Advance directives in the emergency department-a systematic review of the status quo

• Published in: BMC health services research Vol. 24; no. 1; pp. 426 - 8
• Main Authors: Weber, Vincent, Hübner, Aurelia, Pflock, Sandra, Schamberger, Lukas, Somasundaram, Rajan, Boehm, Lennert, Bauer, Wolfgang, Diehl-Wiesenecker, Eva
• Format: Journal Article
• Language: English
• Published: England BioMed Central Ltd 03-04-2024; BioMed Central; BMC
• Subjects: Advance directives; Bibliographic literature; Decision making; Emergency department, hospital; Emergency medical care; Emergency service; End of life decisions; Evaluation; Geriatrics; Hospitals; Medical care; Nursing homes; Palliative care; Palliative treatment; Patients; Population; Quality management; Resuscitation orders; Systematic review; Germany; Advance directives; Palliative care; End of life decisions; Resuscitation orders; Emergency department, hospital
• ISSN: 1472-6963; 1472-6963
• DOI: 10.1186/s12913-024-10819-1

Providing individualised healthcare in line with patient wishes is a particular challenge for emergency healthcare professionals. Documentation of patient wishes (DPW), e.g. as advance directives, can guide clinicians in making end-of-life decisions that respect the patient's wishes and autonomy. However, patient centered decisions are hindered by limited availability of DPWs in emergency settings.
This systematic review aims to congregate present data on recorded rates for DPW existence and availability in the emergency department (ED) as well as contributing factors for these rates.
We searched MEDLINE, Google Scholar, Embase and Web of Science databases in September 2023. Publications providing primary quantitative data on DPW in the ED were assessed. Publications referring only to a subset of ED patients (other than geriatric) and investigating DPW issued after admission were excluded.
A total of 22 studies from 1996 to 2021 were included in the analysis. Most were from the US (n = 12), followed by Australia (n = 4), Canada (n = 2), South Korea, Germany, the United Kingdom and Switzerland (n = 1 each). In the general adult population presenting to the ED, 19.9-27.8% of patients reported having some form of DPW, but only in 6.8% or less it was available on presentation. In the geriatric population, DPW rates (2.6-79%) as well as their availability (1.1-48.8%) varied widely. The following variables were identified as positive predictors of having DPW, among others: higher age, poorer overall health, as well as sociodemographic factors, such as female gender, having children, being in a relationship, higher level of education or a recent previous presentation to hospital.
Existence and availability of a recorded DPW among ED patients was low in general and even in geriatric populations mostly well below 50%. While we were able to gather data on prevalence and predictors, this was limited by heterogeneous data. We believe further research is needed to explore the quality of DPW and measures to increase both rates of existence and availability of DPW in the ED.