The Doctor's Role in Discussing Advance Preferences for End‐of‐Life Care: Perceptions of Physicians Practicing in the VA

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Abstract
OBJECTIVES: Although previous studies have shown physicians support advance directives, little is known about how they actually participate in decision‐making. This study investigates (1) how much experience physicians have had discussing and following advance preferences and (2) how physicians perceive their role in the advance decision‐making process. DESIGN: Mail survey conducted in 1993. SETTING: The Department of Veterans Affairs. PARTICIPANTS: A national probability sample of 1050 VA internists, family physicians, and generalists. MEASUREMENTS AND MAIN RESULTS: Questionnaires were returned by 67% of participants. In the last year, 79% stated they had discussed advance preferences with at least one patient, and 19% had talked to more than 25. Seventy‐three percent had used a written directive to make decisions for at least one incompetent patient. Younger age, board certification, spending less time in the outpatient setting, and personal experience with advance decision‐making, were all associated independently with having advance preference discussions. Among physicians who had discussions, 59% said they often initiated the discussion, 55% said discussions often occurred in inpatient settings, and 31% said discussions often occurred in outpatient settings. Eighty‐two percent of those responding thought physicians should be responsible for initiating discussions. Most would try to persuade a patient to change a decision that was not well informed (91%), not medically reasonable (88%), or not in the patient's best interest (88%); few would attempt to change decisions that conflicted with their own moral beliefs (14%). CONCLUSIONS: Physicians report that they are actively involved with their patients in making decisions about end‐of‐life care. Most say they have had recent discussions with at least some of their patients and feel that as physicians they should play a large and important role in soliciting and shaping patient preferences.