This Article  • References  • Full text PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (30)  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Social Bookmarking   What's this?

Effect of Type of Directive on Physicians' Therapeutic Decisions

William R. Mower, MD; Larry J. Baraff, MD

Arch Intern Med. 1993;153(3):375-381.

Abstract
Background
Despite growing support for advance directives, there are few data validating their utility. We conducted this study to determine if the type of advance directive influences physicians' willingness to withhold specific therapies and if physicians are equally willing to withhold these therapies.

Methods
The 444 full-time faculty of the department of medicine of a university medical center were presented with patient scenarios and accompanying advance directives in three separate surveys that were mailed. They were asked if they would withhold each of 12 specific therapies based on their interpretation of the advance directive. Three types of advance directives were studied: general statement, therapy specific, and therapy specific combined with designation of a proxy and prior patient-physician discussion.

Results
The mean proportion of all 12 therapies that were withheld varied by type of advance directive: general-statement advance directive, 55%; therapy-specific advance directive, 71%; and therapy-specific advance directive with proxy and prior patient-physician discussion, 83%. Respondents were more likely to withhold cardiopulmonary resuscitation when given a therapy-specific advance directive vs general-statement advance directive, 84% vs 73%, respectively. With a therapyspecific advance directive that was supported by a proxy and prior patient-physician discussion, 100% of physicians were willing to withhold cardiopulmonary resuscitation. With the therapy-specific advance directive that was supported by proxy and prior patient-physician discussion, physicians were not equally willing to withhold all therapies, ie, mechanically assisted ventilation, 98%; intravenous fluids, 82%; antibiotics, 80%; simple tests, 70%; and pain medications, 13%.

Conclusions
Detailed advance directives with a supportive proxy, coupled with physician-patient discussion, furnish the most reliable medical directives. Even with such directives, physicians are more likely to withhold life-saving therapies than simple tests, treatments, and pain medications.

(Arch Intern Med. 1993;153:375-381)

Author Affiliations
From The Emergency Medicine Center (Drs Mower and Baraff) and the Departments of Medicine (Dr Mower) and Pediatrics (Dr Baraff), UCLA School of Medicine, and UCLA Medical Center (Drs Mower and Baraff), Los Angeles, Calif.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Patients Who Complete Advance Directives and What They Prefer
Nishimura et al.
Mayo Clin Proc. 2007;82:1480-1486.
ABSTRACT | FULL TEXT  

Ethical Challenges of Partial Do-Not-Resuscitate (DNR) Orders: Placing DNR Orders in the Context of a Life-Threatening Conditions Care Plan
Berger
Arch Intern Med 2003;163:2270-2275.
ABSTRACT | FULL TEXT  

Patient, Physician, and Family Member Understanding of Living Wills
Upadya et al.
Am. J. Respir. Crit. Care Med. 2002;166:1430-1435.
ABSTRACT | FULL TEXT  

Quality Indicators for End-of-Life Care in Vulnerable Elders
Wenger and Rosenfeld
ANN INTERN MED 2001;135:677-685.
FULL TEXT  

Practice Parameter: The Care of the Patient with Amyotrophic Lateral Sclerosis (An Evidence-Based Review): Report of the Quality Standards Subcommittee of the American Academy of Neurology
Miller et al.
Neurorehabil Neural Repair 1999;13:93-107.
 

Practice parameter: The care of the patient with amyotrophic lateral sclerosis (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology
Miller et al.
Neurology 1999;52:1311-1311.
FULL TEXT  

Calibrating the Physician: Personal Awareness and Effective Patient Care
Novack et al.
JAMA 1997;278:502-509.
ABSTRACT  

Can Goals of Care Be Used to Predict Intervention Preferences in an Advance Directive?
Fischer et al.
Arch Intern Med 1997;157:801-807.
ABSTRACT  

The Dangers of Directives or the False Security of Forms
Hoffmann et al.
J Law Med Ethics 1996;24:5-17.
 

Promoting Inpatient Directives About Life-Sustaining Treatments in a Community Hospital: Results of a 3-Year Time-Series Intervention Trial
Reilly et al.
Arch Intern Med 1995;155:2317-2323.
ABSTRACT  

Terminal Care of the Very Old: Changes in the Way We Die
Hesse
Arch Intern Med 1995;155:1513-1518.
ABSTRACT  

Making an advance directive
Robertson
BMJ 1995;310:236-238.
FULL TEXT  

The Influence of the Probability of Survival on Patients' Preferences Regarding Cardiopulmonary Resuscitation
Murphy et al.
NEJM 1994;330:545-549.
ABSTRACT | FULL TEXT