Doctors' Decisions When Faced With Contradictory Patient Advance Directives and Health Care Proxy Opinion: A Randomized Vignette-Based Study

Escher, Monica; Perrier, Arnaud; Rudaz, Sandrine; Dayer, P.; Perneger, Thomas

doi:10.1016/j.jpainsymman.2014.06.012

Cited by 11 publications

(9 citation statements)

References 28 publications

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“…Advance directive and a healthcare proxy or the family’s opinion have been shown to have marked influence on physicians’ decision-making [ 12 , 31 , 35 , 57 , 58 ], but there are no earlier studies about this for palliative care physicians. Our study is in line with previous ones [ 31 , 32 ], since the family’s request for aggressive treatments significantly increased physicians’ willingness to continue or start life-prolonging therapies, and advance directive decreased this. This finding was constant through different physician groups including physicians with cPM.…”

Section: Discussionsupporting

confidence: 92%

“…Therefore, this clear influence of family requests on decision-making is controversial and perhaps an issue needing more attention in the education of PM, which should also introduce legal aspects and official recommendations on decision-making. Knowing a patient’s own will helps in decision-making [ 31 , 32 ], and an advance directive naturally moves the decisions towards a palliative approach. However, the content of an advance directive presented here did not describe the patient’s will in detail, which is often the case in the real world as well.…”

Section: Discussionmentioning

confidence: 99%

“…Most patients wish their closest ones to be involved in EOL decision-making, and discussions with the family are essential [ 28 – 30 ]. The families’ opinions are also shown to influence physicians’ decisions [ 12 , 31 , 32 ], although discordance between patients’ wishes, caregivers’ preferences and caregivers’ predictions of patients’ preferences may exist [ 28 , 33 ]. Advance directives reinforce patients’ participation and help with decision-making [ 31 , 32 , 34 ].…”

Section: Introductionmentioning

confidence: 99%

“…The families’ opinions are also shown to influence physicians’ decisions [ 12 , 31 , 32 ], although discordance between patients’ wishes, caregivers’ preferences and caregivers’ predictions of patients’ preferences may exist [ 28 , 33 ]. Advance directives reinforce patients’ participation and help with decision-making [ 31 , 32 , 34 ]. However, there are variations in how advance directives are understood and taken into account [ 12 , 35 – 37 ].…”

Section: Introductionmentioning

confidence: 99%

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Does special education in palliative medicine make a difference in end-of-life decision-making?

et al. 2018

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BackgroundCharacteristics of the physician influence the essential decision-making in end-of-life care. However, the effect of special education in palliative medicine on different aspects of decision-making in end-of-life care remains unknown. The aim of this study was to explore the decision-making in end-of-life care among physicians with or without special competency in palliative medicine (cPM).MethodsA questionnaire including an advanced lung cancer patient-scenario with multiple decision options in end-of-life care situation was sent to 1327 Finnish physicians. Decisions to withdraw or withhold ten life-prolonging interventions were asked on a scale from 1 (definitely would not) to 5 (definitely would) – first, without additional information and then after the family’s request for aggressive treatment and the availability of an advance directive. Values from chronological original scenario, family’s appeal and advance directive were clustered by trajectory analysis.ResultsWe received 699 (53%) responses. The mean values of the ten answers in the original scenario were 4.1 in physicians with cPM, 3.4 in general practitioners, 3.4 in surgeons, 3.5 in internists and 3.8 in oncologists (p < 0.05 for physicians with cPM vs. oncologists and p < 0.001 for physicians with cPM vs. others). Younger age and not being an oncologist or not having cPM increased aggressive treatment decisions in multivariable logistic regression analysis. The less aggressive approach of physicians with cPM differed between therapies, being most striking concerning intravenous hydration, nasogastric tube and blood transfusions. The aggressive approach increased by the family’s request (p < 0.001) and decreased by an advance directive (p < 0.001) in all physicians, regardless of special education in palliative medicine.ConclusionPhysicians with special education in palliative medicine make less aggressive decisions in end-of-life care. The impact of specialty on decision-making varies among treatment options. Education in end-of-life care decision-making should be mandatory for young physicians and those in specialty training.Electronic supplementary materialThe online version of this article (10.1186/s12904-018-0349-6) contains supplementary material, which is available to authorized users.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Does special education in palliative medicine make a difference in end-of-life decision-making?

et al. 2018

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“…In clinical practice, advance directives and proxy opinions are equally effective in influencing doctors’ decisions [ 19 ]. Vignette studies show that physicians have a mild preference to forgo life sustaining treatment in case of contradictions between written advance directives and proxy opinion [ 20 ]. In our study, two of the three patients in whom a proxy opinion was based on alleged previously expressed wishes, and who could be interviewed at six months, could not recall this expression.…”

Section: Discussionmentioning

confidence: 99%

Advance directives, proxy opinions, and treatment restrictions in patients with severe stroke

et al. 2017

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BackgroundPatients with severe stroke often do not have the capacity to participate in discussions on treatment restrictions because of a reduced level of consciousness, aphasia, or another cognitive disorder. We assessed the role of advance directives and proxy opinions in the decision-making process of incapacitated patients.MethodsSixty patients with severe functional dependence (Barthel Index ≤6) at day four after ischemic stroke or intracerebral hemorrhage were included in a prospective two-center cohort study. The decision-making process with respect to treatment restrictions was assessed by means of a semi-structured questionnaire administered to the treating physician at the day of inclusion.ResultsForty-nine patients (82%) did not have the capacity to participate in the decision-making process. In eight patients, there was no discussion on treatment restrictions and full care was installed. In 41 patients, the decision whether to install treatment restrictions was discussed with proxies. One patient had a written advance directive. In the remaining 40 patients, proxies based their opinion on previously expressed wishes of the patient (18 patients) or advised in the best interest of the patient (22 patients). In 36 of 41 patients, treatment restrictions were installed after agreement between physician and proxy. At six months, 23 of 49 patients had survived. In only three of them the decision on treatment restrictions was based on previously expressed wishes. Remarkably, two of these survivors could not recall any of their alleged previously expressed wishes.ConclusionsTreatment restrictions were installed in the majority of incapacitated patients after stroke. Proxy opinions frequently served as the best way to respect the patients’ autonomy, but their accuracy remains unclear.Electronic supplementary materialThe online version of this article (10.1186/s12904-017-0234-8) contains supplementary material, which is available to authorized users.

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Advance directives and intensity of care delivered to hospitalized older adults at the end-of-life

et al. 2020

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Doctors' Decisions When Faced With Contradictory Patient Advance Directives and Health Care Proxy Opinion: A Randomized Vignette-Based Study

Abstract: Contradictions between advance directives and proxy opinions result in a weak preference for abstention from treatment and increase the difficulty of the decision.

Cited by 11 publications

References 28 publications

Does special education in palliative medicine make a difference in end-of-life decision-making?

Does special education in palliative medicine make a difference in end-of-life decision-making?

Advance directives, proxy opinions, and treatment restrictions in patients with severe stroke

Advance directives and intensity of care delivered to hospitalized older adults at the end-of-life

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