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

Vincent Weber; Aurelia Hübner; Sandra Pflock; Lukas Schamberger; Rajan Somasundaram; Lennert Boehm; Wolfgang Bauer; Eva Diehl-Wiesenecker

doi:10.1186/s12913-024-10819-1

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

BMC Health Serv Res. 2024 Apr 3;24(1):426. doi: 10.1186/s12913-024-10819-1.

Authors

Vincent Weber¹, Aurelia Hübner¹, Sandra Pflock¹, Lukas Schamberger², Rajan Somasundaram¹, Lennert Boehm³, Wolfgang Bauer¹, Eva Diehl-Wiesenecker⁴

Affiliations

¹ Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
² Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia.
³ Emergency Department, Medical Faculty, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany.
⁴ Department of Emergency Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany. eva.diehl-wiesenecker@charite.de.

Abstract

Background: 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.

Objective: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Keywords: Advance directives; Emergency department, hospital; End of life decisions; Palliative care; Resuscitation orders.

Publication types

Systematic Review

MeSH terms

Adult
Advance Directives*
Aged
Child
Decision Making
Emergency Service, Hospital*
Female
Health Personnel
Hospitalization
Humans