The effect of discussions about advance directives on patients' satisfaction with primary care

BACKGROUND: Discussions of end-of-life care should be held prior to acute, disabling events. Many barriers to having such discussions during primary c an exist. These barriers include time constraints, communication difficulti es, and perhaps physicians' anxiety that patients might react negatively to such discussions. OBJECTIVE: To assess the impact of discussions of advance directives on pat ients' satisfaction with their primary care physicians and outpatient visit s. DESIGN: Prospective cohort study of patients enrolled in a randomized, cont rolled trial of the use of computers to remind primary can physicians to di scuss advance directives with their elderly, chronically ill patients. SETTING: Academic primary care general internal medicine practice affiliate d with an urban teaching hospital. PARTICIPANTS: Six hundred eighty-six patients who wen at least 75 years old , or at least 50 years old with serious underlying disease, and their 87 pr imary care physicians (57 residents, 30 faculty general internists) partici pated in the study. MEASUREMENTS AND MAIN RESULTS: We assessed patients' satisfaction with thei r primary can physicians and visits via interviews held in the waiting room after completed visits. Controlling for satisfaction at enrollment and phy sician, patient, and visit factors, discussing advance directives was assoc iated with greater satisfaction with the physician (P = .052). At follow-up , the strongest predictor of satisfaction with the primary care visit was h aving previously discussed advance directives with that physician (P = .004 ), with a trend toward greater visit satisfaction when discussions were hel d during that visit (P = .069). The percentage of patients scoring a visit as "excellent" increased from 34% for visits prior without advance directiv e discussions to 51% for visits with such discussions (P = .003). CONCLUSIONS: Elderly patients with chronic illnesses were more satisfied wi th their primary care physicians and outpatient visits when advanced direct ives were discussed. The improvement in visit satisfaction was substantial and persistent. This should encourage physicians to initiate such discussio ns to overcome communication barriers that might result in reduced patient satisfaction levels.