Advance directives in the intensive care unit of a tertiary cancer center

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Abstract
Background. Advance directives are associated with considerable controversy. The goal of this study was to evaluate the outcomes of critically ill patients with cancer who were admitted to the intensive care unit and who previously had executed an advance directive. The problems associated with interpreting and honoring such documents in a tertiary cancer center also were reviewed. Methods. A prospective observational study of patients with cancer with advance directives who were admitted to the intensive care unit of a major cancer hospital was undertaken. Twenty-six patients with directives were followed from the time of admission to the intensive care unit or, in the case of patients who presented their directives after admission, from the time of presentation of the directive until either discharge or death. Results. Twenty four of the 26 patients were placed on mechanical ventilators. Eight patients died while on the ventilator, nine were terminally weaned, and seven were weaned and survived for at least 24 hours. Of these seven patients, six died before being discharged from the hospital and one was discharged home. Delay in presenting the advance directive, conflict between the dictates of the living will and the wishes of the person named in the durable power of attorney, and controversy among health-care providers as to when in the course of disease the spirit of the advance directive had been met were the most frequent problems encountered; a number of other concerns were also identified. Conclusions. Considerable controversy exists regarding advance directives, and such documents often leave room for confusion about patients' desires in particular clinical situations. Many of the problems identified in this study might be avoided and considerable cost savings achieved by the timely presentation of documents and by the evaluation of clinical goals on an ongoing basis.