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Implementing Advance Directives in the Primary Care Setting

Implementing Advance Directives in the Primary Care Setting Abstract Background: Despite the potential benefits of advance directives, few patients complete them. This study examined whether barriers to advance decision making can be overcome via a combined educational and administrative intervention targeted at physicians. Method: The subjects consisted of all the internists (n=6) at a primary care physician home care (HC) service and all the internists (n=4) at a primary care nursing home (NH) service. Physicians were given a 5-week course on the law relating to advance directives. Administrative consent was obtained to permit physicians to spend additional time with patients to discuss advance directives. Physicians were asked to discuss advance directives with newly enrolled patients and to assist interested patients to complete directives. During the first 2 months of the trial, physicians did not approach any patients. Therefore, the study design was changed to include all active patients, and physicians received additional training that involved observing and leading discussions with their own patients. Results: Physicians approached 74 of 356 competent HC patients, of whom 48 (65%) completed directives. All 42 competent NH patients were approached, and 38 (90%) completed directives. Most patients who completed a directive chose relatives as proxies. Most directed that lifesustaining treatment be withheld in the event they were permanently unconscious (HC, 81%; NH, 92%). Other common choices were to decline long-term mechanical ventilation (HC, 58%; NH, 79%), long-term artificial nutrition (HC, 44%; NH, 79%), and cardiopulmonary resuscitation (HC, 27%; NH, 66%). Conclusions: Physicians can overcome initial reluctance to integrate advance decision making into primary care provided to elderly patients. Teaching physicians about the law is not sufficient to change behavior; physicians also need practical experience discussing directives with patients. Our high patient response suggests that a physician-directed intervention is sufficient to achieve high rates of completing directives without additional, concomitant patient-directed intervention.(Arch Intern Med. 1994;154:2321-2327) References 1. Annas GJ, Glantz LH. The right of elderly patients to refuse life-sustaining medical treatment . Milbank Q . 1986;64:95-162.Crossref 2. President's Commission. Making Health Care Decisions . Washington, DC: US Government Printing Office; (October) 1982;1. 3. Smedira NG, Evans BH, Grais LS, et al. Withholding and withdrawal of life support from the critically ill . N Engl J Med . 1990;322:309-315.Crossref 4. Bedell SE, Pelle D, Majer PL, et al. Do-not-resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact? JAMA . 1986;256:233-237.Crossref 5. Bedell SE, Delbanco TL. Choices about cardiopulmonary resuscitation in the hospital: when do physicians talk with patients? N Engl J Med . 1984;310: 1089-1093.Crossref 6. Danis M, Gerrity S, Southerland LI, et al. A comparison of patient, family, and physician assessments of the value of medical intensive care . Crit Care Med . 1988;16:594-600.Crossref 7. Starr TJ, Pearlman RA, Uhlman RF. Quality of life and resuscitation decisions in elderly patients . J Gen Intern Med . 1986;1:373-379.Crossref 8. Uhlmann RF, Pearlman RA, Cain KC. Physicians' and spouses' predictions of elderly patients' resuscitation preferences . J Gerontol . 1988;43:M115-M121.Crossref 9. Zweibel NR, Cassel CK. Treatment choices at the end of life: a comparison of decisions by older patients and their physician-selected proxies . Gerontologist . 1989;29:615-621.Crossref 10. Diamond EL, Jernigan JA, Moseley RA, et al. Decision-making ability and advance directive preferences in nursing home patients and proxies . Gerontologist . 1989;29:622-626.Crossref 11. Annas GJ. The health care proxy and the living will . N Engl J Med . 1991;324: 1210-1213.Crossref 12. Emanuel LL, Emanuel EJ. The medical directive: a new comprehensive advance care document . JAMA . 1989;261:3288-3293.Crossref 13. Relman A. Michigan's sensible 'living will.' N Engl J Med . 1979;300:1270-1272.Crossref 14. Uhlmann RF, Clark H, Pearlman RA, et al. Medical management decisions innursing home patients . Ann Intern Med . 1987;106:879-885.Crossref 15. Schneiderman LJ, Arras JD. Counseling patients to counsel physicians on future care in the event of patient incompetence . Ann Intern Med . 1985;102:693-698.Crossref 16. Cruzan v Director, Missouri Department of Health, 497 US 261 (1990). 17. LaPuma JL, Orentlicher DO, Moss RJ. Advance directives on admission: clinical implications and analysis of the Patient Self-determination Act of 1990 . JAMA . 1991;266:402-405.Crossref 18. Department of Veterans Affairs. Veterans Health Administration Manual M-2 . Washington, DC: Dept of Veterans Affairs; 1991. Part I, chap 31. 19. Council on Ethical and Judicial Affairs , American Medical Association. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA . 1991;265: 1868-1871.Crossref 20. Davidson KW, Hackler C, Caradine DR, et al. Physicians' attitudes on advance directives . JAMA . 1989;262:2415-2419.Crossref 21. Emanuel LL, Barry MJ, Stoeckle JD, et al. Advance directives for medical care: a case for greater use . N Engl J Med . 1991;324:889.Crossref 22. Finucane TE, Shumway JM, Powers RL, et al. Planning with elderly outpatients for contingencies of severe illness: a survey and clinical trial . J Gen Intern Med . 1988;3:322-325.Crossref 23. Shmerling RH, Bedell SE, Lilienfeld A, et al. Discussing cardiopulmonary resuscitation: a study of elderly outpatients . J Gen Intern Med . 1988;3:317-321.Crossref 24. Lo B, McLeod GA, Saika G. Patient attitudes to discussing life-sustaining treatment . Arch Intern Med . 1986;146:1613-1615.Crossref 25. Katz J. The Silent World of Doctor and Patient . New York, NY: Free Press; 1984. 26. Danis M, Southerland LI, Garrett JM. A prospective study of advance directives for life-sustaining care . N Engl J Med . 1991;324:882-888.Crossref 27. Sachs GA, Stocking CB, Miles SH. Empowerment of the older patient? A randomized, controlled trial to increase discussion and use of advance directives . J Am Geriatr Soc . 1992;40:269-273. 28. Hare J, Nelson C. Will outpatients complete living wills? J Gen Intern Med . 1991;6:41-46.Crossref 29. Awoke S, Mouton CP, Parrott M. Outcomes of skilled cardiopulmonary resuscitation in a long-term-care facility: futile therapy? J Am Geriatr Soc . 1992; 40:593-595. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Implementing Advance Directives in the Primary Care Setting

