Advance directive utilization in the ICU: Ethics, laws, and practice

One out of five Americans dies during hospitalization in the ICU. Over 90% of ICU deaths result from a decision to withhold or withdraw life sustaining treatment. In an effort to preserve individual autonomy and decision making capacity during end-of-life decisions, the idea of an advance directive was developed in the 1970s. Once written, advance directives are supposed to aid physicians and surrogate decision makers in fulfilling the wishes of the patient. Although advance directives are in place to preserve patient autonomy, they are typically vague in nature, and difficult to apply in complex situations. Additionally, a lack of laws requiring physicians, hospitals, and families to follow advance directives during end-of-life decision making has resulted in ethical dilemmas, increased spending, and reduced quality of care. In a society where the majority of deaths follow a barrage of life-extending and life-saving treatments, documenting patient preferences has become increasingly important. Although the importance of advance directives has been emphasized through the passage of public health laws such as the Patient Self Determination Act, the majority of Americans do not have an advance directive. This presentation is intended to offer both legal and lay audience a descriptive analysis of the current laws, ethical dilemmas, and practical barriers to utilization of advance directives in ICUs. Furthermore, this presentation will inform both lay and legal audiences about benefits and drawbacks of advance directives, as well as give recommendations for how advance directives can be utilized to deliver higher quality, more cost effective care in ICUs.