Some physicians may hesitate to discuss advance care directives with patients for fear of scaring or alienating them. But a new study suggests such discussions may have the opposite effect and may enhance the patient-doctor relationship.
Advance care directives allow patients to state health care preferences before they are too sick to do so.
"It is particularly important that physicians hold such discussions in the primary care environment during routine visits," said lead author William M. Tierney, MD, of the Department of Medicine at Indiana University School of Medicine in Indianapolis. "Patients are less likely to be acutely ill during these routine visits and can carefully explore end-of-life care issues with a physician they know and likely trust."
The idea of advance directives is popular among patients and physicians, yet these directives are rarely discussed. Studies have shown physicians and patients each tend to think the other should initiate such discussions. "Other barriers include time limitations, language difficulties and a concern by the physician that patients would be troubled by these discussions," said Tierney.
Tierney and colleagues interviewed nearly 700 patients who were either 75 or older, or 50 or older with a serious disease. Only 2 percent of the study participants had ever discussed advance directives with their physicians before the study period.
More than half of the patients who were interviewed after having discussed advance directives with their physician rated primary care visits as "excellent," compared with 34 percent of those who had not yet had such a discussion, the researchers found.
"The improvement in visit satisfaction was substantial and persistent," said Tierney. The study results are published in the January 2001 issue of the Journal of General Internal Medicine.
The researchers noted several study limitations, including their uncertainty about specifically how the advance care discussions improved patient satisfaction. It may have been that time spent with patients and attention paid to personal matters increased patient satisfaction rather than the nature of the discussion, for example.
"Nonetheless, discussions of advance care directives are appropriate for primary care patients in general and especially for elderly and chronically ill patients," Tierney said. "We urge primary care practices to encourage their physicians to initiate discussions about advance directives."
This study was funded by a grant from the Agency for Healthcare Research and Quality.
The Journal of General Internal Medicine, a monthly peer-reviewed journal of the Society of General Internal Medicine, publishes original articles on research and education in primary care. For information about the journal, contact Renee F. Wilson at (410) 955-9868.
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