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Patient knowledge and physician predictions of treatment preferences after discussion of advance directives

Journal of General Internal Medicine volume 13, pages 447–454 (1998)Cite this article

Abstract

OBJECTIVE: To determine patient knowledge about life-sustaining treatments and physician understanding of patient preferences for proxies and treatments after outpatient discussions about advance directives.

DESIGN: Cross-sectional interview-based and questionnaire-based survey.

SETTING: Two university general internal medicine practices, two Department of Veterans Affairs general internal medicine practices, and one university-based geriatrics practice, in two different cities.

PATIENTS: Fifty-six patients of primary care internists.

INTERVENTION: Physicians discussed “advance directives” (ADs) with one randomly selected patient during an outpatient visit.

MEASUREMENTS AND MAIN RESULTS: After the discussions, physicians identified the patient’s proxy and predicted the patient’s preferences for treatment in 20 scenarios. Patients provided treatment preferences in the 20 scenarios, the name of their preferred surrogate decision maker, and their understanding of cardiopulmonary resuscitation and mechanical ventilation. Of the 39 patients who discussed resuscitation, 43% were able to identify two important characteristics; 26% identified none; 66% did not know that most patients need mechanical ventilation after undergoing resuscitation. None of the 43 patients who had a discussion about mechanical ventilation had a good understanding of it; 67% did not know that patients generally cannot talk while on ventilators; 46% expressed serious misconceptions about ventilators. There was poor agreement between physicians and their patients regarding treatment preferences in 18 of 20 scenarios (κ −0.04 to 0.31). Physicians correctly identified the proxy 89% of the time (κ 0.78).

CONCLUSIONS: Patients leave routine AD discussions with serious misconceptions about life-sustaining treatments. Physicians are unable to predict treatment preferences but do learn about patients’ preferences for surrogate decision makers.

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Author information

Affiliations

  1. Assistant Professor of Medicine, the Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pa.

    Gary S. Fischer MD & Robert M. Arnold MD

  2. Assistant Professor of Medicine, the Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pa.

    Gary S. Fischer MD & Robert M. Arnold MD

  3. Assistant Professor of Medicine, the Center for Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pa.

    Gary S. Fischer MD, Laura A. Siminoff PhD & Robert M. Arnold MD

  4. the Center for Health Services Research in Primary Care, Durham Veteran’s Affairs Medical Center, Duke UniversityMedical Center, Durham, NC

    James A. Tulsky MD

  5. the Center for Clinical Health Policy Research, Duke University Medical Center, Durham, NC

    James A. Tulsky MD

  6. the Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC

    James A. Tulsky MD

  7. the Department of Psychology-Social and Health Sciences (MRR), Duke University Medical Center, Durham, NC

    Mary R. Rose MA

  8. the Department of Medicine, Case Western Reserve University, Cleveland, Ohio

    Laura A. Siminoff PhD

Authors
  1. Gary S. Fischer MD
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  2. James A. Tulsky MD
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  3. Mary R. Rose MA
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  4. Laura A. Siminoff PhD
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  5. Robert M. Arnold MD
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Additional information

Drs. Tulsky and Arnold are Project on Death in American Soros Faculty Scholars. Dr. Tulsky is a Robert Wood Johnson Generalist Physician Faculty Scholar.

Some of the results and conclusions contained in this manuscript were presented to the annual meeting of the Society of General Internal Medicine, May 1995.

Financial support was provided in part by the R. K. Mellon Foundation, the National Institute on Aging Claude D. Pepper Older Americans Independence Center, grant 5-P60-AG11268, VA HSR&D Service, and the John A. Hartford Foundation.

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Fischer, G.S., Tulsky, J.A., Rose, M.R. et al. Patient knowledge and physician predictions of treatment preferences after discussion of advance directives. J GEN INTERN MED 13, 447–454 (1998). https://doi.org/10.1046/j.1525-1497.1998.00133.x

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  • DOI: https://doi.org/10.1046/j.1525-1497.1998.00133.x

Key words

  • advance directives
  • patient-doctor communication
  • medical ethics