Experts practice what they preach - A descriptive study of best and normative practices in end-of-life discussions

Background: Advance directives (ADs) are widely regarded as the best availa ble mechanism to ensure that patients' wishes about medical treatment at th e end of life are respected. However, observational studies suggest that th ese discussions often fail to meet their stated goals. Objectives: To explore best practices by describing what physicians who are considered expert in the area of end-of-life bioethics or medical communic ation do when discussing ADs with their patients and to explore the ways in which best practices of the expert group might differ in content or style from normative practice derived from primary care physicians' discussions o f ADs with their patients collected as part of an earlier study. Design: Nonexperimental, descriptive study of audiotaped discussions. Setting: Outpatient primary care practices in the United States. Participants: Eighteen internists who have published articles in the areas of bioethics or communication and 48 of their patients. Fifty-six academic internists and 56 of their established patients in 5 practice sites in 2 lo cations-Durham, NC, and Pittsburgh, Pa. Eligible patients were at least 65 years old or suffered from serious medical illness and had not previously d iscussed ADs with their physician. Expert clinicians had discretion regardi ng patient selection, while the internists chose patients according to a pr edetermined protocol. Measurements: Coders applied the Roter Interaction Analysis System (RIAS) t o audiotapes of the medical. visits to describe communication dynamics. In addition, the audiotapes were scored on 21 items reflecting physician perfo rmance in specific skills related to AD discussions. Results: Experts spent close to twice as much time (14.7 vs 8.1 minutes, P< .001) and were less verbally dominant (P<.05) than other physicians during AD discussions. When length of visit was controlled statistically, the expe rt physicians gave less information about treatment procedures and biomedic al issues (P<.05) and asked fewer related questions (P<.05) but tended towa rd more psychosocial and lifestyle discussion and questions. Experts engage d in more partnership building (P<.05) with their patients. Patients of the expert physicians engaged in more psychosocial and lifestyle discussion (P <.001), and more positive talk (P<.05) than patients of community physician s. Expert physicians scored higher on the 21 items reflecting AD-specific s kills (P<.001). Conolusions: Best practices as reflected in the performance of expert physi cians reflect differences in measures of communication style and in specifi c AD-related proficiencies. Physician training in ADs must be broad enough to include both of these domains.