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PubMed1994

Physician reluctance to discuss advance directives. An empiric investigation of potential barriers.

BACKGROUND: To determine the relative impact of five proposed barriers to physician usage of advance directives with the aim of increasing the number of advance directives generated. METHODS: Questionnaires were sent to 460 internal medicine resident and attending physicians at a large New York, NY, hospital. Of these, 277 (60%) responded. We used multiple regression to measure the impact of five barriers to physician-initiated discussions of advance directives (time constraints, compensation concerns, discomfort with the subject, beliefs about appropriateness, and lack of understanding) on respondents' estimates of the number of advance directives held by respondents' patients, the number of recent advance directive discussions, and the number of discussions initiated by physicians. RESULTS: Physician lack of understanding and erroneous beliefs about appropriateness had particularly strong effects, serving as barriers to recent advance directive discussions (P < .0001 and P < .0001, respectively) and total number of advance directives held (P < .0001 and P < .02). Physicians' lack of knowledge also served as a barrier to the percentage of discussions that were physician initiated (P < .003 and P < .04). Time constraints and lack of comfort affected only discussions that were physician initiated (P < .001). Compensation concerns did not appear to serve as a barrier. Respondents were supportive of the concept of advance directives but reported minimal use of them in appropriate situations. CONCLUSIONS: Attention can now be focused on methods to overcome the five barriers studied and thereby enhance the execution of advance directives.

Adult↗
PubMed1998

Nurses' knowledge of advance directives.

BACKGROUND: The Patient Self-Determination Act offers persons the opportunity to make their end-of-life choices known by the use of advance directives. Although nurses are designated advocates for patients and are available to communicate patients' concerns and wishes to other healthcare providers, few data on nurses' knowledge of advance directives have been reported. OBJECTIVE: To describe nurses' knowledge of advanced directives. SAMPLE: A volunteer sample of 339 RNs in a 600-bed acute care teaching hospital was surveyed. The sample represents 38% of the approximately 900 nurses employed at this hospital. METHODS: Data obtained from a 44-item questionnaire that tested nurses' knowledge of advance directives were analyzed. In addition, the relationship between nurses' knowledge of advance directives and certain demographic factors was analyzed. RESULTS: The mean score for knowledge of advance directives was 78% correct answers. Fifty-five percent of the respondents indicated that they did not have a good understanding of advance directives. Only 14% had completed these end-of-life documents for themselves, and 92% indicated that further education would increase their understanding of advance directives. An analysis of variance produced only one significant finding: the relationship between ethnicity and knowledge about advance directives. CONCLUSIONS: Nurses must increase their knowledge of advance directives. Results of this survey should stimulate caregivers and hospital policy makers to take a long-range view of their responsibilities to patients regarding advance directives and their responsibilities for educating the persons who convey information about advance directives to patients.

Adult↗
PubMed1992

Advance directives provide answers for tough questions.

Will advance directives provide an effective means of assuring that previously written decisions will be honored by health care providers if the patient becomes incompetent or terminally ill? This and other questions are posed in the following article. The Patient Self-Determination Act of 1990 mandates that all health care providers receiving federal reimbursement for services provide information to each patient and offer the option of executing an advance directive for health care decisions. The author presents an overview of two studies about advance directives as reported in the New England Journal of Medicine.

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PubMed2003

Dr. Jekyll's waiver of Mr. Hyde's right to refuse medical treatment: Washington's new law authorizing mental health care advance directives needs additional protection.

Mental health care advance directives are gaining popularity nationwide. Following a growing trend, the Washington State Legislature has recently passed a law allowing patients to draft mental health care advance directives that could be irrevocable. Patients who sign an irrevocable directive essentially waive their fundamental right to refuse treatment in the future. The United States Supreme Court has held that waivers of fundamental rights must be made knowingly, voluntarily, and intelligently. However, as passed, Washington's new law contains insufficient safeguards to guarantee such a waiver. This Comment proposes that the Washington State Legislature amend this law the require two additional protections: a "rights advocate" to explain the potential waiver of rights, and a written warning in the advance directive form. These safeguards will help ensure that patients make knowing and intelligent waivers of their fundamental right to refuse treatment.

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PubMed2004

Promoting advance directives among elderly primary care patients.

