aggressive care and resuscitation is paramount to the treatment of severely injured patients in the trauma intensive care unit ( ticu ) . modern advances and technological improvements have increased our ability to support a patient 's physiology even in the face of multi - organ injury and failure . while this aggressive support has the ability to restore equilibrium at the cellular level , its ability to ensure a meaningful quality of life is variable . due to the severity of patient illness and uncertainty of functional outcome in the ticu , surgical intensivists are increasingly leading discussions related to end - of - life concerns . in 1976 , the us supreme court set a precedent for withdrawal of care in the case of karen quinlan . this decision established that patients have a right to refuse medical interventions even if they lead to death . this right was also extended to the patient 's surrogate decision maker should illness compromise the patient 's ability to make decisions . this stirred an ethical debate in the 1980s as physicians , ethicists and religious authorities began to recognize and promote living wills . this debate led to the eventual acceptance of advance directives as a means to preserve patient autonomy . advance directives , otherwise known as living wills , give instructions regarding the level of care desired in cases of incapacitating illness . the patient self - determination act was established and mandates healthcare facilities to document the existence living wills when patients are admitted into the hospital . furthermore , it requires that hospitals provide written information to patients that define end - of - life options . building on this , in 1998 , the american college of surgeons ( acs ) committee on ethics developed and approved principles guiding care at the end of life , acknowledging the essential role that surgeons play in the multidisciplinary care of surgical patients facing end - of - life issues . advance care planning has increased in recent years , however , the existence of living wills is variable and few studies have looked specifically at end - of - life care in the ticu . in the united states , 7590% of patients that are admitted to icus however , despite this aggressive care , 22% of all us deaths occur in or after admission to an icu . furthermore , of patients that die in the icu , 6080% do so after life - sustaining therapy is held . the documented frequency of the presence of an advance directive upon admission to the hospital ranges between 3 and 14% in the general population and increases to 1030% in nursing home residents . in 1994 , the support study showed that only 21% of seriously ill patients had an advanced directive , while a 2010 study revealed that 67% had an advanced directive . this increase in documentation , though , is in the elderly population and not the young . patients younger than 65 have rarely completed an advance directive unless they suffer from a chronic , debilitating illness . trauma affects patients indiscriminately with regards to age , and critical care physicians are increasingly involved in end - of - life discussions with the elderly as well as the young . approximately 1020% of trauma patients admitted to the icu will die and there is a clear association of rising injury severity score ( iss ) and age with regards to mortality . hoping for a cure and preparing for potential death surgical intensivists trigger points that usually prompt a palliative care consultation include : death expected during same icu stay ; family request ; brain death considered ; in - hospital cardiac arrest , transcranial gsw , diseases with median survival < 4 mos , family disagreement ( with team , ad , or each other ) ; multisystem organ failure ( in patient age > 60 ) and icu stay > 1 month . moreover , multivariate analyses in the study to understand prognoses and preferences for outcomes and risks of treatments ( support ) found that advanced age , poor functional status and poor quality of life were associated with early dnr decisions . the apache ii score is also an important determinant of dnr directive establishment in the icu . then support study also showed that many patients die after a prolonged stay in the icu with severe pain and inadequate communication regarding their preferences for life support . a palliative care unit integrated into the intensive care team in one study was shown to increase the rate of advance directives from 33 to 83% after their intervention . early palliative care service consultation can additionally assist with pain medicine management as well as address family spiritual needs . if a critically ill patient meets these triggers and does not have a directive , the icu team should be proactive and ask about end - of - life wishes . while directives can guide decisions , discussing each individual case with the surrogate / family is usually necessary as no document can anticipate every nuance . unfortunately these surrogate discussions frequently happen as a result of patient deterioration and the families are under significant emotional stress . families react more favorably to the discussion if these are held as a process rather than a one - time decision . when a meeting regarding goals of care occurs , openness and frankness with regards to predicted prognosis and functional outcome are crucial . studies have also shown that the strongest factor associated with the decision to establish a dnr directive is the physicians prediction of patient 's survival . when presenting data to families , intensivists should always keep the patient 's wishes central to any decision and avoid placing his or her own values / opinions of  quality of life  to the forefront . as the trauma population varies , from the young and healthy to the elderly with multiple comorbidities , the reversibility of the injury should also be considered . perhaps most important to any end - of - life discussion are the attainable endpoints and goals of care . these should be established with family based on directives or what the family thinks the patient would want . a decision does not have to be made immediately and the team should reassess and review the patient 's progress or lack thereof in a few days . what an  acceptable  functional outcome is should also be discussed and defined . some patients want  everything  done despite being confined to a bed and being reliant on external assistance while to others , the loss of independence might be an unacceptable way of life . continually reassessing and readdressing the patient 's condition , contributes to a more favorable end - of - life process in nearly half of the patients that die in us hospitals , the last three days of their life is spent in an icu . furthermore , withholding and withdrawal of life - sustaining therapies accompanies the majority of these deaths . while the frequency of advanced directives may have increased in the past years , the effectiveness of these documents is not definitive . advance directives are problematic as they do not necessarily guide medical decision - making other than naming a healthcare proxy or documenting general preferences . as such , the mere presence of this document moreover , the wording in advance directives tends to be vague and frequently only desires cessation of care in cases of medical futility , for example , when there is no reasonable expectation of recovery from extreme physical or mental disability  or to  forgo artificial means and heroic measures  or  if the outcome is futile  . this wording is confounded by the definition of futility , which is limited to interventions that have no physiologic benefit or as an intervention that has < 1% success.[1618 ] as such , in - depth discussions with families are necessary to delineate the patients wishes as they apply to the medical problem at hand . central to any discussion regarding end - of - life care is the preservation of the ethical principles of autonomy , beneficence , non - maleficence and justice . autonomy is the principle that acknowledges a patient 's sovereignty over their body and ensures that their decisions are self - directed . in the icu , however , decision - making capacity is frequently lost due to the sequelae of narcotics , sedatives and the severity of illness . occasionally , a window of opportunity exists to have this discussion prior to patient deterioration . should a patient become incapacitated , an advance directive serves to preserve the principle of autonomy by conveying to caregivers their wishes and identifying a surrogate decision maker . it is rare for a trauma patient to have a clearly unsurvivable injury , an advanced directive that specifically states the patients wishes and the presence of all family immediately upon arrival to the icu . in the majority of cases , varying degrees of  gray  usually exists in terms of the family 's knowledge of patients wishes , the survivability of the injury and the likelihood of the degree of recovery . furthermore , elderly patients are more likely than their younger counterparts to have filled out an advance directive . however , these documents infrequently accompany the patient on presentation to the emergency department . as such , if the patient 's condition allows , consideration should be given to asking every patient upon admission if they have a living will . if an advance directive is not already established and the patient is incapacitated , the patient 's next - of - kin is usually turned to for guidance and to provide the patient 's known wishes via substituted judgment . frequently with regards to young adults and minorities , a discussion regarding end - of - life wishes has never been held . the optimal advance directive discussion occurs in an elective setting with a physician that the patient has established a good relationship with . however , due to the abrupt nature of trauma , this is not possible in the acute setting . in this scenario , the role of the family is to make a decision based on the best interests of the patient . the difficulty with this is that family members are not always accurate in their assessments of loved ones wishes . when patients and spouses were surveyed as to what they thought their spouses would want if they were critically ill , the majority of the responses overestimated the desire of their spouse to want resuscitation . in the us , state laws vary as to the hierarchy of the decision - making tree and each state 's policy should be referred to individually . the quality of communication by the icu team while addressing end - of - life issues is imperative . in fact , families rate communication with attending physicians as one of the most important aspects of care in the icu . the support study elucidated that while physician patient / family communication is critical , it alone is inadequate to improve the experience of critically ill patients . additionally , surgical intensivists do not have established relationships with patients , morbidity is unexpected , prognosis is uncertain , surrogates may be unreliable and few patients can participate in decisions themselves . a review of trauma rounds revealed that goals of care were only discussed in 36% of patient days , suggesting that patient caseload may not allow for repeated discussion . furthermore , documentation of attending intensivist presence during end - of - life discussions varies between 54 and 94% . additionally , physicians often see death as failure and avoid the topic of mortality altogether . whether this is due to surgeon workload or reluctance to discuss a difficult topic , it adds to the milieu of obstacles to getting a clear plan for end - of - life care if end - of - life issues were addressed earlier , goals of care for the patient could be adjusted such that earlier symptom control . this early implementation could potentially improve patient comfort and lead to a  good death  . moreover , the support study revealed that half of all dnr orders were written in the last two days of life . furthermore , addressing and resolving these topics earlier , enhances the quality of the patient 's and family 's overall icu experience . additional consideration should be given to cultural differences when advance directive discussions occur with families that hold specific cultural and ethnic beliefs . meissner et al found considerable variability in the frequency of end - of - life decisions in different cultures . when discussing this with different ethnic groups , consideration should be given to the patient / family 's ascribed religious , spiritual and cultural values as these can affect the decision . historically , african americans and hispanics infrequently complete advance directives . in an analysis of withdrawal of care in an icu , patients in the withdrawal of care group were more likely to be white or non - hispanic . a separate review also showed that whites are usually more knowledgeable about advanced directives than other ethnic groups . furthermore , hispanic families tend to make decisions as a group rather than having a single power of attorney . conversely , physicians should not assume that just because a patient belongs to a certain culture that all members of this ethnic group ascribe to the same belief . likewise , the impoverished and less educated may be hold suspicions that an advance directive could lead to  less care  . despite potential misperceptions regarding caregiver intentions in obtaining advance directives , the quantity of care received by patients in the icu is not reduced compared with those patients who do not have advance directive statements . furthermore , the quality of care is not affected by the presence or absence of ad statements . however , sensitivity and awareness on the part of the icu physician 's to potential distrust of the medical system by non - caucasian cultures could assist in augmenting effective communication when end - of - life issues arise . the critical care team should also reinforce with the family that a do - not - resuscitate ( dnr ) order and completing an advance directive does not mean ,  do not treat  . despite the vague wording and difficult application of advance directives in the ticu , there are clear benefits of these documents . patients see advance directives as a means of preparation for end - of - life care and death , avoidance of prolongation of dying , strengthening personal relationships , relieving burdens placed on families and communication of future wishes . patients who have living wills and request limited care are more likely to have their wishes followed than those who do not have their preferences documented . silveria described a strong agreement between patients stated preferences and the care they received when they had preexisting living wills and had become incapacitated . additionally , in this retrospective review , the actual decision maker matched the appointed surrogate in 91% of patients . furthermore , advance care planning improves end - of - life care perceptions of family members . surviving relatives often report increased satisfaction and reduced stress when end - of - life discussions were implemented early . moreover , advanced care planning significantly reduces symptoms of post - traumatic anxiety and depression in surviving family members . the family members also believed that the patient would have been satisfied with the quality of their death . despite difficulty in establishing what each patient and family desires , advance care planning is meaningful and patients expect healthcare professionals to initiate the conversation . the ideal advance directive would be available , easily interpreted and applicable . in a trauma situation , it is unlikely that even if a patient has an advance directive that this document would be present on the patient when the traumatic event occurs . upon arrival to the hospital , a patient may then have undesired , invasive interventions performed . next , the patient is transferred to the ticu , on mechanical ventilation , and unable to contribute to any further care decisions . for residents in nursing homes and care facilities , one improvement to this scenario is the physician orders for life sustaining treatment ( polst ) form . implemented in oregon in 1991 , this brightly colored form addresses four different treatment options : first , resuscitation vs. dnr ; second transfer if comfort measures fail vs. more aggressive measures ; third antibiotics for comfort only versus oral of intramuscular antibiotics with the goal of cure and fourth , tube feeding as short - term , long - term , or not at all . it is furthermore entered into a central database that can be easily accessed by emts or emergency physicians in case of injury . multiple studies have evaluated this program 's effectiveness in preventing unwanted treatments and hospitalization as well as unwanted resuscitations . in a review of nursing home patients , additionally in a survey of emts , 93% of them regarded the polst form favorably and greater than half reported using the polst to change a patient 's treatment plan . while this plan is more applicable to those in nursing home facilities , it is an improvement on current advance directives and can aid in decision - making when the elderly are injured . despite the increase in the number of advance directives , the benefit of a living will is rarely clear - cut and while conflict regarding care decisions is rare , it does occur . occasionally , patients and families desire treatments that physicians feel are inadvisable , and vice - versa . if this does occur , it is critical to establish well - defined goals of care with the family . for example , the trauma team should establish from the family if the goal is to restore health , extend life , or relieve pain and suffering . physicians should provide information regarding the prognosis and what goals can or can not be achieved by each desired intervention . if conflict persists , different opinions about the goals of treatment and prognosis can be addressed with all members of the team present . the key to a successful family meeting involves planning ahead and having as many caregivers involved in the discussion including : ethics and palliative care experts , social workers , nurses , residents , attending physicians , consultants and if desired , spiritual supporters . in family meetings , it is important to actively listen to what the family 's expectations are or the patient . it is equally as important for physicians to be forthright and give as accurate of a prognosis as is possible . the family 's understanding of cpr and survival is also likely to be skewed by media . in a study that reviewed cardiac arrest scenes on television , 67% of portrayed actors survived after cpr . in reality , less than 10% of actual patients that undergo cpr actually survive to discharge . it is important to convey accurate information to the family to clear up any potential misconceptions . furthermore , the likelihood of survival as well as insight as to the potential quality of life should also be addressed . for example , consider a patient that has multiple injuries , including a traumatic brain injury , intraabdominal injuries with an open abdomen and concomitant renal failure . each of these services should address each of these injuries with respect to recovery and functional outcome . once a care plan is established , the icu team should frequently update the family if challenges arise that could affect the plan . occasionally , families insist on interventions that physicians consider inadvisable . in cases of conflict , the first step for all parties is to focus on what the patient would want if they could speak for themselves . a judgment that an intervention is inadvisable should only be made after all viewpoints have been expressed . however , interventions that offer no physiologic benefit or have a < 1% chance of having meaningful outcome can be labeled futile and physicians are not required to provide them . if conflict still exists after in - depth family discussions , the hospital ethics committee should be consulted . occasionally , however , the ethics consultation is unsuccessful and resolution options will vary from hospital to hospital . the options to resolve conflict includes getting second opinions from non - involved physicians , consulting the ethics team and transferring the patient to another facility . if the established hospital policy fails to remedy the disagreement then legal mediation may be necessary . the evolution of end - of - life care in the icu has resulted in increased physician and patient awareness as to the importance of advance care planning . the trend has turned away from the paternalistic era of physicians making decisions for the patients to more of a patient - centered dogma to preserve patient autonomy . the current use of advance directives has been promoted to ensure that patient preferences are followed when incapacitating illness occurs . there are advantages and disadvantages to advance directive documents ; however , no form can reasonably document all foreseeable maladies . proactive communication with the patient or healthcare proxy is critical and should be initiated upon admission to the trauma icu . in summary , the actual benefit of an advance directive may be to designate a surrogate decision maker , to stimulate end - of life discussions between patients , families and caregivers , and finally , to document what outcome scenarios are acceptable to the patient .
despite advances in the care of the injured patient , 22% of trauma patients admitted to the intensive care unit will die from their injuries . as a majority of these deaths will occur due to withdrawal of care 
 , intensivists should be proficient in their ability to discuss end - of - life care with patients and families . while the use of advance directives to document patients wishes has increased , their utility is uncertain . 
 we review the effectiveness and obstacles of advance directives .