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Original article

Vol. 144 No. 3940 (2014)

Advance directives and the impact of timing

  • Ina Otte
  • Corinna Jung
  • Bernice Elger
  • Klaus Bally
DOI
https://doi.org/10.4414/smw.2014.14035
Cite this as:
Swiss Med Wkly. 2014;144:w14035
Published
21.09.2014

Summary

PRINCIPLES: Advance directives are seen as an important tool for documenting the wishes of patients who are no longer competent to make decisions in regards to their medical care. Due to their nature, approaching the subject of advance directives with a patient can be difficult for both the medical care provider and the patient. This paper focuses on general practitioners’ perspectives regarding the timing at which this discussion should take place, as well as the advantages and disadvantages of the different moments.

METHODS: In 2013, 23 semi-structured face-to-face interviews were performed with Swiss general practitioners. Interviews were analysed using qualitative content analysis.

RESULTS: In our sample, 23 general practitioners provided different options that they felt were appropriate moments: either (a) when the patient is still healthy, (b) when illness becomes predominant, or (c) when a patient has been transferred to a long-term care facility. Furthermore, general practitioners reported uncertainty and discomfort regarding initiating the discussion.

CONCLUSION: The distinct approaches, perspectives and rationales show that there is no well-defined or “right” moment. However, participants often associated advance directives with death. This link caused discomfort and uncertainty, which led to hesitation and delay on the part of general practitioners. Therefore we recommend further training on how to professionally initiate a conversation about advance directives. Furthermore, based on our results and experience, we recommend an early approach with healthy patients paired with later regular updates as it seems to be the most effective way to inform patients about their end-of-life care options.

References

  1. Evans N, et al. A critical review of advance directives in Germany: attitudes, use and healthcare professionals’ compliance. Patient Educ Couns. 2012:87(3):277–88.
  2. Robertson GS. Making an advance directive. BMJ. 1995;310(6974):236–8.
  3. Hoffenberg R. Advance healthcare directives. Clin Med. 2006;6(3):231–3.
  4. Andorno R, Biller-Andorno N, Brauer S. Advance health care directives: towards a coordinated European policy? Eur J Health Law. 2009;16(3):207–27.
  5. Biller-Andorno N, Brauer S. Advance directives from a cross-cultural perspective. Bioethics. 2010;24(3):ii-iv.
  6. Docker C. Decisions to withdraw treatment. Values histories are more useful than advance directives. BMJ. 2000;320(7226):54.
  7. Peters C, Chiverton P. Use of a values history in approaching medical advance directives with psychiatric patients. J Psychosoc Nurs Ment Health Serv. 2003;41(8):28–36.
  8. Berger JT. What about process? Limitations in advance directives, care planning, and noncapacitated decision making. Am J Bioeth. 2010;10(4):33–4.
  9. Lawrence RE, Brauner DJ. Deciding for others: limitations of advance directives, substituted judgment, and best interest. Virtual Mentor. 2009;11(8):571–81.
  10. Treloar AJ. Advance directives: limitations upon their applicability in elderly care. Int J Geriatr Psychiatry. 1999;14(12):1039–43.
  11. Winter L, Parks SM, Diamond JJ. Ask a different question, get a different answer: why living wills are poor guides to care preferences at the end of life. J Palliat Med. 2010;13(5):567–72.
  12. Rhee JJ, Zwar NA, Kemp LA. Advance care planning and interpersonal relationships: a two-way street. Fam Pract. 2013;30(2):219–26.
  13. Holley JL. Palliative care in end-stage renal disease: focus on advance care planning, hospice referral, and bereavement. Semin Dial. 2005;18(2):154–6.
  14. Thompson TD, Barbour RS, Schwartz L. Health professionals’ views on advance directives: a qualitative interdisciplinary study. Palliat Med. 2003;17(5):403–9.
  15. Bern-Klug M, et al. “Getting everyone on the same page”: nursing home physicians’ perspectives on end-of-life care. J Palliat Med. 2004;7(4):533–44.
  16. Harringer W. Advance directives in general practice. Ther Umsch. 2012;69(2):107–9.
  17. Mayring P. Qualitative Inhaltsanalyse. Grundlagen und Techniken. 2003, Basel, Weinheim: Beltz.
  18. Lamnek S. Qualitative Sozialforschung. Lehrbuch. 2010, Weinheim, Basel: Beltz.
  19. Johnston SC, Pfeifer MP, McNutt R. The discussion about advance directives. Patient and physician opinions regarding when and how it should be conducted. End of Life Study Group. Arch Intern Med. 1995;155(10):1025–30.
  20. Morrison RS, Morrison EW, Glickman DF. Physician reluctance to discuss advance directives. An empiric investigation of potential barriers. Arch Intern Med. 1994;154(20):2311–8.
  21. Sahm S, Will R, Hommel G. What are cancer patients’ preferences about treatment at the end of life, and who should start talking about it? A comparison with healthy people and medical staff. Support Care Cancer. 2005;13(4):206–14.
  22. Stanford J, et al. Conversations Worth Having: The Perceived Relevance of Advance Care Planning among Teachers, Hospice Staff, and Pastors in Knysna, South Africa. J Palliat Med. 2013;16(7):762–7.
  23. Sahm S, Will R, Hommel G. Attitudes towards and barriers to writing advance directives amongst cancer patients, healthy controls, and medical staff. J Med Ethics. 2005;31(8):437–40.
  24. Burgess TA, Brooksbank M, Beilby JJ. Talking to patients about death and dying. Aust Fam Physician. 2004;33(1–2):85–6.
  25. Janssen DJ, et al. Predicting changes in preferences for life-sustaining treatment among patients with advanced chronic organ failure. Chest. 2012;141(5):1251–9.
  26. Carmel S, Mutran EJ. Stability of elderly persons’ expressed preferences regarding the use of life-sustaining treatments. Soc Sci Med. 1999;49(3):303–11.
  27. Berger JT, Majerovitz D. Stability of preferences for treatment among nursing home residents. Gerontologist. 1998;38(2):217–23.
  28. Jox RJ, Hessler HJ, Borasio GD. End-of-life decisions, powers of attorney, and advance directives. Nervenarzt. 2008;79(6):729–37; quiz 738–9.
  29. Fallowfield JLJ, V. A; Beveridge, H. A. Truth may hurt but deceit hurts more: communication in palliative care. Palliat Med. 2002;16(4):297–303.
  30. Silverstein MD, et al. Amyotrophic lateral sclerosis and life-sustaining therapy: patients’ desires for information, participation in decision making, and life-sustaining therapy. Mayo Clin Proc. 1991;66(9):906–13.
  31. Burchardi N, et al. Discussing living wills. A qualitative study of a German sample of neurologists and ALS patients. J Neurol Sci. 2005;237(1–2):67–74.
  32. Suter-Gut D, van Spijk P. Do advance directives facilitate the process of dying in dignity? Praxis (Bern 1994). 2012;101(8):517–22.
  33. Hutton C, Gunn J. Do longer consultations improve the management of psychological problems in general practice? A systematic literature review. BMC Health Serv Res. 2007;7:71.
  34. Dow LA, et al. Paradoxes in advance care planning: the complex relationship of oncology patients, their physicians, and advance medical directives. J Clin Oncol. 2010;28(2):299–304.
  35. Hayley DC, et al. Ethical and legal issues in nursing home care. Arch Intern Med. 1996;156(3):249–56.

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