The quality of patient-doctor communication about end-of-life care: a study of patients with advanced AIDS and their primary care clinicians

Objective: To assess prevalence and quality of end-of-life communication be tween persons with advanced AIDS and their clinicians and to identify patie nt and clinician characteristics associated with this communication. Design: Prospective cohort study of 57 patients with AIDS and their primary care clinicians. Setting: University-based and private clinics in Seattle, Washington. Patients: Patients had a prior AIDS-defining illness and a CD4 cell count o f less than 100 x 10(6) cells/l. Main outcome measures: Quality of patient-clinician communication about end -of-life care, validated against patient satisfaction and patient-clinician concordance on advance directives and treatment preferences. Results: Patients reported they had communication about end-of-life care wi th their clinician in 31 of 57 cases (54%) while clinicians reported they h ad this discussion in 36 of 57 cases (64%). Patients and clinicians gave co ncordant answers in 32 patient-clinician pairs. in 15 pairs (26%), patients and clinicians disagreed about whether end-of-life communication had occur red. African-American and Hispanic patients were less likely to report havi ng communication than non-Hispanic white patients (chi-square analysis: chi (2) = 4.67; P < 0.05); injection drug users and women with high-risk sexual partners were less likely to report communication than homosexual or bisex ual men (chi(2) = 4.67; P < 0.05). A four-item measure of patients' assessm ent of the quality of communication about end-of-life care had good interna l consistency (Cronbach's alpha 0.81) and was significantly correlated with overall satisfaction with medical care (r(2) = 0.76; P < 0.0001). Patients with lower income reported lower quality of communication (chi(2) = 5.82; P = 0.05). If patients assessed quality of communication as high, their cli nicians were more likely to know if the patient had a durable power of atto rney for health care (chi(2) = 4.95; P = 0.03) but were not more likely to predict patients' preferences for life-sustaining treatments. Conclusions: Quality of patient-clinician communication about end-of-life c are can be measured in a brief questionnaire; higher quality of this commun ication is associated with higher satisfaction with care and increased clin ician knowledge of patients' advance directives. Since socioeconomic status and ethnicity are associated with both the occurrence and quality of this communication, future interventions in end-of-life care should assess the e ffect of these variables. Given the important and independent goals of impr oving patient-clinician communication about end-of-life care and improving the quality of care at the end of life, future studies should test interven tions to improve the quality of communication and determine whether improvi ng this communication improves the quality of care at the end of life. (C) 1999 Lippincott Williams & Wilkins.