The Patient Self-Determination Act of 1990 mandates that hospitals reimbursed by Medicare and Medicaid inform each patient about the patient’s right to a natural death.


To describe and explore implementation of the Patient Self-Determination Act in a critical care setting. The goal was to assess patients’ understanding of advance directives.


In a semistructured cross-sectional study, all eligible patients 18 years or older admitted to the cardiac intensive care unit at Duke University Medical Center, Durham, North Carolina, were assessed. Each patient was asked the standard question required by the Patient Self-Determination Act—Do you have an advance directive?—and 3 open-ended questions to ascertain the patient’s understanding of advance directives.


The sample consisted of 505 patients with a mean age of 61.9 years (SD, 14.8), 37.8% (n = 191) were women, and 68.5% (n = 346) were white. Most patients (64.4%; n = 325) did not have an advance directive before admission to the unit. Of the patients who initially declined the opportunity to complete an advance directive (n = 213), 33.8% (n = 72) said they did not understand the question when initially asked and therefore just said no.


Current practice meets the requirement of the Patient Self-Determination Act for documentation of patients’ right to a natural death. However, simply asking Do you have an advance directive? does not elicit an accurate reflection of a patient’s understanding of advance directives.

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