IMPLEMENTING ADVANCE DIRECTIVES IN THE PRIMARY-CARE SETTING

Background: Despite the potential benefits of advance directives, few patients complete them. This study examined whether barriers to advanc e decision making can be overcome via a combined educational and admin is- trative intervention targeted at physicians. Method: The subjects consisted of all the internists (n=6) at a primary care physician home care (HC) service and all the internists (n=4) at a primary care nurs ing home (NH) service. Physicians were given a 5-week course on the la w relating to advance directives. Administrative consent was obtained to permit physicians to spend additional time with patients to discuss advance directives. Physicians were asked to discuss advance directiv es with newly enrolled patients and to assist interested patients to c omplete directives. During the first 2 months of the trial, physicians did not approach any patients. Therefore, the study design was change d to include all active patients, and physicians received additional t raining that involved observing and leading discussions with their own patients. Results: Physicians approached 74 of 356 competent HC patie nts, of whom 48 (65%) completed directives. All 42 competent NH patien ts were approached, and 38 (90%) completed directives. Most patients w ho completed a directive chose relatives as proxies. Mos;t directed th at life-sustaining treatment be withheld in the event they were perman ently unconscious (HC, 81%; NH, 92%). Other common choices were to dec line long-term mechanical ventilation (HC, 58%; NH, 79%), long-term ar tificial nutrition (HC, 44%; NH, 79%), and cardiopulmonary resuscitati on (HC, 27%; NH, 66%). Conclusions: Physicians can overcome initial re luctance to integrate advance decision making into primary care provid ed to elderly patients. Teaching physicians about the law is not suffi cient to change behavior; physicians also need practical experience di scussing directives with patients. Our high patient response suggests that a physician-directed intervention is sufficient to achieve high r ates of completing directives without additional, concomitant patient- directed intervention.