Editorial

Initiating Discussions About Advance Directives: The Family Physician's Role



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Am Fam Physician. 2002 Jun 15;65(12):2443-2445.

Despite federal laws that give persons the right to formulate advance directives, most Americans have not executed living wills or medical powers of attorney designed to clarify their values and wishes about their medical care if they lose decision-making capacity.1 A primary reason that most Americans do not have an advance directive is the reluctance of primary care physicians to initiate discussions about them with their patients.2 This disinclination is understandable, but family physicians should work to overcome their discomfort. Talking with patients about advance care planning while they are relatively healthy and helping patients formulate advance directives can be a great service for patients, their families, and other health care professionals.

Most advance directives are written when patients are admitted to hospitals with acute problems, and treating physicians are often unaware of patients' preferences about end-of-life care.3 Formulating advance directives at this time is less than ideal because the emotional and physical strain associated with the trauma of an injury or a serious illness can make it difficult to consider rationally the implications of complex decisions about end-of-life care. Many patients in acute care settings never discuss their desires about care options with relevant loved ones, and treatment choices frequently conflict with patients' values.4

Poorly informed decisions that are legally binding can create tragic problems for families and health care professionals. Many advance directives contain ambiguous language that makes it difficult to determine what patients' wishes might be in a particular clinical context. Clinically uninformed choices can be made, forcing treatment teams to perform procedures that cause unnecessary suffering for patients who are dying.

Family physicians possess knowledge they can use to guide their patients in appropriate decision-making concerning advance directives. It is important for family physicians to discuss advance care planning with patients and their families as part of an ongoing relationship because complex decisions about end-of-life care should be seen as a process rather than a product.5

In addition to the anxiety that physicians feel over initiating discussions about advance care planning, the limited amount of time available during office visits hinders physicians from initiating these discussions.6 The perception of the physician-patient relationship as a consumer-provider transaction rather than an intimate relationship based on trust further inhibits physicians from initiating discussions.7

Some physicians and policy makers claim that the effort to utilize advance directives to improve end-of-life care has been a failure.8,9 Advance directives have frequently failed to improve adherence to patient preferences in end-of-life decision-making,10 but it remains to be seen whether the usefulness of advance directives can be significantly improved. Some evidence11 already indicates that advance directives written with the help of family physicians influence treatment decisions at the end of life and typically result in less aggressive treatment before death.

If family physicians can overcome the natural tendency to avoid uncomfortable conversations about death and dying, and begin to view the initiation of discussions about advance care planning as an ethical responsibility, then the disappointing results of empirical studies12 investigating the impact of the Patient Self-Determination Act may become balanced by more positive findings. Some physicians and communities have attempted to educate patients and their families about advance directives and have reported success.13 Further benefits can be anticipated if more family physicians recognize that they are ideally situated to help patients formulate medically sound advance directives that accurately reflect their values.

It is often difficult for physicians to ascertain the values or wishes of patients who have lost decision-making capacity, and physicians tend to aggressively treat patients whose wishes are not known. This can lead to unnecessary suffering for patients and increased costs of care without enhancing the quality of life. By initiating advance care planning discussions with patients when they are relatively healthy and using medical expertise to guide patients through the process of formulating advance directives, family physicians can provide a valuable service to patients, families, and other health care professionals.

Blake Sypher, Ph. D., is an assistant professor in the Department of Family and Community Health and director of biomedical ethics education at the Marshall University School of Medicine in Huntington, W. Va. He is currently a clinical ethics consultant for the ethics committee at Cabell-Huntington Hospital and the Hospice of Huntington Ethics Task Force.

Address correspondence to Blake Sypher, Ph. D., Marshall University School of Medicine, Family and Community Health, 1540 Spring Valley Drive, Huntington, WV 25704.

REFERENCES

1. Miles SH, Koepp R, Weber EP. Advance end-of-life treatment planning: a research review. Arch Intern Med. 1996;156:1062–8.

2. Doukas D. Advance directives in patient care: if you ask, they will tell you. Am Fam Physician. 1999;59:530–3.

3. Virmani J, Schneiderman LJ, Kaplan RM. Relationship of advance directives to physician-patient communication. Arch Intern Med. 1994;154:909–13.

4. Teno J, Lynn J, Wenger N, Phillips RS, Murphy DP, Connors AF Jr, et al. Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. J Am Geriatr Soc. 1997;45:500–7.

5. Schneiderman LJ. The family physician and end-of-life care. J Fam Pract. 1997;45:259–61.

6. Silveira MJ, DiPiero A, Gerrity MS, Feudtner C. Patients' knowledge of options at the end of life: ignorance in the face of death. JAMA. 2000;284:2483–8.

7. Sypher B. Professional or technicians? The importance of enhancing patient trust. W V Med J. 2001;97:142.

8. Schneider CE. The best-laid plans. Hastings Cent Rep. 2000;30:24–5.

9. Ditto PH, Danks JH, Smucker WD, Bookwala J, Coppola KM, Dresser R, et al. Advance directives as acts of communication: a randomized controlled trial. Arch Intern Med. 2001;161:421–30.

10. Teno JM, Licks S, Lynn J, Wenger N, Connors AF Jr, Phillips RS, et al. Do advance directives provide instructions that direct care?. J Am Geriatr Soc. 1997;45:508–12.

11. Hanson LC, Earp JA, Garrett J, Menon M, Danis M. Community physicians who provide terminal care. Arch Intern Med. 1999;159:1133–8.

12. Prendergast TJ. Advance care planning: pitfalls, progress, promise. Crit Care Med. 2001;29:N34–9.

13. Hammes BJ, Rooney BL. Death and end-of-life planning in one midwestern community. Arch Intern Med. 1998;158:383–90.


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