C. J. Rust2, S. Agarwal1, K. Haines1 1Duke University Medical Center,Critical Care Surgery,Durham, NC, USA 2University Of Wisconsin,Madison, WI, USA
Introduction: Advanced directives (AD) give patients more control over their medical management when they cannot voice their own decisions. However, end-of-life planning is not equal across the population. Serious injuries happen suddenly and unpredictably, and advance directives provide a framework from which families and caregivers may better understand patient’s wishes. This analysis aimed to determine what populations have advanced directives prior to admission in trauma and how those directives affected outcomes.
Methods: Adult patients admitted to the hospital and recorded using the National Trauma Data Bank were reviewed. The primary outcome was presence of AD. Secondary outcomes included mortality, disposition and length of stay (LOS) among AD patients. A multivariate logistic regression model was developed for DNR status controlling for age, sex, race and ethnicity, insurance status and BMI classification. Multiple multivariate linear and logistic regressions for secondary research outcomes controlled for the same set of covariates and AD.
Results: From 2013-2015, 2.1 million inpatients were identified and 33,768 had AD present on admission. Average age of patients with AD was 78.2 ± 11.2 years and 60.6% were female. Most were Caucasian (91.5%) followed by African American (2.6%). Medicare was the most common insurance (76.1%) followed by private (12.5%). Asian and African American patients were less likely to have AD compared to their Caucasian counterparts (0.526, 0.404; p<0.001). Patients with Medicare were more likely while uninsured patients were 0.6 time less likely (1.249, p <0.001) to have AD. Patients with AD had increased likelihood of mortality (4.069; p<0.001) being discharged to SNF and hospice care (1.214, 4.825; p<0.001). Routine discharge, homecare, and leaving against medical advice were all negatively associated with AD (0.676, 0.421, 0.213; p<0.001). AD was positively associated with use of mechanical ventilation (1.581; p<0.001) however patients spent less time intubated (-1.146; p <0.001). Patients that died or were discharged to hospice and had an AD had shorter LOS (-1.160, -1.740; p<0.001). Of patients with AD, uninsured patients had higher mortality rates (2.775; p<0.001) were less likely to be sent to SNF and receive home care (0.482, 0.319; p<0.001). African American patients (1.248; p<0.001) had increased LOS, as did Medicaid patients (0.757; p<0.02). Medicare and uninsured patients spent fewer days on mechanical ventilation than privately insured patients (-1.519, -1.652; p<0.05).
Conclusion: Patients with AD were predominantly elderly white females. Mortality rates for those with AD were greater than the general population, however, AD did not limit initial care as this population was more likely to be on a ventilator. Those with AD had higher rates of mortality, discharge to hospice and shorter hospital stays, possibly indicating palliative measures were taken.