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Am Fam Physician. 2003;67(9):2001-2005

The Federal Patient Self-Determination Act of 1990 requires that patients admitted to a hospital be asked if they have a living will or need information to make one. However, the wording of living wills may be ambiguous, and recent studies have shown that physicians frequently do not apply these documents appropriately. Upadya and colleagues studied whether patients, their family members, and their physicians understand living wills in regard to the use of endotracheal intubation and cardiopulmonary resuscitation (CPR).

The patients selected for this study were admitted to a community teaching hospital between July and October 2001, and had advance directives regarding “terminal conditions” in which intubation or CPR should be refused. Patients were excluded if they had mental status changes that precluded them from answering simple questions about the living will.

The study included 151 patients, 70 physicians (caring for 120 of the patients), and 108 family members. Understanding of the living will was measured by administering oral questionnaires to each patient, the patient's primary care physician, and a family member chosen by the patient. Validation questions were used to determine if the patients understood the initial patient questionnaire.

Among the three groups, there was greater than 87 percent concordance of understanding concerning the use of life support measures to keep patients alive. However, some key differences were noted. Seven physicians indicated that they would not intubate or perform CPR under any circumstances in patients who had living wills, yet three of their patients wanted intubation and CPR if they had a chance of recovering. Two physicians said that they would administer CPR or intubate even if they thought their patients had no chance for recovery; however, these patients and their family members wanted the procedures done only if the patient's condition was reversible. Five family members interpreted the living will as meaning that intubation was precluded in all situations, whereas two of the patients indicated that they wanted to be intubated if their condition was reversible. Four family members indicated that they would refuse the use of CPR based on the patient's living will, while one patient wanted CPR if recovery was possible.

The authors conclude that discrepancies in the interpretation of living wills occur for the following reasons: patients frequently draft living wills without physician input; the definition of “terminal condition” is not absolute; and patients may have a poor understanding of “life support” and the probability of good survival after CPR.

editor's note: The authors acknowledged that a potential methodologic flaw of the study was that they could not determine whether the answers truly reflected the subjects' understanding of the living will versus their current beliefs (i.e., a change in wishes since drafting the will). Regardless, the take-home point is that physicians should actively engage patients and their family members in discussions about advance directives so that patients can make informed and clearly understood decisions about end-of-life care.—s.m.s.

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