Advance Directives for Medical Care — A Case for Greater Use

Emanuel, Linda L.; Barry, Michael J.; Stoeckle, John D.; Ettelson, Lucy M.; Emanuel, Ezekiel J.

doi:10.1056/nejm199103283241305

Cited by 729 publications

(386 citation statements)

References 17 publications

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“…13 For each of seven life-sustaining treatments, we asked whether it was provided more than, less than, or the same as surveyed pref-…”

Section: Discussionmentioning

confidence: 99%

“…13 For each of seven life-sustaining treatments, we asked whether it was provided more than, less than, or the same as surveyed pref-JGIM erences for that treatment in advance directive scenarios. The period of study was just prior to the Patient SelfDetermination Act, when care was virtually uninfluenced by advance directives.…”

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confidence: 99%

“…Treatment preferences of surveyed populations, physicians, nurses, patients and their families and proxies, medical students, and the general public are available. 6,7,[10][11][12][13][14][15][16][17][18] Although data exist on lifesustaining treatments for certain diagnoses and among deceased patients, these are less suited for investigating utilization in common advance directive scenarios. The present study compares preferences selected in a general advance directive survey and actual treatment practices for patients with conditions described in the advance directive scenarios.…”

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confidence: 99%

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Comparing utilization of life-sustaining treatments with patient and public preferences

Alpert

Emanuel

1998

J Gen Intern Med

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OBJECTIVE:The movement for advance planning of endof-life care was motivated in part by the assumption that medical intervention for terminally ill patients varies from what these patients would prefer. We examined the validity of this assumption by comparing actual life-sustaining treatment practices for patients in critical illness scenarios and surveyed patients' advance care preferences. MEASUREMENTS AND MAIN RESULTS:We selected at random and reviewed 7,400 inpatient medical records from a single urban teaching hospital during the period just prior to the Patient Self-Determination Act. Records of 198 patients with conditions that matched advance directive scenarios were examined, and practices to withhold or withdraw seven life-sustaining treatments were documented. Practices were compared with surveyed preferences of 102 members of the general public and 495 outpatients who were followed by the same physicians as the 198 patients. Concordance of practices and preferences for the 19 surveyed outpatients who eventually fell into one of the scenarios was also evaluated. One hundred sixty-seven inpatient cases met review criteria for the scenario coma with a small chance of recovery . Hospital patients received medical interventions that were not consistently greater or less than the preferences of the surveyed outpatients or members of the general public. Resuscitation, the most frequently withheld treatment (94% of cases), was withheld more often than surveyed preferences to decline it (56% of outpatients, p Ͻ .001). Four treatments-mechanical breathing, artificial nutrition, major surgery, and hemodialysis-were utilized comparably to surveyed outpatients' preferences (range p ‫؍‬ .704-.055). Antibiotics and artificial hydration were withheld (9% and 6%, respectively) less often than surveyed outpatient's prior preferences to decline them (48% and 52%, respectively, p Ͻ .001 for each). Conversely, treatments given to the 19 surveyed patients who subsequently developed one of the illness scenarios were often incongruent with the patients' prior preferences. Again, in some cases more interventions were provided (26 of 63 declined treatments were given), and in some cases less (10 of 21 desired treatments were withheld). CONCLUSIONS:This study does not support the assumption that, collectively, patients' advance care preferences are less interventionist than actual practices for patients in corresponding scenarios. Nevertheless, these results do support the assumption that life-sustaining treatment decisions do not conform well to individual patients' specific preferences. Progress in end-of-life care should focus on shared decision making at the patient-proxy-physician level rather than on overall life-sustaining treatments utilization. L ife-sustaining treatment decisions made for unconscious patients in the absence of advance directives are often assumed, first, to be discordant with individuals' prior preferences, 1 and second, to result in more treatments at the end of life than patients would have wanted....

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“…13 For each of seven life-sustaining treatments, we asked whether it was provided more than, less than, or the same as surveyed pref-…”

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Comparing utilization of life-sustaining treatments with patient and public preferences

Alpert

Emanuel

1998

J Gen Intern Med

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“…(1) While advance directives are not a panacea for the challenges of advance care planning, and there is controversy concerning their effectiveness, (2-4) they are desired by patients (1,5) and may stimulate discussions and decrease stress for surrogate decision-makers. (6,7) In many countries, healthcare organizations are required to provide information about advance directives to patients.…”

Section: Introductionmentioning

confidence: 99%

An advance directive redesigned to meet the literacy level of most adults: A randomized trial

Sudore

Landefeld

Barnes

et al. 2007

Patient Education and Counseling

123

183

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Objective-To determine whether an advance directive redesigned to meet most adults' literacy needs (5 th grade reading level with graphics) was more useful for advance care planning than a standard form (>12 th grade level).Methods-We enrolled 205 English and Spanish-speaking patients, aged ≥ 50 years from an urban, general medicine clinic. We randomized participants to review either form. Main outcomes included acceptability and usefulness in advance care planning. Participants then reviewed the alternate form; we assessed form preference and six-month completion rates.Results-40% of enrolled participants had limited literacy. Compared to the standard form, the redesigned form was rated higher for acceptability and usefulness in care planning, P≤0.03, particularly for limited literacy participants (P for interaction ≤ 0.07). The redesigned form was preferred by 73% of participants. More participants randomized to the redesigned form completed an advance directive at six months (19% vs. 8%, P=0.03); of these, 95% completed the redesigned form.Conclusions-The redesigned advance directive was rated more acceptable and useful for advance care planning and was preferred over a standard form. It also resulted in higher six month completion rates.Practice Implications-An advance directive redesigned to meet most adults' literacy needs may better enable patients to engage in advance care planning.

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“…[2][3][4][5][6] The Joint Commission for the Accreditation of Healthcare Organizations guidelines include a requirement to make advance directives (ADs) available to all patients in hospitalaffiliated outpatient clinics. 7 Furthermore, many patients desire the opportunity to discuss advance care plans with their physicians while they are still relatively healthy.…”

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confidence: 99%

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

et al. 1998

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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 questionnairebased 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:

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Advance Directives for Medical Care — A Case for Greater Use

Cited by 729 publications

References 17 publications

Comparing utilization of life-sustaining treatments with patient and public preferences

Comparing utilization of life-sustaining treatments with patient and public preferences

An advance directive redesigned to meet the literacy level of most adults: A randomized trial

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

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