The Doctor's Role in Discussing Advance Preferences for End-of-Life Care: Perceptions of Physicians Practicing in the VA.
Markson, Lawrence MD, MPH *+; Clark, Jack PhD *; Glantz, Leonard JD *++; Lamberton, Victoria MPH *[S]; Kern, Donald MD, MPH *; Stollerman, Gene MD *
Journal of the American Geriatrics Society.
45(4):399-406, April 1997.
OBJECTIVES: Although previous studies have shown physicians support advance directives, little is known about how they actually participate in decision-making. This study investigates (1) how much experience physicians have had discussing and following advance preferences and (2) how physicians perceive their role in the advance decision-making process.
DESIGN: Mail survey conducted in 1993.
SETTING: The Department of Veterans Affairs.
PARTICIPANTS: A national probability sample of 1050 VA internists, family physicians, and generalists.
MEASUREMENTS AND MAIN RESULTS: Questionnaires were returned by 67% of participants. In the last year, 79% stated they had discussed advance preferences with at least one patient, and 19% had talked to more than 25. Seventy-three percent had used a written directive to make decisions for at least one incompetent patient. Younger age, board certification, spending less time in the outpatient setting, and personal experience with advance decision-making, were all associated independently with having advance preference discussions. Among physicians who had discussions, 59% said they often initiated the discussion, 55% said discussions often occurred in inpatient settings, and 31% said discussions often occurred in outpatient settings.
Eighty-two percent of those responding thought physicians should be responsible for initiating discussions. Most would try to persuade a patient to change a decision that was not well informed (91%), not medically reasonable (88%), or not in the patient's best interest (88%); few would attempt to change decisions that conflicted with their own moral beliefs(14%).
CONCLUSIONS: Physicians report that they are actively involved with their patients in making decisions about end-of-life care. Most say they have had recent discussions with at least some of their patients and feel that as physicians they should play a large and important role in soliciting and shaping patient preferences.
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