Gross M D
Chicago Medical School/Finch University of Health Sciences, Illinois, USA.
Arch Intern Med. 1998 Feb 23;158(4):363-5. doi: 10.1001/archinte.158.4.363.
Since the passage of the Patient Self-Determination Act in 1991, there has been interest in urging patients to execute advance directives (ADs) for medical care. There are not much data, however, as to what the ADs that patients execute actually specify. I have investigated the percentage of inpatients and outpatients who are admitted to a community hospital who have executed ADs, and I have tabulated what preferences are actually expressed in the ADs that are in hospital records.
A questionnaire is filled out by each patient admitted to this hospital, and their response recorded as to whether they have executed an AD. I have tabulated these responses for inpatients and outpatients for the calendar year 1994. I have also examined the ADs in all available hospital records, and tabulated the wishes expressed in these directives.
For inpatient admissions during the calendar year 1994, of 8727 questionnaires completed, 11% of patients indicated that they had executed an AD. For outpatients, the corresponding figures are 22,966 and 15%. A total of 343 hospital records containing ADs were examined. Of these, 15 were nonmedical directives and were excluded. Of the 328 medical ADs, 86 (26%) were living wills, expressing the wish that if the individual had an incurable disease or irreversible injury that he or she not be given any treatment that would only delay death. There were 210 power of attorney for health care forms completed; these were 64% of all the medical ADs. Of these, 7 did not specify any preference that patients wanted their proxy to follow. The remaining 203 forms were divided as follows: 189 individuals requested that they did not want life-sustaining treatment if the burdens of treatment outweighed the expected benefits; 12 wanted their lives to be prolonged unless they were in an irreversible coma; and 2 wanted their lives to be prolonged to the greatest possible extent regardless of the chances for recovery or the cost. There were 32 do not resuscitate forms executed exclusively by residents of nursing homes that specified that they did not want cardiopulmonary resuscitation or artificial feeding.
The overwhelming desire expressed by the patients in the ADs was not to have their lives prolonged if their medical condition were such that treatment would merely delay death. Only a minuscule number of patients, less than 0.7%, wanted everything done to prolong life regardless of the chance for improvement or the cost. Because such a small percentage of patients have ADs, it is recommended that each hospital appoint a committee on ADs to do everything possible to encourage patients to execute an AD. A second mission of this committee would be to do everything possible to encourage physicians to pay close attention to their patients' wishes for medical care at the end of life.
自1991年《患者自我决定法案》通过以来，人们一直热衷于敦促患者签署医疗预先指示（ADs）。然而，关于患者签署的预先指示具体规定了什么，相关数据并不多。我调查了入住社区医院的住院患者和门诊患者中签署预先指示的比例，并将医院记录中的预先指示所表达的实际意愿制成了表格。
每位入住本院的患者都要填写一份问卷，并记录他们是否签署了预先指示。我将1994年日历年的住院患者和门诊患者的这些回答制成了表格。我还检查了所有可用的医院记录中的预先指示，并将这些指示中表达的意愿制成了表格。
在1994年日历年的住院患者中，在完成的8727份问卷中，11%的患者表示他们签署了预先指示。对于门诊患者，相应的数字分别为22966人和15%。共检查了343份包含预先指示的医院记录。其中，15份是非医疗指示，已被排除。在328份医疗预先指示中，86份（26%）是生前遗嘱，表示如果个人患有不治之症或不可逆转的损伤，他或她不希望接受任何只会延迟死亡的治疗。有210份医疗保健委托书表格已填写完成；这些占所有医疗预先指示的64%。其中，7份没有具体说明患者希望其代理人遵循的任何偏好。其余203份表格的分布如下：189人要求如果治疗负担超过预期益处，他们不希望接受维持生命的治疗；12人希望延长生命，除非他们处于不可逆转的昏迷状态；2人希望无论康复机会或成本如何，都尽可能延长生命。有32份“不要复苏”表格是由养老院居民专门签署的，规定他们不希望进行心肺复苏或人工喂养。
预先指示中患者表达的压倒性愿望是，如果他们的医疗状况使治疗只会延迟死亡，就不希望延长生命。只有极少数患者，不到0.7%，希望不惜一切代价延长生命，无论改善的机会或成本如何。由于签署预先指示的患者比例如此之小，建议每家医院任命一个预先指示委员会，尽一切可能鼓励患者签署预先指示。该委员会的第二项任务将是尽一切可能鼓励医生密切关注患者在生命末期对医疗护理的意愿。
