Continuing improvement in the process of end-of-life decision making is needed

In a study using hypothetical cases, physicians commonly made end-of-life treatment decisions that were not consistent with patient preferences stated in explicit advance directives, according to an article in the July 26 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.

According to background information in the article, significant concern remains about how well physicians know and follow the treatment preferences of their patients. Decisions are particularly problematic for critically ill and dying patients who lose their capacity to make medical decisions. A variety of factors may influence treatment decisions - including the probability of survival or recovery, and perceived quality of life. While advance directives have been widely promoted as a means to ensure that patients' treatment preferences are followed, there is limited evidence that they actually accomplish this purpose.

Steven B. Hardin, M.D., and colleagues with the Jerry L. Pettis Memorial Veterans Affairs Medical Center and Loma Linda University School of Medicine, Loma Linda, Calif., devised a survey of six hypothetical cases describing patients with serious or life-threatening illnesses who had lost their decision-making capacity. Each case contained an explicit advance directive with potential conflict between the directive and (1) prognosis, (2) wishes of family or friends, or (3) quality of life. The study participants were all internal medicine faculty and resident physicians from Loma Linda University Medical Center and affiliated hospitals.

Data were collected on the clinical treatment decisions made by physicians and the reasons for those decisions. Of the 250 surveys mailed, 117 analyzable surveys were returned from 77 faculty and 40 resident physicians.

"Despite the presence of an explicit advance directive, physicians frequently made treatment decisions contrary to documented patient preferences," the authors report.

In 65 percent of cases, decisions by faculty and residents were not consistent with the advance directive. This inconsistency was similar for faculty (68 percent of cases) and residents (61 percent of cases). When physicians made decisions inconsistent with the advance directive, they were more likely to list reasons other than the directive for their decisions.

"In difficult clinical situations, internists appear to consider other factors such as prognosis, perceived quality of life, and the wishes of family or friends as more determinative than the directive," the authors write.

The authors point out that advance directives have helped to encourage physicians and patients to start conversing about treatment decisions. But they assert that the limitation of advance directives illustrates the need for more effective conflict resolution when patients, family, and staff disagree about treatment choices.

"Continuing improvement in the process of end-of-life decision making is needed," the authors conclude. "This process will have to recognize the inherent uncertainties in caring for seriously ill patients."