SYMPOSIUM ON END OF LIFE CARE
Year : 2011 | Volume
: 1 | Issue : 2 | Page : 132--137
Advance directives in the trauma intensive care unit: Do they really matter?
Stephanie Gordy, Eran Klein
Departments of Surgery and Neurology, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park, Portland, Oregon 97239, USA
Department of Surgery, Oregon Health and Science University, Mail Code L611, 3181 SW Sam Jackson Park, Portland, Oregon 97239
Despite advances in the care of the injured patient, 22% of trauma patients admitted to the intensive care unit will die from their injuries. As a majority of these deaths will occur due to withdrawal of care, intensivists should be proficient in their ability to discuss end-of-life care with patients and families. While the use of advance directives to document patients«SQ» wishes has increased, their utility is uncertain. We review the effectiveness and obstacles of advance directives.
|How to cite this article:|
Gordy S, Klein E. Advance directives in the trauma intensive care unit: Do they really matter?.Int J Crit Illn Inj Sci 2011;1:132-137
|How to cite this URL:|
Gordy S, Klein E. Advance directives in the trauma intensive care unit: Do they really matter?. Int J Crit Illn Inj Sci [serial online] 2011 [cited 2020 Jan 21 ];1:132-137
Available from: http://www.ijciis.org/text.asp?2011/1/2/132/84800
Aggressive care and resuscitation is paramount to the treatment of severely injured patients in the trauma intensive care unit (TICU). Modern advances and technological improvements have increased our ability to support a patient's physiology even in the face of multi-organ injury and failure. While this aggressive support has the ability to restore equilibrium at the cellular level, its ability to ensure a meaningful quality of life is variable. Due to the severity of patient illness and uncertainty of functional outcome in the TICU, surgical intensivists are increasingly leading discussions related to end-of-life concerns.
In 1976, the US Supreme Court set a precedent for withdrawal of care in the case of Karen Quinlan. This decision established that patients have a right to refuse medical interventions even if they lead to death.  This right was also extended to the patient's surrogate decision maker should illness compromise the patient's ability to make decisions. This stirred an ethical debate in the 1980s as physicians, ethicists and religious authorities began to recognize and promote living wills. This debate led to the eventual acceptance of advance directives as a means to preserve patient autonomy.
Advance directives, otherwise known as living wills, give instructions regarding the level of care desired in cases of incapacitating illness. Additionally, these directives often name a surrogate decision maker. In 1991, the Patient Self-Determination Act was established and mandates healthcare facilities to document the existence living wills when patients are admitted into the hospital. Furthermore, it requires that hospitals provide written information to patients that define end-of-life options.  Building on this, in 1998, the American College of Surgeons (ACS) Committee on Ethics developed and approved Principles Guiding Care at the End of Life, acknowledging the essential role that surgeons play in the multidisciplinary care of surgical patients facing end-of-life issues. 
Trauma Intensive Care Unit
Advance care planning has increased in recent years, however, the existence of living wills is variable and few studies have looked specifically at end-of-life care in the TICU. In the United States, 75-90% of patients that are admitted to ICUs survive to discharge.  However, despite this aggressive care, 22% of all US deaths occur in or after admission to an ICU.  Furthermore, of patients that die in the ICU, 60-80% do so after life-sustaining therapy is held.  The documented frequency of the presence of an advance directive upon admission to the hospital ranges between 3 and 14% in the general population and increases to 10-30% in nursing home residents.  In 1994, the SUPPORT study showed that only 21% of seriously ill patients had an advanced directive, while a 2010 study revealed that 67% had an advanced directive.  This increase in documentation, though, is in the elderly population and not the young. Patients younger than 65 have rarely completed an advance directive unless they suffer from a chronic, debilitating illness. Trauma affects patients indiscriminately with regards to age, and critical care physicians are increasingly involved in end-of-life discussions with the elderly as well as the young.
Timing of The Advance Directive Discussion
Approximately 10-20% of trauma patients admitted to the ICU will die and there is a clear association of rising Injury Severity Score (ISS) and age with regards to mortality. 
