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Implementing Advance Directives in the Primary Care Setting

Lawrence J. Markson, MD, MPH; James Fanale, MD; Knight Steel, MD; Donald Kern, MD, MPH; George Annas, JD, MPH
Arch Intern Med. 1994;154(20):2321-2327. doi:10.1001/archinte.1994.00420200075008.
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Background:  Despite the potential benefits of advance directives, few patients complete them. This study examined whether barriers to advance decision making can be overcome via a combined educational and administrative intervention targeted at physicians.

Method:  The subjects consisted of all the internists (n=6) at a primary care physician home care (HC) service and all the internists (n=4) at a primary care nursing home (NH) service. Physicians were given a 5-week course on the law relating to advance directives. Administrative consent was obtained to permit physicians to spend additional time with patients to discuss advance directives. Physicians were asked to discuss advance directives with newly enrolled patients and to assist interested patients to complete directives. During the first 2 months of the trial, physicians did not approach any patients. Therefore, the study design was changed to include all active patients, and physicians received additional training that involved observing and leading discussions with their own patients.

Results:  Physicians approached 74 of 356 competent HC patients, of whom 48 (65%) completed directives. All 42 competent NH patients were approached, and 38 (90%) completed directives. Most patients who completed a directive chose relatives as proxies. Most directed that lifesustaining treatment be withheld in the event they were permanently unconscious (HC, 81%; NH, 92%). Other common choices were to decline long-term mechanical ventilation (HC, 58%; NH, 79%), long-term artificial nutrition (HC, 44%; NH, 79%), and cardiopulmonary resuscitation (HC, 27%; NH, 66%).

Conclusions:  Physicians can overcome initial reluctance to integrate advance decision making into primary care provided to elderly patients. Teaching physicians about the law is not sufficient to change behavior; physicians also need practical experience discussing directives with patients. Our high patient response suggests that a physician-directed intervention is sufficient to achieve high rates of completing directives without additional, concomitant patient-directed intervention.(Arch Intern Med. 1994;154:2321-2327)


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