ADVANCE DIRECTIVES: Physicians Fail Communication Test
A study published in the Annals of Internal Medicine indicates that physicians inadequately discuss end-of-life decisions with their patients, the Pittsburgh Post-Gazette reports (Voas, 9/16). A research group led by Dr. James Tulsky of Durham VA Medical Center tape-recorded 56 conversations between physicians and their elderly or seriously ill patients at clinics in Durham, NC, and Pittsburgh, PA. The study found that physicians discussed advance directives with their patients for an average of five minutes, with the physicians dominating the conversations for two-thirds of the duration. The study group further found that physicians used "vague language" to convey varying degrees of illness, failed to explore patients' preferences or definitions of common responses and often described treatment options in complex medical jargon without providing further explanation. In addition, physicians presented extreme scenarios that did not elicit patients' views about the less clear-cut scenarios that are more common when terminal decisions are made (Annals of Internal Medicine release, 9/15). Furthermore, the researchers found that the majority of the patient-physician conversations ended without resolution. And while formal advanced directive forms were discussed in 88% of the cases, 45% of physicians "did not instruct patients on how to obtain advance directive forms" (Tulsky et al, Annals of Internal Medicine, 9/15 issue).
Patients In The Dark?
Surprisingly, interviews with the patients immediately following their discussions with the physicians found that 100% of patients said their doctors "did a good job talking about these issues" (AIM release, 9/15). But the study authors emphasized that better communication is needed, despite patients' perceptions. Specifically citing physicians' inability to discuss realistic scenarios with patients, the authors concluded: "A conversation about advance directives that probes no further than dire or reversible scenarios leaves most physicians and families no better off when they confront the more common, less clear-cut predicaments surrounding end-of-life care." The authors noted that most physicians learn how to talk about advance directives and end-of-life care through personal experience, rather than formal training. In addition, "practitioners face severe time pressures," limiting their ability to address advance directives (AIM, 9/15 issue). Tulsky said physicians must improve the quality of these conversations. "Unfortunately," he said, "after discussions such as the ones we observed, patients, families and their physicians may find themselves no better off than if the conversations had never occurred" (AIM release, 9/15).