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Deciding in the dark: Advance directives and continuation of treatment in chronic critical illness*

Camhi, Sharon L. MD; Mercado, Alice F. RN, MBA; Morrison, R Sean MD; Du, Qingling MS; Platt, David M. MD; August, Gary I. BS; Nelson, Judith E. MD, JD

doi: 10.1097/CCM.0b013e31819613ce
Clinical Investigations

Objective: Chronic critical illness is a devastating syndrome for which treatment offers limited clinical benefit but imposes heavy burdens on patients, families, clinicians, and the health care system. We studied the availability of advance directives and appropriate surrogates to guide decisions about life-sustaining treatment for the chronically critically ill and the extent and timing of treatment limitation.

Design: Prospective cohort study.

Setting: Respiratory Care Unit (RCU) in a large, tertiary, urban, university-affiliated, hospital.

Patients: Two hundred three chronically critically ill adults transferred to RCU after tracheotomy for failure to wean from mechanical ventilation in the intensive care unit.

Interventions: None.

Measurements and Main Results: We interviewed RCU caregivers and reviewed patient records to identify proxy appointments, living wills, or oral statements of treatment preferences, resuscitation directives, and withholding/withdrawal of mechanical ventilation, nutrition, hydration, renal replacement and vasopressors. Forty-three of 203 patients (21.2%) appointed a proxy and 33 (16.2%) expressed preferences in advance directives. Do not resuscitate directives were given for 71 patients (35.0%). Treatment was limited for 39 patients (19.2%). Variables significantly associated with treatment limitation were proxy appointment prior to study entry (time of tracheotomy/RCU transfer) (odds ratio = 6.7, 95% confidence interval [CI], 2.3–20.0, p = 0.0006) and palliative care consultation in the RCU (OR = 40.9, 95% CI, 13.1–127.4, p < 0.0001). Median (interquartile range) time to first treatment limitation was 39 (31.0–45.0) days after hospital admission and 13 (8.0–29.0) days after RCU admission. For patients dying after treatment limitation, median time from first limitation to death ranged from 3 days for mechanical ventilation and hydration to 7 days for renal replacement.

Conclusions: Most chronically critically ill patients fail to designate a surrogate decision-maker or express preferences regarding life-sustaining treatments. Despite burdensome symptoms and poor outcomes, limitation of such treatments was rare and occurred late, when patients were near death. Opportunities exist to improve communication and decision-making in chronic critical illness.

From the Division of Pulmonary and Critical Care Medicine (SLC), VA Pittsburgh Health Care System, Pittsburgh, PA; Division of Pulmonary, Critical Care and Sleep Medicine (JEN, DMP, AFM, GIA), Department of Medicine and the Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics and Adult Development (JEN, RSM, QD), Mount Sinai School of Medicine, New York, NY; and the Geriatric Research, Education and Clinical Center (RSM), Bronx VA Medical Center, Bronx, NY.

Supported, in part, by R01 AG21172 from the National Institute on Aging (NIA). Dr. Nelson is the recipient of an Independent Scientist Award (K02 AG024476) from NIA. Dr. Morrison has a Midcareer Investigator Award in Patient-Oriented Research from NIA (K24 AG022345).

This study was performed at the Mount Sinai Medical Center, New York, NY.

The authors have not disclosed any potential conflicts of interest.

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© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins