Using advance directives effectively in the intensive care unit. Terminating care in the presence--or absence--of directives.

When a patient is admitted to the ICU, determine whether the person has decisional capacity and whether an advance directive exists. If so, discuss treatment options and the directive with the patient--as well as with family members and appointed surrogates; clarify the patient's wishes. If no directive has been drawn up, encourage the patient to do so. If a patient lacks decisional capacity but has a directive, determine whether it applies to the current situation. If it does, follow its instructions. If no directive exists or if it does not apply, consult with family members to determine the patient's wishes, and ascertain whether these substitute judgments meet state laws.