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Impact of advance directives and a health care proxy on doctors' decisions: a randomized trial.
J Pain Symptom Manage. 2014 Jan; 47(1):1-11.JP

Abstract

CONTEXT

Advance directives or proxy designations are widely recommended, but how they affect doctors' decision making is not well known.

OBJECTIVES

The aim of this study was to quantify the influence of advance directives and proxy opinions on doctors' decisions.

METHODS

We mailed to all the generalists and internists in French-speaking Switzerland (N = 1962) three vignettes describing difficult decisions involving incapacitated patients. In each case, the advance directive requested that further care be withheld. One vignette tested the impact of a written advance directive vs. a proxy. Another compared the impact of a handwritten directive vs. a formalized document. The third vignette compared the impact of a family member vs. a doctor as a proxy. Each vignette was prepared in three or four versions, including a control version in which no directive or proxy was present. Vignettes were randomly allocated to respondents. We used logistic regression to predict the decision to forgo a medical intervention.

RESULTS

Compared with the control condition, the odds of forgoing a medical intervention were increased by the written advance directive (odds ratio [OR] 7.3; P < 0.001), the proxy (OR 7.9; P < 0.001), and the combination of the two (OR 35.7; P < 0.001). The handwritten directive had the same impact (OR 13.3) as the formalized directive (OR 13.8). The effect of proxy opinion was slightly stronger when provided by a doctor (OR 11.3) rather than by family (OR 7.8).

CONCLUSION

Advance directives and proxy opinions are equally effective in influencing doctors' decisions, but having both has the strongest effect. The format of the advance directive and the identity of the proxy have little influence on decisions.

Authors+Show Affiliations

Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland. Electronic address: Monica.Escher@hcuge.ch.Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland.Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland.Pain and Palliative Care Consultation, Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva, Geneva, Switzerland.Division of General Internal Medicine, University Hospitals of Geneva, Geneva, Switzerland.

Pub Type(s)

Journal Article
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

23742734

Citation

Escher, Monica, et al. "Impact of Advance Directives and a Health Care Proxy On Doctors' Decisions: a Randomized Trial." Journal of Pain and Symptom Management, vol. 47, no. 1, 2014, pp. 1-11.
Escher M, Perneger TV, Rudaz S, et al. Impact of advance directives and a health care proxy on doctors' decisions: a randomized trial. J Pain Symptom Manage. 2014;47(1):1-11.
Escher, M., Perneger, T. V., Rudaz, S., Dayer, P., & Perrier, A. (2014). Impact of advance directives and a health care proxy on doctors' decisions: a randomized trial. Journal of Pain and Symptom Management, 47(1), 1-11. https://doi.org/10.1016/j.jpainsymman.2013.03.010
Escher M, et al. Impact of Advance Directives and a Health Care Proxy On Doctors' Decisions: a Randomized Trial. J Pain Symptom Manage. 2014;47(1):1-11. PubMed PMID: 23742734.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Impact of advance directives and a health care proxy on doctors' decisions: a randomized trial. AU - Escher,Monica, AU - Perneger,Thomas V, AU - Rudaz,Sandrine, AU - Dayer,Pierre, AU - Perrier,Arnaud, Y1 - 2013/06/04/ PY - 2012/09/30/received PY - 2013/03/02/revised PY - 2013/03/19/accepted PY - 2013/6/8/entrez PY - 2013/6/8/pubmed PY - 2016/3/2/medline KW - Advance directives KW - advance care planning KW - end of life KW - ethics KW - palliative care KW - surrogate decision making SP - 1 EP - 11 JF - Journal of pain and symptom management JO - J Pain Symptom Manage VL - 47 IS - 1 N2 - CONTEXT: Advance directives or proxy designations are widely recommended, but how they affect doctors' decision making is not well known. OBJECTIVES: The aim of this study was to quantify the influence of advance directives and proxy opinions on doctors' decisions. METHODS: We mailed to all the generalists and internists in French-speaking Switzerland (N = 1962) three vignettes describing difficult decisions involving incapacitated patients. In each case, the advance directive requested that further care be withheld. One vignette tested the impact of a written advance directive vs. a proxy. Another compared the impact of a handwritten directive vs. a formalized document. The third vignette compared the impact of a family member vs. a doctor as a proxy. Each vignette was prepared in three or four versions, including a control version in which no directive or proxy was present. Vignettes were randomly allocated to respondents. We used logistic regression to predict the decision to forgo a medical intervention. RESULTS: Compared with the control condition, the odds of forgoing a medical intervention were increased by the written advance directive (odds ratio [OR] 7.3; P < 0.001), the proxy (OR 7.9; P < 0.001), and the combination of the two (OR 35.7; P < 0.001). The handwritten directive had the same impact (OR 13.3) as the formalized directive (OR 13.8). The effect of proxy opinion was slightly stronger when provided by a doctor (OR 11.3) rather than by family (OR 7.8). CONCLUSION: Advance directives and proxy opinions are equally effective in influencing doctors' decisions, but having both has the strongest effect. The format of the advance directive and the identity of the proxy have little influence on decisions. SN - 1873-6513 UR - https://www.unboundmedicine.com/medline/citation/23742734/Impact_of_advance_directives_and_a_health_care_proxy_on_doctors'_decisions:_a_randomized_trial_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0885-3924(13)00241-8 DB - PRIME DP - Unbound Medicine ER -