DECEMBER 11, 1995 VOLUME 3, NUMBER 24
A disturbing new study calls into question the very basis for patient's advance directives. According to researchers, doctors are likely to honor patients' about treatment options only in about half of all cases.
The $28 million study, funded by the Robert Wood Johnson Foundation and published in the Journal of the American Medical Association, also found that efforts to increase doctors' understanding of individual patients' wishes had no positive effect on the problem. While the study did not directly address living wills or durable powers of attorney for health care, the results call into question the value of such directives in the real world.
Researchers interviewed hospital patients at six medical centers around the country to find out whether they would want to be resuscitated in the event of cardiopulmonary arrest. Nearly a third declined CPR, but fully 80% of doctors either misunderstood or ignored their patients' wishes. The result for half of the patients; although they refused CPR, their hospital records indicated that they were to receive such treatment in the event of an attack.
Even in those cases where doctors correctly understood their patients' wishes, the delay in securing "no code" orders in medical charts was unreasonably long. The average length of time between the request for a "no code" order and its insertion in medical records varied by facility, but the most prompt hospital averaged 22 days; the least prompt took, on average, 73 days before charting the patient's wishes.
Perhaps the most disturbing element of the study emerged during its second phase. Researchers utilized specially trained nurses to document the patients' wishes and estimate their prognoses for doctors (using specially designed computer software). The result of this expensive intervention: no improvement in the rate of compliance with patients' wishes.
At the same time the study reviewed the circumstances of death for those patients who died in the facilities. Half were found to have died in moderate to severe pain and half were receiving mechanical ventilation for at least eight days at the end of life. Neither result changed after the intervention of the specially trained nurses.
The same JAMA issue included a number of commentaries on these striking study results. Observers suggested that the entire medical system is constructed to promote disregard for patients' wishes not to be treated. One commentator noted that doctors usually have a financial incentive to treat patients aggressively. Another observed that the best course for patients and their families is to aggressively insist on their preferences.
While the study did not assess the value of advance directives, one conclusion seems inescapable. While doctors may ignore the wishes expressed in a living will, naming an agent for health care decision-making should help produce compliance with patients' instructions. But no one should assume that doctors will determine and follow patients' wishes in most cases.