OBJECTIVE: To determine efficient ways of promoting advance directives among heterogeneous populations of elderly ambulatory patients. DESIGN: One-year quasi-experimental trial. SETTING: Five suburban and urban health centers in one region of a large managed care organization. One additional suburban center served as a control site. PARTICIPANTS: Individuals ages 65 and older (N= 2,120) who were continuously enrolled and had a health maintenance visit with their primary care provider during the study year. INTERVENTION: Physician education (oral and written) and physician and patient prompts to discuss advance directives. MAIN RESULTS: Sixty-six (7.8%) of patients at the intervention centers completed new advance directives, versus 9 of 1,277 (<1%) at the comparison center (P <.001). Patients 75 and older were twice as likely (odds ratio [OR], 2.0; 95% confidence limits [CL], 1.2 to 3.3) as those 65 to 74 to file a new advance directive, and the odds were twice as great (OR, 2.6; 95% CL, 1.4 to 4.6) at centers serving communities with median household income over the state median. Gender, recent hospitalization, emergency room visits, and number of chronic conditions were not related to making new directives nor was predominant ethnicity of the center community (African-American versus white). Adjusted for these factors, the intervention resulted in a 20-fold increase (95% CL, 10.4 to 47.8) in the odds of creating a new advance directive. Doctors reported barriers of time and unwillingness to press discussions with patients. CONCLUSIONS: A replicable intervention largely targeting doctors achieved a modest increase in advance directives among elderly ambulatory patients. Future interventions may need to target lower-income patients, "younger" elderly, and more specifically address doctors' attitudes and comfort discussing advance directives.

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PubMed2003

Thinking ahead: factors associated with executing advance directives.

This article examines why older adults do or do not execute advance directives. METHODS. Secondary data analysis was conducted on data from the Charlotte County (Florida) Healthy Aging Study, on 451 adults who were relatively healthy and affluent. Exploratory logistic regressions were conducted on the probability that respondents had executed advance directives. RESULTS. Findings indicated that increasing age and higher income were the most consistent indicators of having executed an advance directive. Also, individuals reporting taking more prescription medications were more likely to have all the advance directives, except the durable power of attorney for health care. Reporting more negative life events was predictive of having executed the durable power of attorney for health care. DISCUSSION. These findings suggest that in addition to awareness of advance directives, demographic, health, and situational factors may affect the willingness of older adults to execute advance directives. Further research should examine other, more representative, samples to confirm these findings.

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PubMed2005

[Advance directives in the prehospital setting -- emergency physicians' attitudes].

OBJECTIVE: The German physician based emergency medical system (EMS) might confront physicians with advance directives in the field. A multi-question survey was used to evaluate emergency physicians' experience with advance directives in the prehospital setting and to assess their attitudes towards forms and statements of advance directives. METHODS: A questionnaire was mailed to the members of the Association of Emergency Physicians of Northern Germany ("AGNN"), an interest group of emergency physicians, in 2001. RESULTS: 511 emergency physicians (50,4 % of the AGNN members) filled in the questionnaire completely and sent it back for evaluation. 75 % of the participants were working as emergency physicians at present, 72 % had emergency experiences of more than 5 years. One third had previously dealt with advance directives in the prehospital setting. 77 % of these physicians thought advance directives generally helpful. Nevertheless 88 % based their management on the context of the individual circumstances (e. g. emergency conditions, underlying diseases, expected prognosis), only 7 % said they would always exactly follow the statements of the directive. In the view of the emergency physicians the advance directive should contain information on cardiopulmonary resuscitation (CPR: 88 %), intensive care-treatment (75 %) and preclinical emergency treatment (55 %). Information on underlying diseases (87 %) and a legal substitute (84 %) should be contained as well. As formal requirements, 47 % of the physicians wanted the family doctor to be involved, 49 % desired a notary authenticity confirmation, additionally or solely. Pragmatically, the advance directive should be kept with the personal documents (84 %). A regular reconfirmation was deemed necessary (twice to once a year: 64 %). The current legal situation was regarded as unclear by 81 % of the emergency physicians, 85 % favored a unique, officially authorized type of directive. CONCLUSION: The high number of returned questionnaires shows the importance of the topic "advance directives" for emergency physicians. Despite some practical and legal problems, a big majority of the experienced emergency physicians in this survey thought the advance directives in the prehospital setting to be helpful. A clear statement on resuscitation as well as simplification of the many existing types of directives are the most essential requirements demanded by the emergency physicians. A solution could be the creation of an extra "emergency advance directive".

Attitude of Health Personnel↗
PubMed2004

[Medical advance directives as instruments of patient self-determination].

Medical advance directives and durable powers of attorney for health care increasingly gain importance and recognition as instruments of patient self-determination. This article explores the various possibilities for advance directives as well as their ethical legal background. Furthermore, results of a current patient and population survey are presented, showing how (potential) patients think about the possibilities of advance directives. Finally, practical recommendations on how to deal with medical advance directives are given.

Adult↗
PubMed2003

[Advance Directives: theoretical concept and practical significance in the USA].

