Use of advance directives for nursing home residents in the emergency department

Documented requests can ensure that patients' end-of-life care preferences are implemented, particularly in emergent circumstances. This study a) compared information on advance directives found in different sources of documentation in the hospital record of nursing home patients admitted through the emergency department and b) assessed emergency department clinicians' perceptions of how end-of-life care requests are communicated to them. Seven potential sources of documentation were reviewed in the medical records of 40 patients, and semistructured interviews were conducted with 10 emergency department clinicians. We found little concordance among sources of advance directive documentation. Our results suggest variability in documentation for nursing home patients on transfer to the emergency department, and that emergency department clinicians experience substantial difficulty in reliably obtaining information about advance directives. As treatment may vary based solely on available documentation, such information gaps may decrease the likelihood of adherence in the emergency department to patients' previously expressed care preferences.