How Do Physicians Communicate About Advance Directives?

Abstract & Commentary

Synopsis: When primary care physicians discussed advance directives, conversations were brief (about 5 minutes), with the physician speaking two-thirds of the time, and the conversations rarely dealt with values or attitudes toward uncertain recovery.

Source: Tulsky JA, et al. Ann Intern Med 1998;129: 441-449.

To understand why advance directives do not work, Tulsky and colleagues audiotaped conversations between 56 primary care providers and established patients randomly selected from the office schedule. Patients were eligible for the study if they were at least 65 years old or had a serious medical illness (such as cancer, prior cardiac arrest, HIV infection, renal insufficiency, chronic obstructive pulmonary disease, or congestive heart failure), and had not previously discussed this topic with their physician.

The physician was asked to "discuss advance directives in whatever way you think is appropriate for this patient." Comments were coded and analyzed using standard techniques. The median age of the physicians was 37 years, and 56% were men. Ninety-five percent of the physicians said they were comfortable talking to patients about advance directives, although 61% said they rarely did this.

The median discussion lasted 5.6 minutes (range, 0.9-15.0 minutes), with the physician speaking for 3.9 minutes (range, 0.6-10.9 minutes) and the patient for 1.7 minutes (range 0.3-9.6 minutes). Most physicians (93%) discussed advance directives by posing hypothetical scenarios. The scenarios were typically dire (no hope of recovery) or completely reversible (no change in functional level). Relatively few of these scenarios (55%) had an unpredictable outcome. When the physicians discussed treatment options, such as cardiopulmonary resuscitation or mechanical ventilation, they rarely clarified what the patient knew about the treatment. Several patients expressed a desire not to be a "vegetable," but no physician asked what this meant to the patient. Patients overwhelmingly viewed these discussions as positive experiences. All stated they were glad to have had the discussion, 96% felt it had been worthwhile, and all believed that their physician did a good job talking about these issues. Only 7% of the patients felt uncomfortable during the discussion.

Comment by Leslie A. Hoffman, PhD, RN

Numerous organizations, legislators, and the courts advocate use of advance directives to ensure that the patient’s wishes are respected when making end-of-life decisions. Discussions regarding advance directives are supposed to introduce patients to the concept and elicit their preferences when they are competent and can provide input. Nevertheless, prior research indicates that advance directives rarely influence how care is provided at the end of life.

Findings from this study suggest that this outcome may be appropriate, rather than inappropriate. The study was conducted in five primary care medicine practices in two states (NC, PA), and involved 56 primary care physicians and 56 established patients, all of whom gave consent to participate. The physicians knew that they were being audiotaped, so the results presumably represent a best case scenario. Nevertheless, conversations were brief and infrequently included situations in which the outcome was uncertain. Most patients told their physicians they would reject treatment in the face of certain death and would desire aggressive treatment for reversible illnesses, an expected outcome.

Only 13% of physicians mentioned outcomes of life-sustaining treatment other than complete recovery or death, such as continued dependence on mechanical ventilation or impaired cognition. Physicians rarely asked patients to define what they meant by "a good quality of life" or "being a burden." Instead, they asked if they wanted specific interventions. The conversations accomplished the goal of introducing the topic of advance directives, but their usefulness in guiding future treatment decisions was unclear. Nevertheless, the patients valued these discussions.

Prior studies have examined a number of factors to explain why advance directives do not work as intended. Part of the explanation may lie in the findings of this study. We cannot be certain that a previously written directive accurately reflects the preferences of the patient in the current circumstances. Given this, it appears appropriate to reaffirm preferences, rather than simply follow the directive. It is not possible to know whether the prior discussion was of the quality necessary to accurately elicit preferences, or whether the patient understood all the implications. Rather than trying to increase the number of conversations about this topic, it would seem more important to attempt to increase the quality of communication and information shared during these conversations.