PubMed · 10152589
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L Jaroff. 1995-12-04. Knowing when to stop.. https://pubmed.ncbi.nlm.nih.gov/10152589/
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Advance directives have not fulfilled their promise of facilitating decisions about end-of-life care for incompetent patients. Many legal requirements and restrictions concerning advance directives are counterproductive. Requirements for witnessing or notarizing advance directives make it difficult for patients to complete a written directive during a physician visit. State laws that establish a hierarchy of family surrogates for incompetent patients who have not appointed a proxy are inflexible and may not apply to common clinical situations. Advance directives would be more useful if they emphasized discussing end-of-life care with physicians rather than completing a legal document. State laws should be revised to encourage patients to discuss advance directives with physicians and to complete them during an office visit. Such patient-physician discussions about end-of-life care can lead to more informed patient decisions. Procedures for written advance directives should be simplified. Patients should be able to designate health care proxies through oral statements to physicians. These reforms will encourage discussions between patients and physicians about advance directives and may lead to more informed decisions near the end of life.
BACKGROUND: Advance directives are widely promoted as a means to plan for patients' decisional incapacity, yet there is little evidence of their effectiveness. We devised a study to assess physicians' compliance with hypothetical advance directives and further examine their clinical reasoning. METHODS: The study consisted of an analysis of a mailed written survey containing 6 hypothetical cases of seriously ill patients. Each case contained an explicit advance directive with potential conflict between the directive and (1) prognosis, (2) wishes of family or friends, or (3) quality of life. Data were collected on the clinical treatment decisions made by physicians and the reasons for those decisions. Study participants were all internal medicine faculty and resident physicians from a single academic institution. RESULTS: A total of 47% analyzable surveys (117/250) were returned. Decisions by faculty and residents were not consistent with the advance directive in 65% of cases. This inconsistency was similar for faculty and residents (68% and 61%, respectively; P>.05). When physicians made decisions inconsistent with the advance directive, they were more likely to list reasons other than the directive for their decisions (89%; P<.001). CONCLUSIONS: Internists frequently made treatment decisions that were not consistent with an explicit advance directive. In difficult clinical situations, internists appear to consider other factors such as prognosis, perceived quality of life, and the wishes of family or friends as more determinative than the directive. Future work needs to explore the generalizability of these findings and examine how strictly patients desire their advance directives to be followed.