Advance directives in the cardiac care unit.
BACKGROUND
Despite effective therapies, mortality for many cardiovascular diseases remains higher than for many cancers and is difficult to predict. Guidelines recommend discussing advance directives (AD), including living wills and durable powers of attorney, with heart failure patients. The Patient Self-Determination Act mandates such discussions with all hospitalized patients. Little data are available on AD prevalence in patients with serious cardiac disease.


METHODS
Patients admitted to a cardiac care unit (CCU) were surveyed regarding demographics, medical history, prevalence of AD, and interest in obtaining more information about AD. Histories of life-threatening cardiac diagnoses were tabulated. Prevalence of AD and interest in obtaining more information about AD were obtained via chart review from patients on an oncology (ONC) floor at the same hospital.


RESULTS
One hundred twelve CCU (average age 58 +/- 16 years, 47 women) and 105 ONC (average age 58 +/- 14 years, 32 women) patients were enrolled. Prevalence of AD was not different between CCU and ONC patients (26% vs 31%, P = .37). Among CCU patients with prior hospitalizations but no AD, 21 of 64 did not recall being asked about AD. Cardiac care unit patients with heart failure and pulmonary hypertension were more likely to report being asked about AD in the past (39 of 54, P = .03 and 7 of 9, P = .008, respectively), but only heart failure patients were more likely to want more information about AD (P = .005). Of patients without AD, 83% from CCU and 18% from ONC wanted more information on AD (P < .001).


CONCLUSIONS
Prevalence of AD in the CCU was low, and many patients did not recall prior AD discussions. The CCU patients without AD were more likely to want information about AD than the ONC patients. A renewed emphasis on AD discussions with cardiovascular patients is needed and would be welcomed. Advance directives should be emphasized in cardiovascular training programs.