Doctors often disregard patients' last wishes

Doctors' responses to a series of hypothetical scenarios reveal that many make treatment decisions that are contrary to patients' dying wishes, researchers reported Monday.

In all scenarios, treatment decisions were potentially in conflict with either the patients' directives, the wishes of their family or friends, or their quality of life.

Advance directives - made while people are healthy - have been widely promoted to circumvent problems when patients become incapacitated and unable to voice their preferences for treatment. However, little evidence exists to show that advance directives actually fulfill their intentions.

For instance, doctors do not always know that patients have advance directives, and some research suggests that even when they do know, the plans are not necessarily followed.

To investigate, Dr. Steven B. Hardin and Dr. Yasmin A. Yusufaly, both from the Loma Linda University School of Medicine in California, created scenarios in which physicians had to make end-of-life decisions for patients who had a serious or life-threatening illness and had become unable to make their own decisions. Every patient had advance directives.

In one scenario, a 48-year-old woman with diabetes and on dialysis has a stroke. Her prognosis is poor, but in her advance directive, she asks for full treatment. However, she also lists her husband as her proxy, and he asks the doctor to stop dialysis.

In this and the other conflict-ridden scenarios, doctors were asked whether they would opt for aggressive or nonaggressive treatment, and why.

One hundred and seventeen internal medicine faculty and resident physicians answered the surveys, which contained 6 scenarios.

In 65 percent of the scenarios, doctors went against patients' advance directives.

Writing in the Archives of Internal Medicine, Hardin and Yusufaly note that both faculty and resident doctors were equally as likely to decide against an advance directive, suggesting that experience has little influence.

They write that doctors tended to be influenced by more than one factor when treating dying patients. "While compelling, the advance directive may have been viewed as only part of the information needed to make treatment decisions," they note.

Despite these findings, the authors note that advance directives still serve an important purpose, by encouraging physicians and patients to "start conversing about treatment decisions."

SOURCE: Archives of Internal Medicine, July 26, 2004.