Can We Talk? Inpatient Discussions About Advance Directives in a Community Hospital: Attending Physicians' Attitudes, Their Inpatients' Wishes, and Reported Experience

doi:10.1001/archinte.1994.00420200049006

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Vol. 154 No. 20, 24 October 1994

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Can We Talk? Inpatient Discussions About Advance Directives in a Community Hospital

Attending Physicians' Attitudes, Their Inpatients' Wishes, and Reported Experience

Brendan M. Reilly, MD; C. Richard Magnussen, MD; James Ross; Jeffrey Ash, MD; Louis Papa, MD; Michael Wagner, MD

Arch Intern Med. 1994;154(20):2299-2308.

Abstract

Background
The attitudes of hospitalized patients and their attending physiciansabout advance directives have not been well studied. We comparedthese attitudes and explored relationships between them andthe frequency of actual directives and directive discussionsduring hospitalization.

Methods
We conducted scripted interviews with 258 (94.5%) of 273 patientsadmitted consecutively to the acute medical service of a communityteaching hospital in Rochester, NY, and contemporaneously surveyedtheir attending physicians (n=68) regarding attitudes aboutadvance directives. Primary outcome measures were patients'willingness to discuss directives, actual physician-patientdirective discussions, and patients' preferences for life-sustainingtreatments. Also measured were physicians' indications for directivediscussions, their reasons not to discuss directives, and theirknowledge and attitudes about life-sustaining treatments.

Results
Eighty-one percent (172/212) of competent interviewed patientseither did (100) or wanted to (72) discuss advance directivesin hospital. Forty-one percent of patients chose to forgo cardiopulmonaryresuscitation; 24% to 41% refused other life-sustaining interventions(intensive care unit admission, mechanical ventilation, cardioversion,vasopressors). Overall, 90% (246/273) of all patients met atleast one of three criteria reported by their physicians asindications for advance directive discussions: age at least75 years, critical or potentially fatal illness, and patients'desire to discuss directives. Multiple logistic regression revealedthat these same variables predicted patients' willingness todiscuss cardiopulmonary resuscitation, their preferences toreceive or forgo cardiopulmonary resuscitation, and the frequencyof physician-patient discussions about these issues.

Conclusions
Most medical inpatients in a community hospital want to, areable to, and meet their own physicians' indications to discussadvance directives. Hospitalization presents an unrealized opportunityfor physicians and patients to initiate these discussions.

(Arch Intern Med. 1994;154:2299-2308)

Author Affiliations

From the Department of Medicine, St Mary's Hospital, and the University of Rochester (NY) School of Medicine.

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