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Am Fam Physician. 2001;64(2):319-320

Results from many studies have shown that patients and physicians believe that discussions about advance directives are important. However, there is some disagreement about who should broach this sometimes difficult subject. Tierney and colleagues conducted this prospective cohort study to determine the level of patients' satisfaction with their physician relative to whether discussions about end-of-life care occurred.

This study was undertaken in the context of a randomized, controlled trial of computerized reminders to physicians to discuss advance directives with elderly or chronically ill patients. Patients who were at least 75 years of age or 50 to 74 years of age with chronic heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, chronic renal insufficiency, liver failure or cancer were included in the study. Patients who had previously completed an advance directive were excluded. Patients who passed a brief cognitive examination were then evaluated with two instruments that measured patient satisfaction: the American Board of Internal Medicine questionnaire assessed a patient's satisfaction with the physician, and the Visit-Specific Questionnaire assessed satisfaction with the visit itself. Demographic information about each patient and information about the physician (location of medical school, number of patients seen, etc.) was also collected. After the visit with the physician, each patient was asked if there had been a discussion about advance directives at that visit or at a previous visit.

Of the 1,051 patients enrolled in the study, 686 were included in the final analysis. Before the study, only 2 percent of the patients reported having had a discussion about advance directives with their physician. During the study, 110 (16 percent) patients discussed advance directives with their physician. The factors that correlated most strongly with current visit satisfaction were satisfaction with the enrollment visit and a previous discussion of advance directives. If there was an advance directive discussion that day, the rating of “excellent” was given to 44 percent of visits, compared with a 35 percent “excellent” rating for visits that did not include advance directive discussions. If there had been a prior discussion of advance directives, the “excellent” rating was given to 51 percent of visits compared with 34 percent of visits in patients who had not previously had such a discussion.

The authors conclude that improved patient satisfaction with the physician's care of the patient is among the many benefits of discussing advance directives. These discussions should occur during routine health maintenance visits whenever possible, instead of waiting until the patient is acutely ill, a time when end-of-life discussions will probably be much more difficult.

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