COLOGNE. For most patients in intensive care, the patient records contain neither an advance directive nor a medical power of attorney. This is the finding of a survey of 998 intensive care patients at a university hospital, reported on by Geraldine de Heer and coauthors in the current issue of the Deutsches Ärzteblatt International (Dtsch Arztebl Int 2017; 114: 363-70). Of those surveyed, 51.3% responded that they had completed at least one of the two documents, and of these, 39.6% said they had passed on the documents to the hospital–but for only 23% of those surveyed were the documents actually present in the patient records.
Of the 508 patients who reported having completed a medical power of attorney or advance directive, "fear of being at the mercy of others, lack of self-determination, or of overtreatment" was the most frequent reason given (48%). On inspecting the documents that had been handed in, the authors found that 39.8% of the powers of attorney and 44.1% of the advance directives were difficult to interpret, because preprinted forms had been used that had not been correctly completed.
However, the authors also point out that most advance directives, which often contain prewritten wording, cannot reflect the complex situations that arise in intensive care units. For a non-medically trained person, creating a patient advance directive alone and without medical advice is difficult in view of the unpredictable and medically complex developments that can occur in intensive care. Structured consultation is helpful for patients writing an advance directive, and is welcomed by patients. This is the only way to comply with a leading decision of the German Federal Supreme Court, which stated that phrases such as "I decline life sustaining treatment" are not specific enough for the individual case, and that a written patient advance directive is binding only when it contains specific decisions about patient consent or withholding of consent to particular medical interventions.
Prof. Dr. med. Stefan Kluge
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