Relationship of Advance Directives to Physician-Patient Communication

BACKGROUND: Although advance medical directives, such as living wills and durable powers of attorney for health care, are by themselves imperfect instruments for expressing patients' treatment preferences, a possible benefit of these documents is that they will enhance patient-physician communication, especially when end-of-life treatment decisions have to be made. METHOD: Structured interviews were completed for 115 seriously ill cancer patients and 22 of their physicians. The questions dealt with various aspects of advance directives, including communications between the two parties regarding general and specific treatment wishes. Responses were compared in 37 physician-patient pairs for patients who had executed advance directives and in 31 physician-patient pairs for patients who had not executed advance directives. RESULTS: Physicians were frequently unaware of their patients' advance directives. Although patients with advance directives were marginally more likely than patients without advance directives to report discussions about end-of-life treatment decisions, only 34 (30%) out of the total of 115 patients claimed that they had any discussion of treatment decisions with their physicians. Such discussions tended to be about general life attitudes and feelings rather than specific treatments, such as use of artificial nutrition or ventilation. CONCLUSION: Despite public enthusiasm for the use of advance directives and great efforts to promote them, we found little evidence that these documents are associated with enhanced communication between patients and physicians about end-of-life treatment decisions.