The utility of standardized advance directives: the general practitioners’ perspective

Abstract

Advance directives (AD) are written documents that give patients the opportunity to communicate their preferences regarding treatments they do or do not want to receive in case they become unable to make decisions. Commonly used pre-printed forms have different formats. Some offer space for patients to (a) appoint a surrogate decision maker, and/or (b) to determine future medical treatments and/or (c) give a statement of personal values. So far it is unknown which forms GPs preferably use and why they decide to do so. 23 semi-structured interviews with GPs were analysed using content analysis. Interviewees mainly use short templates (to appoint surrogate decision makers) and medium length templates with checkboxes to indicate patients’ preferences in regards to life prolonging measures. Especially when patients faced the progression of a disease, participants use the latter version. Only then, the interviewees remarked, patients are capable to rate concrete situations reliably. GPs also realize the importance of the verbal assessment of patients’ preferences; however they rarely keep a written form of the conversation. Some GPs hand out one or more templates and ask their patients to read and think about them at home with the option to talk to them about it later on, while others prefer their patients to fill them out alone at home. Regardless of template usage, most GPs emphasize that ADs require regular updates. GPs tend to see standardized advance directives mainly as a tool to start a conversation with their patients and to identify their real preferences and values. When the patient is still not facing the progression of an already existing disease it could be sufficient to only appoint a surrogate decision maker instead of creating a full AD. However, in all other situations, appointing a surrogate decision maker should be backed up by a written statement of a patient’s general values. Patients and their relatives should always have the opportunity to ask their GP for medical advice when drafting an AD. It is crucial to regularly verify and update existing ADs within the course of a disease.

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

“…Doctors in this study reported validity concerns to be a key barrier to ACD adherence, in accordance with past Australian and international research findings 15 18 20 24. Doubts about validity, including currency of decisions, were particularly prominent where participants disagreed with the treatment decision specified in the ACD.…”

“…In responding to the scenario, only 32% of doctors reported that they would adhere to the ACD in accordance with the law. Studies have identified a number of barriers to ACD adherence, including family opposition,14–16 lack of clinical relevance15 17–20 and concerns about the validity of ACDs 15 18 20…”

Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis

“…Other studies found individuals with lived experience of caring for someone else at end of life, or experience with ACP had increased uptake of ACP,47 58 and this also included GPs with personal experience of ACP 31. Two studies reported the process of discussion and reflection of values over multiple visits as enabling ACP to be most effective,14 34 supported by similar findings from others 43 57 64 65…”

“…System level barriers to ACP were commonly considered in the available literature. Common system level concerns included, for example, the suitability of ACP templates45 57; or uncertainty about the efficacy of one information kit versus another 53. Lack of consensus about what information was required in a written ACP including the relative importance of value statements, contributed to a lack of clarity 45.…”

“…The importance of ACP resources including templates and standardised documentation was a recurrent theme 61. A number of studies recommended the need for standardised and improved ACP templates and tools to support discussion in general practice,57 with testing and development of tools and fit for purpose approaches for target populations. This included one study with findings about efficacy of an ACP template designed for people with low health literacy,45 another study developed and tested a tool to assess stage of change71 and a study that found personalised ACPs increased uptake 70…”