Advance directives for medical care - attitudes of patients toward treatment preferences - Tips from

Date: Sept, 1991

Advance directives for medical care determine the use of life-sustaining interventions when patients are no longer competent to make these decisions. Treatment preferences may be documented in a living will or written advance directive. Through a durable powre of attorney, a person may designate a proxy who will make decisions for health care if the person becomes incapacitated. Most states have laws regarding living wills and durable powers of attorney. More than half of these laws have been enacted during the past five years. However, despite compelling reasons for the use of advance directives and widespread professional and public endorsement, in 1987 only 9 percent of Americans had written preferences for care.

Emanuel and colleagues conducted a study to determine the attitudes of patients toward planning, treatment preferences and the possibility of using a specific document in the outpatient setting to specify advance directives. The survey included 405 outpatients of 30 primary care physicians at Massachusetts General Hospital and 102 members of the general public in Boston. The advance directive was included as part of the survey and took a median of 14 minutes to complete.

Ninety-three percent of the outpatients and 89 percent of the members of the general public reported that they would use an advance directive. Patients who were young and healthy expressed as much interest in the advance directive as elderly patients and those in fair to poor health. The lack of physician initiative was the greatest perceived barrier to issuing advance directives. The disturbing nature of the topic was among the least important conceived barriers. When asked to imagine themselves as being incompetent with a poor prognosis, 70 percent of the subjects with dementia, 70 percent of the subjects reported that they would decide against life-sustaining treatments. The study findings showed that advance directives are desired by most people, can be obtained during an office visit and require physician initiative to complete.

However, in an accompanying article, Danis and colleagues report that the effectiveness of written directives is limited by physician inattention to the directive and by decisions to place priority on considerations other than the patient's autonomy. In a prospective study of 126 competent residents of a nursing home and 49 family members of incompetent patients who placed written directives in the medical record, 25 percent of the subsequent life-sustaining treatment decisions were inconsistent with advance directives. These findings suggest that, while written directives cannot be expected to anticipate all situations, their effectiveness would be enhanced through continued discussions among the physician, health care personnel, patient and family members. (New England Journal of Medicine, March 28, 1991, vol. 324, pp. 882, 889.)

COPYRIGHT 1991 American Academy of Family PhysiciansCOPYRIGHT 2004 Gale Group

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