New research shows most older patients do not have documentation of an advance directive when they present to a hospital for a traumatic injury, such as a fall.1

A multicenter analysis of patients older than age 65 years who experienced a traumatic injury between Jan. 1, 2017, and Dec. 31, 2019, revealed the vast majority did not have an advance directive. Of 6,135 patients, only 751 had an advance directive. The patients with an advance directive presented with more pre-existing conditions, including cerebrovascular accident, congestive heart failure, and functional dependence.1

It is challenging for case managers and healthcare providers to discuss end-of-life issues with patients, particularly when they are facing a life-threatening injury or illness. But it is useful to make advance directives a part of a palliative care service as well as a general part of case management with geriatric patients after a traumatic injury.

Case managers, social workers, providers, and palliative care can take on an important role in the ED by discussing advance directives with patients.

“Anyone who is comfortable [with end-of-life care] can have this discussion and assist in documentation,” says Janet S. Lee, MD, resident physician in the department of trauma and acute care surgery at the University of Colorado Health Memorial Hospital. Lee also is a resident physician at Anschutz Medical Campus.

The simplest first step is to check the medical record or ask patients if they have an advance directive on record at the hospital or at home. For example, asking about advance directives could be a routine part of taking a patient’s history when he or she is admitted to the ICU. This could involve offering patients an advance directive form and asking them who they would like to be their decision-makers. When patients sign it, hospital staff can scan it and upload it to the medical record.

“Our hospital has a patient portal that you can go through steps and identify power of attorney and advance directives,” Lee explains. “You can upload it to our electronic medical record [EMR], and everyone with access to the EMR can take a look to see if the patient has an advance directive.”

Case managers in hospitals that do not offer a portal for advance directive documentation can advocate with hospital management to add one in the electronic record, she adds.

For patients without an advance directive, the biggest hurdle is talking with them about what it means and how it would be used. “There’s some stigma about involving palliative care service, but having it does not mean the patient is dying,” she explains. “They just help in the ICU when the team would have that [end-of-life] discussion.”

Palliative care teams can teach case managers and others how to hold these conversations in a way that patients and their families can accept and learn. For example, patients sometimes fear that an advance directive might lead to their receiving less care.

“The study showed that advance directives did not lead to increased withdrawal of care, which is one of the fears of advance directives — that they’ll get their line unplugged,” Lee says.

Advance care education also could emphasize the importance of a person putting their own decisions and needs in writing. “It’s important to recognize that having documentation about what you want for end-of-life care is super important,” Lee says. “Families do not always know what patients want.”

The study also showed that socially and economically disadvantaged groups especially lacked advance care planning. “We should target everyone, but especially these populations,” Lee says.

With documented advance directives, patients have autonomy over their own care. “Our study highlights that we have a huge deficit in advance directive planning, especially in the geriatric population, and we need to do a better job,” Lee says.

Even if the first attempt to discuss advance directives does lead to a patient signing a document, it is a step in the right direction. Many patients have heard of advance directives, even if they have not yet signed one, Lee says.

Holding repeated discussions helps. Eventually, the patient might decide to create an advance directive, she adds.


  1. Lee JS, Khan AD, Dorlac WC, et al. The patient’s voice matters: The impact of advance directives on elderly trauma patients. J Trauma Acute Care Surg 2021; Sep 14. doi: 10.1097/TA.0000000000003400. [Online ahead of print].