Journal
JOURNAL OF INTENSIVE CARE
Volume 11, Issue 1, Pages -Publisher
BMC
DOI: 10.1186/s40560-023-00705-z
Keywords
Advance directives; Patients' will; Intensive care; Neurocritical illness
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This review examines the challenges and obstacles in implementing and translating patients' advance directives (ADs) in intensive care units (ICUs). The study reveals variations in the prevalence of ADs across different regions and significant effects of ADs on intensive care provision, do-not-resuscitate orders, and treatment costs. However, insufficient knowledge, lack of awareness, communication issues, and ethical/legal concerns hinder the implementation of ADs.
ObjectivesThis review examined studies regarding the implementation and translation of patients' advance directives (AD) in intensive care units (ICUs), focusing on practical difficulties and obstacles.MethodsThe digital PubMed and Medline databases were screened using predefined keywords to identify relevant prospective and retrospective studies published until 2022.ResultsSeventeen studies from the United States, Europe, and South Africa (including 149,413 patients and 1210 healthcare professionals) were identified. The highest prevalence of ADs was described in a prospective study in North America (49%), followed by Central Europe (13%), Asia (4%), Australia and New Zealand (4%), Latin America (3%), and Northern and Southern Europe (2.6%). While four retrospective studies reported limited effects of ADs, four retrospective studies, one survey and one systematic review indicated significant effects on provision of intensive care, higher rates of do-not-resuscitate orders, and care withholding in patients with ADs. Four of these studies showed shorter ICU stays, and lower treatment costs in patients with ADs. One prospective and two retrospective studies reported issues with loss, delayed or no transmission of ADs. One survey revealed that 91% of healthcare workers did not regularly check for ADs. Two retrospective studies and two survey revealed that the implementation of directives is further challenged by issues with their applicability, phrasing, and compliance by the critical care team and family members.ConclusionsAlthough ADs may improve intensive- and end-of-life care, insufficient knowledge, lack of awareness, poor communication between healthcare providers and patients or surrogates, lack of standardization of directives, as well as ethical and legal concerns challenge their implementation.
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