Practical Problems with Advance Directives

There are practical barriers to the use of advance directives. Although this entry describes an ideal of advance care planning in which patients first consult with loved ones and physicians, and then document their wishes, most advance directives are not products of this sort of process. Patients often write advance directives when they create an estate will. They may leave the document in a safe-deposit box or with their lawyer. Occasionally, they will give it to a family member. All too often, they will not take it to their doctors. Advance directives created in this manner might not be available when needed for decision making. Because there has been no discussion with physicians about life goals and values and how medicine fits into these, the physicians are deprived of critical information that is needed in interpreting the advance directives. Patients, meanwhile, might have signed documents that they do not completely understand and that are not truly in keeping with their values. The same is true for documents created in the hospital in the midst of a medical crisis. To overcome this problem, physicians need to routinely ask their patients if they have advance directives.

Furthermore, advance directives may not be available when needed. They often do not accompany patients transferred to the hospital from a nursing home. Patients may not be under the care of their regular doctor when they are hospitalized, and the hospital staff may not know about the existence of an advance directive. In addition to the federal regulations requiring hospitals to ask about advance directives, electronic medical records and registries of advance directives may also help with this problem.

Another problem is that physicians are often reluctant to raise the subject with their patients. They may be under overwhelming time constraints. They may have never been trained to discuss this issue and are not sure how to introduce the topic. They may be worried that they will give patients the impression that they are "giving up" on them or that they think they will die soon. If they have focused in past discussions on interventions rather than patient values and goals, they may have found these discussions frustrating and unhelpful.

Time constraints are difficult to overcome. Physicians could dedicate visits to discussing advance directives; but insurance companies may not pay for such a visit, and many patients may not wish to make a separate trip to the doctor for this purpose. The use of booklets and other tools to introduce the concepts involved in advance care planning may help physicians efficiently use their time to answer specific questions patients may have and to guide patients through the process. Enlisting nurses and social workers to help patients with the advance care planning process may also help.

Although physicians are often worried that patients will be put off by a discussion about advance care plans, surveys show that most patients want to discuss these issues, early in the course of their disease, and that they think that the doctor should bring up the topic. Nevertheless, there will be some patients who are not ready to discuss advance directives. Healthcare providers must be sensitive to these patients. Advance care planning is a process that should be offered to patients, not forced upon them.

The root cause of much of physicians' reluctance stems from lack of training in how to have these discussions. With training, physicians can feel more comfortable having these discussions, can learn how to deal with patients' emotional responses, and can have effective discussions that the physician will find truly helpful in caring for patients.

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