Advance directives in the intensive care unit: An eight-year vanguard cohort study

Purpose: To investigate the frequency, content, and clinical translation of advance directives in intensive care units (ICUs).

Material and methods: Retrospective cohort study in a Swiss tertiary ICU, including patients with advance directives treated in ICUs ≥48 h. The primary endpoint was the violation of directives. Key secondary endpoints were the directives' prevalence and their translation into clinical practice.

Results: Of 5'851 patients treated ≥48 h in ICUs, 2.7 % had documented directives. Despite 92 % using templates, subjective or contradictory wording was found in 19 % and 12 %. Nine percent of directives were violated. Patients with directive violations had worse in-hospital outcomes (p = 0.012). At admission, 64 % of patients experiencing violations could not communicate, and directives were missing/unrecognized in 30 %. Mostly, directives were not followed regarding life-prolonging measures (6 %), ICU admission (5 %), and mechanical ventilation (3 %). Kaplan Meier statistics revealed a lower survival rate with directives recognized at admission (p = 0.04) and when treatment was withheld (p < 0.001).

Conclusions: Advance directives are available in a minority of ICU patients and often contain subjective/contradictory wording. Physicians respected directives in 90 % of patients, with treatment adapted following their wishes. However, violation of directives may have serious consequences with unfavorable in-hospital outcomes and decreased long-term survival with treatment adaption following directives.