Reversal of Advanced Directives in Neurologic Emergencies

Area of Science:

• Neurology
• Critical Care Medicine
• Medical Ethics

Background:

• Patients with advanced directives, including Medical Orders for Life-Sustaining Treatment (MOLST) like Do Not Resuscitate (DNR) or Do Not Intubate (DNI), may require interventions during acute neurologic emergencies.
• These interventions, while potentially limiting morbidity and mortality, often necessitate the reversal of existing MOLST.

Purpose of the Study:

• To investigate the outcomes of patients who underwent MOLST reversal for the treatment of acute neurologic emergencies.
• To understand the decision-making process and patient characteristics associated with MOLST reversal in this critical care setting.

Main Methods:

• A retrospective chart review was conducted between July 1, 2019, and April 30, 2021.
• Data were collected on patients treated in a NeuroMedicine Intensive Care Unit who had their MOLST reversed, including neurologic disease, decision-maker, procedural interventions, and outcomes.

Main Results:

• Twenty-seven patients (median age 78) with MOLST reversal were identified, most commonly with DNR/DNI orders (81%).
• Ischemic stroke was the most frequent neurologic emergency (52%). Outcomes were heterogeneous: 52% died, 26% went to skilled nursing, and 22% returned home or assisted living.
• MOLST reversals were often initiated by surrogates (85%) and occurred a median of 603 days after initial MOLST completion.

Conclusions:

• Urgent shared decision-making is crucial in neurologic emergencies to align care with patient goals, potentially involving MOLST reversal.
• The heterogeneous outcomes underscore the importance of patient-centered care, carefully weighing intervention risks and benefits.
• Reversal of advanced directives requires deliberate consideration of individual patient circumstances and preferences.