Advance Directives Are Just One Factor Physicians Consider when Making End-of-life Treatment Decisions
Advance directives give you a voice in treatment decisions should you become too ill to communicate with your healthcare team, such as in the case of a coma or other conditions affecting your mental capacity. These documents include living wills, durable powers of attorney (DPA) for healthcare, and Do Not Resuscitate (DNR) orders. A living will stipulates the type of care you would like to receive or not receive, such as a breathing tube. A living will only comes into affect if you have less than six months to live. A DPA allows you to appoint another person, called a proxy, to make medical decisions for you. It comes into effect anytime you are unable to make decisions. A DNR order specifically prohibits life-saving interventions if your heart stops.
Previous studies examining the influence of advance directives have found they have little bearing on doctors’ care decisions. In some cases, physicians do not know their patients have made such directives. In other cases, the complexity of the situation is beyond what is covered in the directive, making other factors more influential. Such factors include changes in health status, prognosis, quality of life, and family wishes. In this study, published in the July 26, 2004 issue of Archives of Internal Medicine, researchers set out to determine how closely doctors would stick to patient wishes—as outlined in advance directives—when making difficult treatment decisions.
About the Study
The researchers designed a survey with six made-up cases. In each case, the patient had a serious or life-threatening illness and had lost his or her ability to make decisions. Each patient had an advance directive. However, the cases also included factors that conflicted with the patient’s stated wishes.
After reading each case, the physicians selected one of two treatment options. They indicated the main reason for their decisions by choosing one of the following:
- Advance directives take priority
- Families/friends take priority
- Likelihood of survival takes priority
- Quality of life takes priority
- Physicians were also provided space to write comments about their decisions.
A sample hypothetical case follows:
Patient: A 48-year-old woman with type 1 diabetes mellitus is receiving dialysis. She has had a stroke and is now completely aphasic (unable to use or comprehend words). The neurologists believe that there is a poor prognosis for recovery.
Advance directive: She requests full treatment regardless of prognosis and names her husband as proxy. However, he requests that dialysis be stopped.
Respondent treatment choices: Stop dialysis or continue dialysis?
Despite this hypothetical woman’s request for full treatment, 66% of physicians in this study chose to stop dialysis. This result is representative of the responses to all six cases. Analysis of the 117 surveys completed found that physicians’ decisions were inconsistent with the advanced directives in 65% of cases. When such decisions were made, physicians indicated that other factors took priority over the advance directives.
How Does This Affect You?
Does this mean that you need not bother to write an advance directive for your medical care? Not at all. An advance directive can help guide your physician when you cannot participate in decision making. However, directives are limited in that they cannot anticipate all situations. As the doctors in this study showed, most medical decisions are made after careful consideration of all relevant factors, and do not depend solely on wishes expressed in a directive.
Perhaps the most important function of an advance directive is that of a conversation starter. While discussions about future medical care can be difficult, it is important to talk with your doctor and your loved ones about your wishes, should other people need to make decisions for you. An advance directive provides a good starting point for this discussion.
American Academy of Family Physicians
Promoting Excellence in End-Of-Life-Care
Hardin, SB and Yusufaly, YA. Difficult end-of-life treatment decisions. Archives of Internal Medicine . 2004;164:1531-1533.
American Academy of Family Physicians. Advance directives and do not resuscitate orders. Available at: http://familydoctor.org/003.xml Accessed July 28, 2004.
Last reviewed Jul 30, 2004 by ]]>Richard Glickman-Simon, MD]]>
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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