Hoping for a cure and preparing for potential death need not be mutually exclusive.  Triggers that should prompt earlier care discussions have been identified. Surgical intensivists' trigger points that usually prompt a palliative care consultation include: Death expected during same ICU stay; Family request; Brain death considered; In-hospital cardiac arrest, transcranial GSW, diseases with median survival <4 mos, family disagreement (with team, AD, or each other); Multisystem organ failure (in patient age >60) and ICU stay >1 month.  Moreover, multivariate analyses in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) found that advanced age, poor functional status and poor quality of life were associated with early DNR decisions.  The APACHE II score is also an important determinant of DNR directive establishment in the ICU.  This proactive identification allows for earlier intervention of a palliative care team. Then SUPPORT study also showed that many patients die after a prolonged stay in the ICU with severe pain and inadequate communication regarding their preferences for life support.  A palliative care unit integrated into the intensive care team in one study was shown to increase the rate of advance directives from 33 to 83% after their intervention.  Early palliative care service consultation can additionally assist with pain medicine management as well as address family spiritual needs. 
If a critically ill patient meets these triggers and does not have a directive, the ICU team should be proactive and ask about end-of-life wishes. While directives can guide decisions, discussing each individual case with the surrogate/family is usually necessary as no document can anticipate every nuance. Unfortunately these surrogate discussions frequently happen as a result of patient deterioration and the families are under significant emotional stress. Families react more favorably to the discussion if these are held as a process rather than a one-time decision.
When a meeting regarding goals of care occurs, openness and frankness with regards to predicted prognosis and functional outcome are crucial.  Studies have also shown that the strongest factor associated with the decision to establish a DNR directive is the physicians' prediction of patient's survival.  When presenting data to families, intensivists should always keep the patient's wishes central to any decision and avoid placing his or her own values/opinions of "quality of life" to the forefront. As the trauma population varies, from the young and healthy to the elderly with multiple comorbidities, the reversibility of the injury should also be considered.
Perhaps most important to any end-of-life discussion are the attainable endpoints and goals of care. These should be established with family based on directives or what the family thinks the patient would want. A decision does not have to be made immediately and the team should reassess and review the patient's progress or lack thereof in a few days. What an "acceptable" functional outcome is should also be discussed and defined. Some patients want "everything" done despite being confined to a bed and being reliant on external assistance while to others, the loss of independence might be an unacceptable way of life. Continually reassessing and readdressing the patient's condition, contributes to a more favorable end-of-life process
Obstacles of Advance Directives
In nearly half of the patients that die in US hospitals, the last three days of their life is spent in an ICU.  Furthermore, withholding and withdrawal of life-sustaining therapies accompanies the majority of these deaths.  While the frequency of advanced directives may have increased in the past years, the effectiveness of these documents is not definitive. Advance directives are problematic as they do not necessarily guide medical decision-making other than naming a healthcare proxy or documenting general preferences.  As such, the mere presence of this document does not ensure accurate decision-making about resuscitation.  Moreover, the wording in advance directives tends to be vague and frequently only desires cessation of care in cases of medical futility, for example, "…when there is no reasonable expectation of recovery from extreme physical or mental disability" or to "forgo artificial means and heroic measures" or "if the outcome is futile".  Few scenarios offer such black and white distinctions. This wording is confounded by the definition of futility, which is limited to interventions that have no physiologic benefit or as an intervention that has <1% success. ,, As such, in-depth discussions with families are necessary to delineate the patients' wishes as they apply to the medical problem at hand. This process can be quite arduous as the documents are subject to much interpretation.
Central to any discussion regarding end-of-life care is the preservation of the ethical principles of autonomy, beneficence, non-maleficence and justice. Autonomy is the principle that acknowledges a patient's sovereignty over their body and ensures that their decisions are self-directed.  In the ICU, however, decision-making capacity is frequently lost due to the sequelae of narcotics, sedatives and the severity of illness. Occasionally, a window of opportunity exists to have this discussion prior to patient deterioration. This opportunity should be addressed immediately upon arrival to the TICU. Should a patient become incapacitated, an advance directive serves to preserve the principle of autonomy by conveying to caregivers their wishes and identifying a surrogate decision maker. It is rare for a trauma patient to have a clearly unsurvivable injury, an advanced directive that specifically states the patients' wishes and the presence of all family immediately upon arrival to the ICU. In the majority of cases, varying degrees of "gray" usually exists in terms of the family's knowledge of patients' wishes, the survivability of the injury and the likelihood of the degree of recovery. Furthermore, elderly patients are more likely than their younger counterparts to have filled out an advance directive.  However, these documents infrequently accompany the patient on presentation to the emergency department. As such, if the patient's condition allows, consideration should be given to asking every patient upon admission if they have a living will. If an advance directive is not already established and the patient is incapacitated, the patient's next-of-kin is usually turned to for guidance and to provide the patient's known wishes via substituted judgment.