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Publisher
American Medical Association
Copyright
Copyright © 1994 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1994.00420200075008
Publisher site
See Article on Publisher Site

Abstract

Abstract Background: Despite the potential benefits of advance directives, few patients complete them. This study examined whether barriers to advance decision making can be overcome via a combined educational and administrative intervention targeted at physicians. Method: The subjects consisted of all the internists (n=6) at a primary care physician home care (HC) service and all the internists (n=4) at a primary care nursing home (NH) service. Physicians were given a 5-week course on the law relating to advance directives. Administrative consent was obtained to permit physicians to spend additional time with patients to discuss advance directives. Physicians were asked to discuss advance directives with newly enrolled patients and to assist interested patients to complete directives. During the first 2 months of the trial, physicians did not approach any patients. Therefore, the study design was changed to include all active patients, and physicians received additional training that involved observing and leading discussions with their own patients. Results: Physicians approached 74 of 356 competent HC patients, of whom 48 (65%) completed directives. All 42 competent NH patients were approached, and 38 (90%) completed directives. Most patients who completed a directive chose relatives as proxies. Most directed that lifesustaining treatment be withheld in the event they were permanently unconscious (HC, 81%; NH, 92%). Other common choices were to decline long-term mechanical ventilation (HC, 58%; NH, 79%), long-term artificial nutrition (HC, 44%; NH, 79%), and cardiopulmonary resuscitation (HC, 27%; NH, 66%). Conclusions: Physicians can overcome initial reluctance to integrate advance decision making into primary care provided to elderly patients. Teaching physicians about the law is not sufficient to change behavior; physicians also need practical experience discussing directives with patients. Our high patient response suggests that a physician-directed intervention is sufficient to achieve high rates of completing directives without additional, concomitant patient-directed intervention.(Arch Intern Med. 1994;154:2321-2327) References 1. Annas GJ, Glantz LH. The right of elderly patients to refuse life-sustaining medical treatment . Milbank Q . 1986;64:95-162.Crossref 2. President's Commission. Making Health Care Decisions . Washington, DC: US Government Printing Office; (October) 1982;1. 3. Smedira NG, Evans BH, Grais LS, et al. Withholding and withdrawal of life support from the critically ill . N Engl J Med . 1990;322:309-315.Crossref 4. Bedell SE, Pelle D, Majer PL, et al. Do-not-resuscitate orders for critically ill patients in the hospital: how are they used and what is their impact? JAMA . 1986;256:233-237.Crossref 5. Bedell SE, Delbanco TL. Choices about cardiopulmonary resuscitation in the hospital: when do physicians talk with patients? N Engl J Med . 1984;310: 1089-1093.Crossref 6. Danis M, Gerrity S, Southerland LI, et al. A comparison of patient, family, and physician assessments of the value of medical intensive care . Crit Care Med . 