The article examines on the basic of empirical data the discrepancy between the theoretical demand and the practical role of advance directives. Often advance directives have no influence on medical decision-making in clinical care of critically ill patients. The vague language of the widely used standard living wills and the lack of physician-patient communication in the process of delivering an advance directives are contributing factors. However, many physicians even disregard patients' preferences in concrete and meaningful living wills at the end of life. Besides the lack of information many even seriously ill patients do not deliver an advance because they misjudge their medical prognosis and life expectancy. Often the communication between patients and doctors are blocked because they expect from the each other the first step to talk about end of life decisions and advance directives. In this context physicians claim lack of time, training in communication skills and their discomfort in talking about death and dying with their patients.

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PubMed2004

Improving completion of advance directives in the primary care setting: a randomized controlled trial.

BACKGROUND: Since 1991, hospitals have asked patients whether they have advance directives, but few patients complete these documents. We assessed two simple interventions to improve completion of advance directives among elderly or chronically ill outpatients. METHODS: We conducted a cluster randomized controlled trial involving 1079 patients from five general medicine clinics that were affiliated with an academic medical center. Patients were either > or =70 years of age or > or =50 years old with a chronic illness. The study comprised three arms: physician reminders recommending documentation of advance directives, physician reminders plus mailing advance directives to patients together with educational literature, or neither intervention (control). The main outcome measure was completion of an advance directive. RESULTS: After 28 weeks, 1.5% (5/332) of patients in the physician reminder group, 14% (38/277) in the physician reminder plus patient mailing group, and 1.8% (5/286) in the control group had completed advance directives. In multivariate analyses, patients in the physician reminder plus patient mailing group were much more likely than controls to have completed advance directives (odds ratio [OR] = 5.9; 95% confidence interval [CI]: 1.5 to 22), whereas patients in the physician reminder-only group were no more likely than controls to have completed advance directives (OR = 0.88; 95% CI: 0.21 to 3.7). CONCLUSION: Mailing health care proxy and living will forms and literature to patients before an appointment at which their physicians received a reminder about advance directives yielded a small but significant improvement in completion of these documents. A physician reminder alone did not have an effect.

Adult↗
PubMed2001

Advance directives as acts of communication: a randomized controlled trial.

BACKGROUND: Instructional advance directives are widely advocated as a means of preserving patient self-determination at the end of life based on the assumption that they improve surrogates' understanding of patients' life-sustaining treatment wishes. However, no research has examined whether instructional directives are effective in improving the accuracy of surrogate decisions. PARTICIPANTS AND METHODS: A total of 401 outpatients aged 65 years or older and their self-designated surrogate decision makers (62% spouses, 29% children) were randomized to 1 of 5 experimental conditions. In the control condition, surrogates predicted patients' preferences for 4 life-sustaining medical treatments in 9 illness scenarios without the benefit of a patient-completed advance directive. Accuracy in this condition was compared with that in 4 intervention conditions in which surrogates made predictions after reviewing either a scenario-based or a value-based directive completed by the patient and either discussing or not discussing the contents of the directive with the patient. Perceived benefits of advance directive completion were also measured. RESULTS: None of the interventions produced significant improvements in the accuracy of surrogate substituted judgment in any illness scenario or for any medical treatment. Discussion interventions improved perceived surrogate understanding and comfort for patient-surrogate pairs in which the patient had not completed an advance directive prior to study participation. CONCLUSIONS: Our results challenge current policy and law advocating instructional advance directives as a means of honoring specific patient wishes at the end of life. Future research should explore other methods of improving surrogate decision making and consider the value of other outcomes in evaluating the effectiveness of advance care planning.

Advance Care Planning↗
PubMed2006

Compliance with and understanding of advance directives among trainee doctors in the United Kingdom.

AIM: To investigate doctors' response to and understanding of the legal status of advance directives. METHODS: A vignette-based study administered at palliative medicine, oncology, general practice, and geriatric medicine specialist registrar meetings (United Kingdom). Respondents determined the treatment to provide for a patient presenting with a myocardial infarction with or without an advance directive requesting maximum therapy. RESULTS: Response rate 77% (43/56). Twenty-five percent (10/40) of respondents increased the care that they would provide in response to the advance directive (p = 0.004); 77% (33/43) support/strongly support use of advance directives; 51% (22/43) did not know the legal status of advance directives; 44% found that their medical school education was not an important influence on their decision making. CONCLUSIONS: Advance directives requesting treatment can increase the level of care provided by the physician, however, most trainees chose a level of care different from that in the advance directive. Confusion exists among doctors about the legal status of advance directives, which limits their usefulness. Medical education needs to be improved to train doctors to deal with advance directives.

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PubMed1998

Advance directives for non-therapeutic dementia research: some ethical and policy considerations.

