The results of our survey suggest that physician adherence to ADs is situation-specific, and that in rapidly reversible conditions (i.e. Scenario 2) physicians believe their judgment supersedes previously-specified patient instructions. The fear of legal action did not appear to be a major factor in the compliance or non-compliance with ADs, except in the case of Scenario 3 in which there was family disagreement with patient wishes.
Although ADs may not offer the results initially envisioned by those who advocated for their existence, they nonetheless may provide a valuable, societally-acceptable approach to communicating one’s desires regarding end-of-life care goals and preferences
. Similar to other reports
[5, 7–9, 11, 15], our study found that despite knowledge of their existence, physicians do not consistently honor patients’ ADs. In our survey, the temporal remoteness of the AD and the reversibility of the immediate condition appeared to hold greater relevance for clinicians’ decision making.
A majority of physicians surveyed would refuse to provide emergency care to a patient who completed an AD before undergoing a previous routine surgical procedure (Scenario 1) but would deliver treatment in a case where the AD reflected a patient’s wish to pass away in peace (Scenario 2). Like physicians and other health care providers, courts have been confronted with disputes over the appropriateness of providing emergency treatment to patients who have previously requested limits to their care through ADs
. One representative Ohio court judgment held that an earlier decision by a patient to forego life-saving measures could carry over to an emergency condition only after it was determined that the patient had both knowledge and understanding of how the two settings may differ
. By example, the court acknowledged the difference between a terminally ill patient who had previously requested to die in peace and now suffers injuries sustained in an automobile accident and the treatment of an emergency condition developing from their terminal condition. In line with this judicial reasoning, respondents we surveyed appeared to be concerned that the request to “pass away in peace” in Scenario 2 was effectively different from the condition that brought the patient to the hospital that day.
Legal concerns influencing decisions on advance directives
Over half (52%) of the respondents in our study agreed that the risk of liability was lower when maintaining someone alive against their wishes than in mistakenly failing to provide resuscitative efforts. Prior reports also suggest that the risk of legal liability may influence a practitioner’s decision regarding end-of-life care and resuscitative efforts
[15, 19]. In a survey of emergency medicine physicians, 58% of respondents stated that their decisions regarding resuscitation were largely influenced by fears of litigation or criticism
. Although 80% admitted legal concerns should not influence physician decision-making regarding resuscitation, 92% reported that the present legal environment did influence their practice
Although claims have been filed against hospitals and physicians alike for damages arising from delivery of care against the express wishes of patients, it should offer comfort to providers that courts have struggled when deciding if and how to award compensation for “continued living”
[5, 19]. In Anderson v. St. Francis-St. George Hospital, Inc, a patient, who had provided clear instructions upon admission to the emergency room to forgo extraordinary life-sustaining treatment, sued for damages resulting from a stroke sustained following cardiac defibrillation for ventricular fibrillation
[5, 19–21]. The Anderson court held that such damage awards were unavailable unless the patient could show that “defibrillation itself caused or contributed to [his] stroke in any way other than simply prolonging his life ”
[5, 21]. Instead, damages would only be awarded for direct injuries resulting from resuscitation efforts such as burns due to defibrillation.
When confronted with a spouse’s wishes that conflict with those provided by the patient’s AD, over half of respondents (53%) considered the threat of legal liability as important or very important to their decision. The fear of liability was more prevalent than expressed in the two prior patient scenarios (37% and 42%, respectively). Furthermore, a majority of those failing to honor the AD in Scenario 3 were strongly influenced by the spouse’s request for continued care (77%) and potential risk of future liability (63%). Our results remain in line with other reports suggesting that due to the limited number of cases filed against practitioners for failing to abide by a patient’s AD, along with the courts’ general unwillingness to award damages for continued life, practitioners often consider the risk of mistakenly failing to deliver treatment greater than providing care against the wishes of patient or surrogate
With many confounding factors influencing physician decisions to honor or forego patient ADs, some have advocated that a better means of ensuring physician compliance with patient wishes is to limit legal liability to only those instances where intentional disregard for the instructions provided in the AD occurs
. Despite proposed benefits, only 56% of respondents agreed with this approach to balancing liability. The majority of respondents (74%) disagreed that the complexity of medical care should limit the level of patient participation in decisions at the end-of-life. Perhaps this strong view among those surveyed could help explain why a standard of liability limited to the intentional disregard for patient wishes alone did not gain greater support.
