Physician perspectives and compliance with patient advance directives: the role external factors play on physician decision making

Abstract

BackgroundFollowing passage of the Patient Self Determination Act in 1990, health care institutions that receive Medicare and Medicaid funding are required to inform patients of their right to make their health care preferences known through execution of a living will and/or to appoint a surrogate-decision maker. We evaluated the impact of external factors and perceived patient preferences on physicians’ decisions to honor or forgo previously established advance directives (ADs). In addition, physician views regarding legal risk, patients’ ability to comprehend complexities involved with their care, and impact of medical costs related to end-of-life care decisions were explored.MethodsAttendees of two Mayo Clinic continuing medical education courses were surveyed. Three scenarios based in part on previously court-litigated matters assessed impact of external factors and perceived patient preferences on physician compliance with patient-articulated wishes regarding resuscitation. General questions measured respondents’ perception of legal risk, concerns over patient knowledge of idiosyncrasies involved with their care, and impact medical costs may have on compliance with patient preferences. Responses indicating strength of agreement or disagreement with statements were treated as ordinal data and analyzed using the Cochran Armitage trend test.ResultsThree hundred eighty-eight of 951 surveys were completed (41% response rate). Eighty percent reported they were likely to honor a patient’s AD despite its 5 year age. Fewer than half (41%) would honor the AD of a patient in ventricular fibrillation who had expressed a desire to “pass away in peace.” Few (17%) would forgo an AD following a family’s request for continued resuscitative treatment. A majority (52%) considered risk of liability to be lower when maintaining someone alive against their wishes than mistakenly failing to provide resuscitative efforts. A large percentage (74%) disagreed that patients could not appreciate complexities surrounding their care while 69% agreed that costs should never impact a physician’s decision as to whether to comply with a patient’s AD.ConclusionsOur findings highlight the impact, albeit small, external factors have on physician AD compliance. Most respondents based their decision on the clinical situation at hand and interpretation of the patient’s initial wishes and preferences expressed by the AD.

The role of law in decisions to withhold and withdraw life-sustaining treatment from adults who lack capacity: a cross-sectional study

“…Although ADs can influence treatment that patients receive at the end of life,39 our findings accord with other studies that show low rates of compliance with ADs that are inconsistent with what is clinically indicated 20 22 24 25. However, this study is significant because it explores whether accurate legal knowledge improves compliance, and the role that the law plays in specialists' decision-making.…”

“…The sample, which included all doctors from the seven specialties most likely to be involved in end-of-life decision-making in the largest Australian states, is more representative than previous related studies which have generally been drawn from those participating in specified training courses or cohorts,7 9 20 specific health facilities13 14 21 25 or a single specialty or society 11 12 18 19 22 24. However, our results from seven specialties in the acute setting may not be generalisable to other doctors or other settings.…”

“…A few studies have also determined that perceptions of legal risk can alter medical decision-making at the end of life 13 19 20. One set of studies by McCrary and others has linked legal knowledge with attitudes, namely whether doctors are likely to be legally defensive 13 14 21.…”

“…There is also a substantial body of research that points to challenges with doctors following legal mechanisms for decision-making such as ADs 20 22–26. But again, this research does not grapple with what the law actually requires as a normative force on decision-making.…”

Conocimientos y actitudes de los profesionales sanitarios en el proceso de declaración de las voluntades vitales anticipadas

“…Dicho cuestionario tenía como fortaleza ir dirigido tanto a personal sanitario como no sanitario, y como debilidad no utilizar una metodología para la construcción del cuestionario reproducible. Un estudio de 2012 en el ámbito de Estados Unidos evaluó el impacto de los factores externos y las preferencias del paciente percibidos sobre las decisiones de los médicos para atender o renunciar a las directivas anticipadas previamente establecidas a través de un cuestionario dirigido a médicos 24 .…”