89 Advance health directives in end-of-life decision-making in ED and ICU: a multi-methods study

<h3>Aim (Research Questions)</h3> The aim of this research was to explore healthcare professionals’ knowledge and understanding of the law, including how Advance Health Directives (AHD) are applied when making end-of-life decisions in the emergency department (ED) and intensive care unit (ICU) <h3>Background</h3> When a person lacks the capacity to make their own healthcare decisions, a valid AHD can enable decision-making that is consistent with their preferences and goals. While significant attention has been given to encouraging the completion of AHDs, whether directions in an AHD are followed depends on a range of factors, including healthcare professionals’ knowledge and understanding of the law. <h3>Methods</h3> A multi-methods approach involving an online state-wide survey completed by 126 participants (nurses, n=70; doctors, n=56); and 32 semi-structured interviews with doctors (n=13), nurses (n=16) and social workers (n=3) who worked in the ED or ICU of one Queensland Hospital and Health Service, was used. Survey data were reported using descriptive statistics, and the qualitative data were analysed thematically. <h3>Results</h3> Survey data indicated that most doctors (n=36, 64%) and nurses (n=49, 70%) correctly identified when directions in an AHD should be followed. However, in the majority of cases (doctors, n= 24, 66%; nurses, n=42, 86%) the decision was based on the false belief that while directions in an AHD should be considered, other factors may be more relevant. Thematic analysis of the interview data identified three themes: The complexity of communication is laid bare at the end of life; Decision-making has layers; and, How the law should apply is uncertain. Collectively, these themes reinforce that end-of-life decision-making occurs amidst a myriad of, at times, competing factors. <h3>Discussion</h3> Decision-making at the end of life is complex. Seeking to work within legal frameworks that prioritise a person’s preferences and goals can be challenging when directions in an AHD are ambiguous, there is uncertainty about the weight given to other factors, or who has decision-making authority. <h3>Contribution</h3> This research highlights that although the legal framework for decision-making at the end of life has been in place in Queensland for nearly two decades, healthcare professionals remain uncertain about the law, and how it should be applied. <h3>Implications</h3> For AHDs to enable decisions that are consistent with an adult’s end-of-life preferences and goals, novel strategies to support healthcare professionals to understand the law, and work collaboratively with family, carers, or substitute decision-makers should be developed and implemented.