Family influence on physician compliance with advance directives
Almost three-quarters of physicians surveyed (74%) in our study stated they would continue to honor an AD despite the spouse’s request to the contrary. However, among those who reported that they would not comply with the patient’s AD (17%), a large majority (77%) considered the spouse’s demand important or very important in their decision. Demands for care by the family that are at odds with those expressed by patient’s AD, have been considered the leading cause for physician noncompliance with ADs
. However, the general lack of spousal influence on those we surveyed may reflect problems others in the past have highlighted
. Family members and surrogates often fail to accurately predict a patient’s treatment wishes by overestimating the patient’s desire for continued treatment
Older (over 50 years of age) physicians and those with more practice experience (>15 years) were more influenced by the spouse’s demand than their younger colleagues. Prior studies suggest that physician age may impact the level of influence a family’s appeal has on physician practices
. Hinkka et al. reported that while family requests had a greater initial influence on younger physicians’ care decisions, any age-specific trends tended to fade with the introduction of an AD
. As those we surveyed were aware that an AD existed, any bias on the part of younger physicians to respect family requests may have been nullified.
Limitations of care
At our institution, and in many other institutions, there is a distinction between “comfort measures only” and a desire not to undergo cardiopulmonary resuscitation (i.e. to be “Do Not Resuscitate/Do Not Intubate” [DNR/DNI]). In the former, all treatment measures that are not intended to alleviate discomfort are discontinued, except for the use of opiates, benzodiazepines, anti-sialogogues and nursing cares are continued to maximize comfort. This practice is consistent with the thoughts of the 67% of respondents who disagreed or strongly disagreed with the statement that "comfort measures only should allow physicians to continue life support measures." (Table
5) In contrast, when a patient has made a decision to not be resuscitated or intubated (i.e. they are DNR/DNI), but has
decided to be “comfort measures only”, this can still be consistent with aggressive therapy directed towards a patient’s goals of care (i.e. chemotherapy, radiation, antibiotics, pressors, etc.)
[23–27]. Withholding treatment at the end-of-life does not necessarily suggest that all care should be discontinued and patients who are DNR/DNI do not necessarily wish to forego ICU care. Several states have enacted laws ensuring end-of-life care and surrogate-decision making occurs in line with a patient’s expressed wishes to promote a patient’s dignity
. Practitioners should be aware that the blurring of lines between treatment and comfort measures not only stands at odds with patient autonomy and the right to decision making, but comes with some additional (while rare) legal risk
. For example, a Michigan court awarded damages to the family of a patient who awoke from a coma but remained in a vegetative state after a hospital provided care in excess of the patient’s health care proxy requests for comfort measures only
Costs of care
Two-thirds of those we surveyed (69%) agreed that costs should never impact a physician’s decision as to whether to comply with a patient’s AD. According to a recent report released by the Agency for Healthcare Research and Quality, 1% and 5% of the population accounted for 22% and 50% of health care expenditures respectively (using 2009 data)
. Forty-percent of health-care costs involved care delivered to patients 65 years of age or older. Our results appear in line with prior surveys of physicians finding that a majority object to the use of cost-effectiveness data to determine the benefit of treatment provided to patients
. Others have suggested that physicians may be unwilling to enter the controversial domain they believe better belongs to politicians, administrative bodies and health care advocates
Our study has methodological limitations. Given that 41% of surveys were returned, our results may not be generalized to all clinicians who are commonly confronted with the issue of deciding on whether to follow or forego patient ADs. Another potential limitation of our study is that those surveyed were not asked if they are commonly confronted with issues related to patient advance directives during their normal course of daily practice, although in general, many of the general internists who attend these meetings are hospitalists and commonly address these issues.