Advance directives are associated with "good deaths" in chronic dialysis patients

The effect of prior advance directives (AD) on the outcome when chronic dialysis patients died was evaluated in a retrospective review of consecutive deaths over a period of more than 6 yr in a large academic dialysis center. Among 182 patients who died during the period under review, 74 (41%) had previously stated their AD verbally or in writing and the prevalence of AD was highest among patients with age-related or chronically debilitating diseases. Previous statement of AD was significantly more prevalent (P < 0.001) among patients who withdrew from treatment in reconciled fashion than among patients who died suddenly and unexpectedly or who died without a reconciled decision to forego life-sustaining intervention (e.g., dialysis, intubation, emergency surgery). Further analysis shows that patients stating prior AD and patients withdrawing from treatment were most often those who made their own medical decisions ("internal" locus of decision making), rather than relying on relatives or other agents ("external" locus), and tended to be those with a definite spouse or spouse-equivalent relationship. Finally, retrospective assessment suggests that cases in which patients stated prior AD and cases in which patients withdrew from treatment were associated more frequently with a favorable outcome. It was concluded that addressing AD before a medical crisis ensues may increase the likelihood of a "good death" when complications bring the course of chronic dialysis to termination.(ABSTRACT TRUNCATED AT 250 WORDS)