Frequently with regards to young adults and minorities, a discussion regarding end-of-life wishes has never been held. The optimal advance directive discussion occurs in an elective setting with a physician that the patient has established a good relationship with. However, due to the abrupt nature of trauma, this is not possible in the acute setting. In this scenario, the role of the family is to make a decision based on the best interests of the patient. The difficulty with this is that family members are not always accurate in their assessments of loved ones' wishes. When patients and spouses were surveyed as to what they thought their spouses would want if they were critically ill, the majority of the responses overestimated the desire of their spouse to want resuscitation.  In the US, state laws vary as to the hierarchy of the decision-making tree and each state's policy should be referred to individually.
The quality of communication by the ICU team while addressing end-of-life issues is imperative. In fact, families rate communication with attending physicians as one of the most important aspects of care in the ICU.  The SUPPORT study elucidated that while physician-patient/family communication is critical, it alone is inadequate to improve the experience of critically ill patients. Additionally, surgical intensivists do not have established relationships with patients, morbidity is unexpected, prognosis is uncertain, surrogates may be unreliable and few patients can participate in decisions themselves.  A review of trauma rounds revealed that goals of care were only discussed in 36% of patient days,  suggesting that patient caseload may not allow for repeated discussion. Furthermore, documentation of attending intensivist presence during end-of-life discussions varies between 54 and 94%.  Additionally, physicians often see death as failure and avoid the topic of mortality altogether. Whether this is due to surgeon workload or reluctance to discuss a difficult topic, it adds to the milieu of obstacles to getting a clear plan for end-of-life care
If end-of-life issues were addressed earlier, goals of care for the patient could be adjusted such that earlier symptom control. This early implementation could potentially improve patient comfort and lead to a "good death". Moreover, the SUPPORT study revealed that half of all DNR orders were written in the last two days of life. This reiterates that earlier opportunities exist to discuss prognosis and functional outcomes. Furthermore, addressing and resolving these topics earlier, enhances the quality of the patient's and family's overall ICU experience. 
Additional consideration should be given to cultural differences when advance directive discussions occur with families that hold specific cultural and ethnic beliefs. Meissner et al found considerable variability in the frequency of end-of-life decisions in different cultures.  When discussing this with different ethnic groups, consideration should be given to the patient/family's ascribed religious, spiritual and cultural values as these can affect the decision.  Historically, African Americans and Hispanics infrequently complete advance directives. In an analysis of withdrawal of care in an ICU, patients in the withdrawal of care group were more likely to be white or non-Hispanic. A separate review also showed that whites are usually more knowledgeable about advanced directives than other ethnic groups.  Furthermore, Hispanic families tend to make decisions as a group rather than having a single power of attorney. Conversely, physicians should not assume that just because a patient belongs to a certain culture that all members of this ethnic group ascribe to the same belief.
Likewise, the impoverished and less educated may be hold suspicions that an advance directive could lead to "less care". Despite potential misperceptions regarding caregiver intentions in obtaining advance directives, the quantity of care received by patients in the ICU is not reduced compared with those patients who do not have advance directive statements.  Furthermore, the quality of care is not affected by the presence or absence of AD statements. However, sensitivity and awareness on the part of the ICU physician's to potential distrust of the medical system by non-Caucasian cultures could assist in augmenting effective communication when end-of-life issues arise. The critical care team should also reinforce with the family that a do-not-resuscitate (DNR) order and completing an advance directive does not mean, "do not treat".
Utility of Advance Directives
Despite the vague wording and difficult application of advance directives in the TICU, there are clear benefits of these documents. Patients see advance directives as a means of preparation for end-of-life care and death, avoidance of prolongation of dying, strengthening personal relationships, relieving burdens placed on families and communication of future wishes.  Patients who have living wills and request limited care are more likely to have their wishes followed than those who do not have their preferences documented. Silveria described a strong agreement between patients' stated preferences and the care they received when they had preexisting living wills and had become incapacitated. Additionally, in this retrospective review, the actual decision maker matched the appointed surrogate in 91% of patients.  Furthermore, advance care planning improves end-of-life care perceptions of family members. Surviving relatives often report increased satisfaction and reduced stress when end-of-life discussions were implemented early. Moreover, advanced care planning significantly reduces symptoms of post-traumatic anxiety and depression in surviving family members. The family members also believed that the patient would have been satisfied with the quality of their death.  Despite difficulty in establishing what each patient and family desires, advance care planning is meaningful and patients expect healthcare professionals to initiate the conversation.
