Opportunities for Improvement in Caring for Critically Ill Patients Who Are Incapacitated With No Evident Advance Directives or Surrogates: A Nested Case-Control Study.

Providing ethical, timely, and goal-concordant care for critical patients who are incapacitated with no evident advance directives or surrogates (INEADS) can pose challenges to nursing staff and other care team members and may delay or alter care trajectories. In a nested case-control study, we aimed to determine whether critical care patients who are INEADS have different hospitalization timelines, consultative services, and discharge dispositions relative to matched control subjects. Data were obtained from the publicly accessible Medical Information Mart for Intensive Care III database of 23 904 adult critical care hospitalizations in a Boston, Massachusetts, hospital from 2001 to 2012. Using natural language processing and verifying by manual chart review, we identified 40 patients in this cohort who were INEADS and matched them 1:1 with control subjects based on age, sex, and comorbidity index. Average length of hospitalization was 11 days for patients and 9 days for control subjects; average time until code status documentation was 8 days for patients and 6 days for control subjects, and average time until documentation of social work involvement was 9 days for patients and 2 days for control subjects. Although these differences were not statistically significant, procedures to support timely ethical decision-making for patients who are INEADS require attention.