This paper explores the use of advance directives in clinical dementia research. The focus is on advance consent to participation of demented patients in non-therapeutic research involving more than minimal risks and/or burdens. First, morally relevant differences between advance directives for treatment and care, and advance directives for dementia research are discussed. Then attention is paid to the philosophical issue of dementia and personal identity, and the implications for the moral authority of research advance directives. Thirdly, a number of practical shortcomings of advance directives for non-therapeutic dementia research are explored and attention is paid to the role of proxies. It is concluded that upon a closer look the initial attractiveness of advance directives for dementia research is lessened, and that it is doubtful whether these instruments can compensate for the lack of subject consent in case of non-therapeutic dementia research involving more than minimal risks and/or burdens for the incompetent demented subject.

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PubMed1995

Advance directives in the intensive care unit of a tertiary cancer center.

BACKGROUND: Advance directives are associated with considerable controversy. The goal of this study was to evaluate the outcomes of critically ill patients with cancer who were admitted to the intensive care unit and who previously had executed an advance directive. The problems associated with interpreting and honoring such documents in a tertiary cancer center also were reviewed. METHODS: A prospective observational study of patients with cancer with advance directives who were admitted to the intensive care unit of a major cancer hospital was undertaken. Twenty-six patients with directives were followed from the time of admission to the intensive care unit or, in the case of patients who presented their directives after admission, from the time of presentation of the directive until either discharge or death. RESULTS: Twenty four of the 26 patients were placed on mechanical ventilators. Eight patients died while on the ventilator, nine were terminally weaned, and seven were weaned and survived for at least 24 hours. Of these seven patients, six died before being discharged from the hospital and one was discharged home. Delay in presenting the advance directive, conflict between the dictates of the living will and the wishes of the person named in the durable power of attorney, and controversy among health-care providers as to when in the course of disease the spirit of the advance directive had been met were the most frequent problems encountered; a number of other concerns were also identified. CONCLUSIONS: Considerable controversy exists regarding advance directives, and such documents often leave room for confusion about patients' desires in particular clinical situations. Many of the problems identified in this study might be avoided and considerable cost savings achieved by the timely presentation of documents and by the evaluation of clinical goals on an ongoing basis.

Advance Directives↗
PubMed1992

Family physicians' attitudes toward advance directives.

OBJECTIVE: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario. DESIGN: Cross-sectional survey. PARTICIPANTS: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded. RESULTS: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission. CONCLUSIONS: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.

Adult↗
PubMed2003

Use of a values history in approaching medical advance directives with psychiatric patients.

The Patient Self-Determination Act became federal law in 1990. However, many psychiatric facilities are just beginning to actively address the issue of medical advance directives. The term advance directives, for the purposes of this article, refers exclusively to medical advance directives. Psychiatric advance directives, which are related to issues such as involuntary hospitalization, are beyond the scope of this article.

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PubMed1998

Optimal use of orders not to intervene and advance directives.

More rigorous efforts in advance care planning are required in order to tailor end-of-life care to the preferences of patients so that they can experience a satisfactory last chapter of their lives. There is need for better availability and tracking of advance directives, and more uniform adoption of form documents that can be honored in every state. The discouraging evidence of inadequate end-of-life decision making indicates the necessity of several improvement strategies. In response to this need, the Council on Ethical and Judicial Affairs of the American Medical Association has examined this issue again and presents the following report and recommendations.

Advance Care Planning↗
PubMed1998

Opening the black box: how do physicians communicate about advance directives?

BACKGROUND: The quality of communication that leads to the completion of written advance directives may influence the usefulness of these documents, but the nature of that communication remains relatively unexplored. OBJECTIVE: To describe how physicians discuss advance directives with patients. DESIGN: Prospective study. SETTING: Five outpatient primary care medicine practices in Durham, North Carolina, and Pittsburgh, Pennsylvania. PARTICIPANTS: 56 attending internists and 56 of their established patients. Eligible patients were at least 65 years of age or had a serious medical illness. MEASUREMENTS: Two raters coded transcripts of audiotaped discussions about advance directives to document how physicians introduced the topic of advance directives, discussed scenarios and treatments, provided information, elicited patient values, and identified surrogate decision makers. RESULTS: Conversations about advance directives averaged 5.6 minutes; physicians spoke for two thirds of this time. In 91% of cases, physicians discussed dire scenarios in which most patients would not want to be treated, and 48% asked patients about their preferences in reversible scenarios. Fifty-five percent of physicians discussed scenarios involving uncertainty, typically using vague language. Patients' values were rarely explored in detail. In 88% of cases, physicians discussed surrogate decision making and documents to aid in advance care planning. CONCLUSIONS: Although they accomplished the goal of introducing patients to advance directives, discussions infrequently dealt with patients' values and attitudes toward uncertainty. Physicians may not have addressed the topic in a way that would be of substantial use in future decision making, and these discussions did not meet the standards proposed in the literature.

Adult↗