Living wills as advance decision-making

Advance directives provide a way for patients to have a voice in decisions about medical care when they are unable to speak for themselves in life-threatening or end-of-life situations. If a patient is unconscious or otherwise unable to make decisions and does not have advance directives on file, a family member or physician will make the decision about what medical treatment to provide. This study showed that advance directives, or "living wills", are particularly useful in helping physicians in emergency rooms and critical care units make decisions about levels of medical care that are more like what individuals would choose for themselves.

Advance directives have two parts. First, the living will is a description of the types of medical treatments people want when unable to make decisions themselves. Second, an individual may choose another person to be his or her durable power of attorney for health care - and that person has full authority to make decisions about types of medical treatment. For this study, advance directives refers primarily to the living will - a written set of instructions about what types of care to provide in specific medical situations.

Aim and scope of study

This study had two major goals:

• to compare treatment decisions of family members with decisions of two types of physicians - the primary care physician, or "family doctor", and hospital-based physicians, such as in emergency rooms or critical care areas;
• to see if advance directives, or "living wills", help physicians in both primary care and hospital settings make better decisions about what types of medical care to provide to patients who were unable to speak for themselves.

The patients in this study were 82 adults, age 65 or older, all from the Ohio area in the United States. There were three other groups of participants:

1. family members, or family surrogates (chosen by the patients), who provided judgements about the type of care they believed the patients would want
2. primary care physicians, or "family doctors"
3. hospital-based emergency and critical care physicians who did not know the patients

Patient participants answered questions about types of medical treatment they would prefer. The questions asked about 4 life-sustaining medical treatments, some more invasive than others:

• Antibiotics
• CPR (helping restart the heart and breathing)
• Surgery
• Artificial nutrition and hydration (giving fluids through a vein)

Patients then read 9 different medical scenarios chosen to reflect a broad range of conditions with varying degrees of severity, chance of recovery, and level of pain. These scenarios included: the patient's current health, Alzheimer's, emphysema, coma and stroke (with different chances of recovery), and cancer (with different levels of pain).

For each scenario, the patients indicated which of the 4 medical treatments they would want to receive. Patients had the option of requesting "no treatment" or "all possible treatments."

Family members and the two groups of physicians read the same treatment options and medical scenarios, then made predictions of the patients' treatment preferences.

Decisions made without living wills

As might be expected, family members and family surrogates made decisions about medical treatment of patients that were closest to what the individuals would have chosen for themselves when there were no advance directives. Family members were much more accurate than either group of physicians in making decisions about overall medical care, and specifically about treatment of emphysema, stroke with a slight chance of recovery, and cancer with no pain. When family members made decisions different from the patient, it was usually to do more treatment than what the patient would have preferred.

Although neither group of physicians made decisions as accurately as the families, the primary care physicians chose treatments slightly more aligned with patient wishes than the hospital-based physicians did when there were no advance directives. When primary care physicians made errors about patient preferences, they usually chose less treatment than what the patient would have wanted. Primary care physicians were most accurate in the "extreme" scenarios, such as coma with no chance of recovery, and terminal cancer with pain. They were less accurate in judging patient wishes in scenarios where there was no clear choice or no clear idea if the patient would recover.

Hospital-based physicians tended to choose more treatment than patients preferred, particularly when the scenario involved significant pain, loss of reasoning ability, and poor chance for recovery. Researchers speculated that this may be due to the assumption that, in emergency situations, physicians must do everything to preserve life - particularly when they do not know the patient.

Living wills improve hospital treatment decisions

Hospital-based physicians showed a remarkably improved ability to make treatment decisions aligned with patient wishes when advance directives, or "living wills", were available. In fact, with living wills, their decisions about patient care improved to a level better than decisions made by the primary care physicians. Their treatment choices were almost as accurate as decisions made by family members. Researchers noted that advance directives improved decisions by physicians in emergency rooms and critical care areas to a level of someone well acquainted with the patient.

Living wills did not improve decision-making by either family members or primary care physicians. But keep in mind that family members and the primary care physician already know the patient - a substantial improvement in knowing the patient's wishes was not expected in these groups.

Comment

Advance directives, particularly the part called a "living will", can provide some control over how a person is treated when unable to make her or his own decisions about medical treatment. But according to surveys conducted in the United States, the number of persons having any type of advance directive on file ranges from only 2 to 30%, depending upon the study¹, ². This study provided a strong argument for completing advance directives in order to improve decision-making by hospital-based physicians in the event of a medical emergency.

Anyone who is currently in good health can carry out an advance directive, but it is especially recommended for the elderly and for individuals with known medical problems.

There are several types of advance directives. Some describe general values, such as "I do not wish to be a burden to my family", and others have very specific scenarios, such as "If I am in a coma and am expected to survive, provide all necessary treatment." A separate section of this study found that the more specific, scenario-based instructions from patients were the most helpful to physicians in making treatment decisions aligned with patient wishes. So when completing advance directives, it is better to be as specific as possible. People with a known medical problem, such as a heart condition or cancer, can address specific treatment-related issues in the living will.

In addition to being helpful in the event of an emergency, the process of completing advance directives can provide an excellent opportunity for the elderly to have good conversations with family members and their regular physician about medical care and to better define their ideas for quality of life.