1988;16:594-600.Crossref 7. Starr TJ, Pearlman RA, Uhlman RF. Quality of life and resuscitation decisions in elderly patients . J Gen Intern Med . 1986;1:373-379.Crossref 8. Uhlmann RF, Pearlman RA, Cain KC. Physicians' and spouses' predictions of elderly patients' resuscitation preferences . J Gerontol . 1988;43:M115-M121.Crossref 9. Zweibel NR, Cassel CK. Treatment choices at the end of life: a comparison of decisions by older patients and their physician-selected proxies . Gerontologist . 1989;29:615-621.Crossref 10. Diamond EL, Jernigan JA, Moseley RA, et al. Decision-making ability and advance directive preferences in nursing home patients and proxies . Gerontologist . 1989;29:622-626.Crossref 11. Annas GJ. The health care proxy and the living will . N Engl J Med . 1991;324: 1210-1213.Crossref 12. Emanuel LL, Emanuel EJ. The medical directive: a new comprehensive advance care document . JAMA . 1989;261:3288-3293.Crossref 13. Relman A. Michigan's sensible 'living will.' N Engl J Med . 1979;300:1270-1272.Crossref 14. Uhlmann RF, Clark H, Pearlman RA, et al. Medical management decisions innursing home patients . Ann Intern Med . 1987;106:879-885.Crossref 15. Schneiderman LJ, Arras JD. Counseling patients to counsel physicians on future care in the event of patient incompetence . Ann Intern Med . 1985;102:693-698.Crossref 16. Cruzan v Director, Missouri Department of Health, 497 US 261 (1990). 17. LaPuma JL, Orentlicher DO, Moss RJ. Advance directives on admission: clinical implications and analysis of the Patient Self-determination Act of 1990 . JAMA . 1991;266:402-405.Crossref 18. Department of Veterans Affairs. Veterans Health Administration Manual M-2 . Washington, DC: Dept of Veterans Affairs; 1991. Part I, chap 31. 19. Council on Ethical and Judicial Affairs , American Medical Association. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA . 1991;265: 1868-1871.Crossref 20. Davidson KW, Hackler C, Caradine DR, et al. Physicians' attitudes on advance directives . JAMA . 1989;262:2415-2419.Crossref 21. Emanuel LL, Barry MJ, Stoeckle JD, et al. Advance directives for medical care: a case for greater use . N Engl J Med . 1991;324:889.Crossref 22. Finucane TE, Shumway JM, Powers RL, et al. Planning with elderly outpatients for contingencies of severe illness: a survey and clinical trial . J Gen Intern Med . 1988;3:322-325.Crossref 23. Shmerling RH, Bedell SE, Lilienfeld A, et al. Discussing cardiopulmonary resuscitation: a study of elderly outpatients . J Gen Intern Med . 1988;3:317-321.Crossref 24. Lo B, McLeod GA, Saika G. Patient attitudes to discussing life-sustaining treatment . Arch Intern Med . 1986;146:1613-1615.Crossref 25. Katz J. The Silent World of Doctor and Patient . New York, NY: Free Press; 1984. 26. Danis M, Southerland LI, Garrett JM. A prospective study of advance directives for life-sustaining care . N Engl J Med . 1991;324:882-888.Crossref 27. Sachs GA, Stocking CB, Miles SH. Empowerment of the older patient? A randomized, controlled trial to increase discussion and use of advance directives . J Am Geriatr Soc . 1992;40:269-273. 28. Hare J, Nelson C. Will outpatients complete living wills? J Gen Intern Med . 1991;6:41-46.Crossref 29. Awoke S, Mouton CP, Parrott M. Outcomes of skilled cardiopulmonary resuscitation in a long-term-care facility: futile therapy? J Am Geriatr Soc . 1992; 40:593-595.

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Oct 24, 1994

References