients hospitalized lacked an AD. Our data did not indicate a greater predominance of ADs from a private practice or clinic setting. ADs did not increase with increasing age. Moreover, with longer years with an HIV diagnosis, the number of ADs did not increase. Our results would indicate that a different approach is necessary to adequately address ADs with this specific population, especially as their longevity increases.