The Validity of Advance Directives in Acute Situations

Nearly every fourth person in Germany has an advance directive that is to be used in certain medical situations. It is questionable, however, whether advance directives truly influence important treatment decisions in the intensive care unit. We studied the extent to which doctors and patients' relatives agree on the applicability of advance directives in the acute setting.

A prospective study was carried out by questionnaire among the physicians and relatives of 50 patients with advance directives who were hospitalized on four different multidisciplinary intensive care units. The answers of 25 residents in training, 14 senior physicians, and 19 relatives were analyzed both quantitatively and qualitatively. The extent of agreement was assessed by means of Gwet's AC1 with linear weighting.

In most of the advance directives, the conditions under which they were meant to apply were stated in broad, general terms in prewritten blocks of text. 23 of the 50 patients (46%) died. All relatives stated that they were very familiar with the patients' wishes; 18 of 19 were legally responsible for decision-making. In assessing whether the advance directive was applicable to the situation at hand, the strength of agreement between physicians and relatives as well as between the two groups of physicians was only fair and non-significant (0.35; 95% confidence interval [CI]: -0.01 to 0.71; p = 0.059 and 0.24; 95% CI: -0.03 to 0.50; p = 0.079). The relatives found the advance directives more useful than the doctors did (median, 5 vs. 3 [p = 0.018] on a Likert scale ranging from 0 [not useful at all] to 5 [very useful]) and favored their literal application (median, 5 vs. 4 [p = 0.018] on a Likert scale ranging from 0 [favoring the doctor's interpretation] to 5 [favoring literal application]). 30 days after the decision, 13 relatives (68%) felt that the patient's wishes had been fully complied with.

These groups' clearly differing assessments of the applicability of advance directives imply that the currently most common types of advance directive are not suitable for use in intensive care. In order to support patients' relatives in their role as surrogate participants in decision-making, improved advance directives should be developed, and their implementation should be incorporated into the training and continuing medical education of intensive-care physicians.