Doctors’ perspectives on adhering to advance care directives when making medical decisions for patients: an Australian interview study

Abstract

ObjectiveAdvance care planning (ACP) assists people to identify their goals, values and treatment preferences for future care. Ideally, preferences are documented in an advance care directive (ACD) and used by doctors to guide medical decision-making should the patient subsequently lose their decision-making capacity. However, studies demonstrate that ACDs are not always adhered to by doctors in clinical practice. We aim to describe the attitudes and perspectives of doctors regarding ACD adherence and the utility of ACDs in clinical practice.DesignFace-to-face semistructured interviews were conducted using three case-based vignettes to explore doctors’ decision-making and attitudes towards ACDs. Transcripts were analysed using a thematic analysis.SettingDoctors from a variety of medical specialties and with varying experience levels were recruited from a large tertiary hospital in Melbourne, Australia.ParticipantsA total of 21 doctors were interviewed, 48% female (10/21). Most (19/21) reported having experience using ACDs.ResultsFour themes were identified: aligning with patient preferences (avoiding unwanted care, prioritising autonomy and anticipating family opposition), advocating best interests (defining futile care, relying on clinical judgement, rejecting unreasonable decisions and disregarding legal consequences), establishing validity (doubting rigour of the decision-making process, questioning patients’ ability to understand treatment decisions, distrusting outdated preferences and seeking confirmation) and translating written preferences into practice (contextualising patient preferences, applying subjective terminology and prioritising emergency medical treatment).ConclusionsACDs provide doctors with opportunities to align patient preferences with treatment and uphold patient autonomy. However, doctors experience decisional conflict when attempting to adhere to ACDs in practice, especially when they believe that adhering to the ACD is not in the patients’ best interests, or if they doubt the validity of the ACD. Future ACP programmes should consider approaches to improve the validity and applicability of ACDs. In addition, there is a need for ethical and legal education to support doctors’ knowledge and confidence in ACP and enacting ACDs.

Advance Care Planning (ACP) vs. Advance Serious Illness Preparations and Planning (ASIPP)

“…A qualitative study from Australia offers further validation of this concern [9]. These investigators performed a qualitative study of doctor's attitudes and beliefs about advance care planning.…”

“…Over the past decade, have we made progress in "preparing patients for end of life decision-making?" Recent studies suggest there are still considerable problems with the current approach [6][7][8][9][10][11][12][13][14]16]. Health care expenditures in the last years of life are increasing at a phenomenal rate suggesting the current approach to "end of life" planning is not working [20].…”

“…These investigators performed a qualitative study of doctor’s attitudes and beliefs about advance care planning. While the authors of the JAMA paper on POLST want to encourage doctors to pay more attention to the previously documented wishes of patients, many doctors looking after these critically ill patients are suspicious about the validity of the prior-expressed wishes (see Box 2 for illustrative quotes from this study) [ 9 ].

Doctor’s Concerns About the Validity of Advance Directives.

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Implementing advance directives—An international literature review of important considerations for nurses

“…However, Moore et al. 's (2019) Australian study of hospital doctors ( n = 21) shows that medical paternalism persists, especially when the doctor strongly disagrees with patients' decisions, believes decisions are not in the patient's best interests or has doubts about instrument validity, suggesting that the legacy of medical paternalism and ‘doctor knows best’ still persists, albeit unwittingly.…”

“…(2013) identify a clear lack of skill among health care providers in advance care planning. Furthermore, the voice of health care professionals across the disciplines—via all 16 studies reviewed—is unequivocal: further training is needed in order to facilitate better advance care planning discussions and optimal take‐up of advance health care directives (Bond & Lowton, 2011; Brazil et al., 2015; Chan et al., 2018; Clark et al., 2015; Cornally et al., 2015; de Vleminck et al., 2014; Detering et al., 2010; Dube et al., 2015; Harrison‐Dening et al, 2016; Moore et al., 2019; Poppe et al., 2013; Robinson et al., 2013; Sampson et al., 2010; Smebye et al., 2012; Son et al., 2020; Wicki, 2018). An interesting view shared by two of the studies, the Norwegian GPs in de Vleminck et al.…”