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Patient and Physician Opinions Regarding When and How It Should Be Conducted

Sarah Coate Johnston, MD; Mark P. Pfeifer, MD; Robert McNutt, MD; End of Life Study Group; Harold M. Adelman, MD; Paul M. Wallach, MD; Joseph F. Boero, MD; Dennis Crnkovich, MD; Kevin A. Halbritter, MD; Sarah C. Johnston, MD; Rita Layson, MD; Robert McNutt, MD; Mark P. Pfeifer, MD; Jaan E. Sidorov, MD; Arthur Evans, MD, MPH; Miriam B. Settle, PhD

Arch Intern Med. 1995;155(10):1025-1030.

Abstract
Background
Widely publicized court cases have focused national attention on the importance of advance directives. In spite of initiatives such as the Patient Self-Determination Act of 1991, fewer than 10% of Americans have prepared advance directives. One way to increase the preparation of advance directives may be to increase the frequency and quality of discussions about them between individual patients and their physicians. We performed a multicenter observational study to assess the opinions of primary care patients and physicians regarding these discussions.

Methods
This was a cross-sectional descriptive survey of randomly selected primary care patients and physicians in eight primary care internal medicine clinics in the eastern and midwestern United States. Quantitative questionnaires were used to elicit subjects' demographic characteristics, and their opinions regarding the timing, content, and location of discussions about advance directives.

Results
The 883 subjects included 329 adult outpatients, 282 resident physicians, and 272 practicing physicians. Physician and patient response rates were 75% and 76%, respectively. Patients felt that the discussion should occur earlier than did the physicians: at an earlier age, earlier in the natural history of disease, and earlier in the patient-physician relationship. Most subjects agreed it was the physician's responsibility to initiate the discussion.

Conclusion
We defined a discrepancy between the preferences of primary care patients and physicians regarding the timing of the discussion about advance directives. We propose physician education regarding patient preferences as the most effective way to accomplish the goal of improving the frequency and quality of discussions about advance directives.

(Arch Intern Med. 1995;155:1025-1030)

Author Affiliations
University of South Florida, Tampa; University of Illinois, Rockford; University of Illinois, Peoria; West Virginia University, Morgantown; University of Kansas—Wichita; University of North Carolina—Greensboro; University of Wisconsin at Milwaukee; University of Louisville (Ky); Geisinger Medical Center, Danville, Pa; University of North Carolina—Chapel Hill.

From the Departments of Internal Medicine, University of Kansas School of Medicine—Wichita (Dr Johnston); University of Louisville (Ky) (Dr Pfeifer); and University of Wisconsin at Milwaukee (Dr McNutt). Members of the End of Life Study Group are listed at the end of the article.

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