The ideal advance directive would be available, easily interpreted and applicable.  In a trauma situation, it is unlikely that even if a patient has an advance directive that this document would be present on the patient when the traumatic event occurs. Upon arrival to the hospital, a patient may then have undesired, invasive interventions performed. Next, the patient is transferred to the TICU, on mechanical ventilation, and unable to contribute to any further care decisions. For residents in nursing homes and care facilities, one improvement to this scenario is the Physician Orders for Life Sustaining Treatment (POLST) form. Implemented in Oregon in 1991, this brightly colored form addresses four different treatment options: First, Resuscitation vs. DNR; second transfer if comfort measures fail vs. more aggressive measures; third antibiotics for comfort only versus oral of intramuscular antibiotics with the goal of cure and fourth, tube feeding as short-term, long-term, or not at all.  The form information is recorded and kept on an easily identifiable pink form. It is furthermore entered into a central database that can be easily accessed by EMTs or emergency physicians in case of injury. Multiple studies have evaluated this program's effectiveness in preventing unwanted treatments and hospitalization as well as unwanted resuscitations.  In a review of nursing home patients, 91% had DNR orders, which were ultimately honored.  Additionally in a survey of EMTs, 93% of them regarded the POLST form favorably and greater than half reported using the POLST to change a patient's treatment plan.  While this plan is more applicable to those in nursing home facilities, it is an improvement on current advance directives and can aid in decision-making when the elderly are injured.
Despite the increase in the number of advance directives, the benefit of a living will is rarely clear-cut and while conflict regarding care decisions is rare, it does occur. Occasionally, patients and families desire treatments that physicians feel are inadvisable, and vice-versa.  If this does occur, it is critical to establish well-defined goals of care with the family. For example, the trauma team should establish from the family if the goal is to restore health, extend life, or relieve pain and suffering. Physicians should provide information regarding the prognosis and what goals can or cannot be achieved by each desired intervention.  If conflict persists, different opinions about the goals of treatment and prognosis can be addressed with all members of the team present.  The key to a successful family meeting involves planning ahead and having as many caregivers involved in the discussion including: ethics and palliative care experts, social workers, nurses, residents, attending physicians, consultants and if desired, spiritual supporters. 
In family meetings, it is important to actively listen to what the family's expectations are or the patient. It is equally as important for physicians to be forthright and give as accurate of a prognosis as is possible.  The family's understanding of CPR and survival is also likely to be skewed by media. In a study that reviewed cardiac arrest scenes on television, 67% of portrayed actors survived after CPR. In reality, less than 10% of actual patients that undergo CPR actually survive to discharge.  It is important to convey accurate information to the family to clear up any potential misconceptions. Furthermore, the likelihood of survival as well as insight as to the potential quality of life should also be addressed. Consulting subspecialists should be present to address specific organ system recovery. For example, consider a patient that has multiple injuries, including a traumatic brain injury, intraabdominal injuries with an open abdomen and concomitant renal failure. A family discussion should then involve the neurosurgical, trauma and renal subspecialists. Each of these services should address each of these injuries with respect to recovery and functional outcome. Once a care plan is established, the ICU team should frequently update the family if challenges arise that could affect the plan.
Occasionally, families insist on interventions that physicians consider inadvisable. In cases of conflict, the first step for all parties is to focus on what the patient would want if they could speak for themselves. A judgment that an intervention is inadvisable should only be made after all viewpoints have been expressed. However, interventions that offer no physiologic benefit or have a <1% chance of having meaningful outcome can be labeled futile and physicians are not required to provide them. , If conflict still exists after in-depth family discussions, the hospital ethics committee should be consulted. The ethics consultation is usually successful in resolving conflict. Occasionally, however, the ethics consultation is unsuccessful and resolution options will vary from hospital to hospital. One such plan is the Bay Area Network of Ethics Committees (BANEC). The options to resolve conflict includes getting second opinions from non-involved physicians, consulting the ethics team and transferring the patient to another facility. If the established hospital policy fails to remedy the disagreement then legal mediation may be necessary. 
The evolution of end-of-life care in the ICU has resulted in increased physician and patient awareness as to the importance of advance care planning. The trend has turned away from the paternalistic era of physicians making decisions for the patients to more of a patient-centered dogma to preserve patient autonomy. The current use of advance directives has been promoted to ensure that patient preferences are followed when incapacitating illness occurs. There are advantages and disadvantages to advance directive documents; however, no form can reasonably document all foreseeable maladies. Proactive communication with the patient or healthcare proxy is critical and should be initiated upon admission to the trauma ICU. In summary, the actual benefit of an advance directive may be to designate a surrogate decision maker, to stimulate end-of life discussions between patients, families and caregivers, and finally, to document what outcome scenarios are acceptable to the patient.
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