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Doctors' perspectives on adhering to advance care directives when making medical decisions for patients: an Australian interview study.
BMJ Open. 2019 10 31; 9(10):e032638.BO

Abstract

OBJECTIVE

Advance care planning (ACP) assists people to identify their goals, values and treatment preferences for future care. Ideally, preferences are documented in an advance care directive (ACD) and used by doctors to guide medical decision-making should the patient subsequently lose their decision-making capacity. However, studies demonstrate that ACDs are not always adhered to by doctors in clinical practice. We aim to describe the attitudes and perspectives of doctors regarding ACD adherence and the utility of ACDs in clinical practice.

DESIGN

Face-to-face semistructured interviews were conducted using three case-based vignettes to explore doctors' decision-making and attitudes towards ACDs. Transcripts were analysed using a thematic analysis.

SETTING

Doctors from a variety of medical specialties and with varying experience levels were recruited from a large tertiary hospital in Melbourne, Australia.

PARTICIPANTS

A total of 21 doctors were interviewed, 48% female (10/21). Most (19/21) reported having experience using ACDs.

RESULTS

Four themes were identified: aligning with patient preferences (avoiding unwanted care, prioritising autonomy and anticipating family opposition), advocating best interests (defining futile care, relying on clinical judgement, rejecting unreasonable decisions and disregarding legal consequences), establishing validity (doubting rigour of the decision-making process, questioning patients' ability to understand treatment decisions, distrusting outdated preferences and seeking confirmation) and translating written preferences into practice (contextualising patient preferences, applying subjective terminology and prioritising emergency medical treatment).

CONCLUSIONS

ACDs provide doctors with opportunities to align patient preferences with treatment and uphold patient autonomy. However, doctors experience decisional conflict when attempting to adhere to ACDs in practice, especially when they believe that adhering to the ACD is not in the patients' best interests, or if they doubt the validity of the ACD. Future ACP programmes should consider approaches to improve the validity and applicability of ACDs. In addition, there is a need for ethical and legal education to support doctors' knowledge and confidence in ACP and enacting ACDs.

Authors+Show Affiliations

Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia. Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia.Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia. Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia.Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia. Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia.Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia.Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia. Clinical Gerontology Division, National Ageing Research Institute, Parkville, Victoria, Australia.Advance Care Planning Australia, Austin Health, Heidelberg, Victoria, Australia marcus.sellars@austin.org.au. Northern Clinical School, Faculty of Medicine, University of Sydney, Kolling Institute of Medical Research, Sydney, New South Wales, Australia.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31676659

Citation

Moore, Nadia, et al. "Doctors' Perspectives On Adhering to Advance Care Directives when Making Medical Decisions for Patients: an Australian Interview Study." BMJ Open, vol. 9, no. 10, 2019, pp. e032638.
Moore N, Detering KM, Low T, et al. Doctors' perspectives on adhering to advance care directives when making medical decisions for patients: an Australian interview study. BMJ Open. 2019;9(10):e032638.
Moore, N., Detering, K. M., Low, T., Nolte, L., Fraser, S., & Sellars, M. (2019). Doctors' perspectives on adhering to advance care directives when making medical decisions for patients: an Australian interview study. BMJ Open, 9(10), e032638. https://doi.org/10.1136/bmjopen-2019-032638
Moore N, et al. Doctors' Perspectives On Adhering to Advance Care Directives when Making Medical Decisions for Patients: an Australian Interview Study. BMJ Open. 2019 10 31;9(10):e032638. PubMed PMID: 31676659.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Doctors' perspectives on adhering to advance care directives when making medical decisions for patients: an Australian interview study. AU - Moore,Nadia, AU - Detering,Karen M, AU - Low,Tessa, AU - Nolte,Linda, AU - Fraser,Scott, AU - Sellars,Marcus, Y1 - 2019/10/31/ PY - 2019/11/3/entrez PY - 2019/11/5/pubmed PY - 2019/11/5/medline KW - advance care directives KW - advance care planning KW - autonomy KW - end-of-life KW - interviews KW - semistructured interviews SP - e032638 EP - e032638 JF - BMJ open JO - BMJ Open VL - 9 IS - 10 N2 - OBJECTIVE: Advance care planning (ACP) assists people to identify their goals, values and treatment preferences for future care. Ideally, preferences are documented in an advance care directive (ACD) and used by doctors to guide medical decision-making should the patient subsequently lose their decision-making capacity. However, studies demonstrate that ACDs are not always adhered to by doctors in clinical practice. We aim to describe the attitudes and perspectives of doctors regarding ACD adherence and the utility of ACDs in clinical practice. DESIGN: Face-to-face semistructured interviews were conducted using three case-based vignettes to explore doctors' decision-making and attitudes towards ACDs. Transcripts were analysed using a thematic analysis. SETTING: Doctors from a variety of medical specialties and with varying experience levels were recruited from a large tertiary hospital in Melbourne, Australia. PARTICIPANTS: A total of 21 doctors were interviewed, 48% female (10/21). Most (19/21) reported having experience using ACDs. RESULTS: Four themes were identified: aligning with patient preferences (avoiding unwanted care, prioritising autonomy and anticipating family opposition), advocating best interests (defining futile care, relying on clinical judgement, rejecting unreasonable decisions and disregarding legal consequences), establishing validity (doubting rigour of the decision-making process, questioning patients' ability to understand treatment decisions, distrusting outdated preferences and seeking confirmation) and translating written preferences into practice (contextualising patient preferences, applying subjective terminology and prioritising emergency medical treatment). CONCLUSIONS: ACDs provide doctors with opportunities to align patient preferences with treatment and uphold patient autonomy. However, doctors experience decisional conflict when attempting to adhere to ACDs in practice, especially when they believe that adhering to the ACD is not in the patients' best interests, or if they doubt the validity of the ACD. Future ACP programmes should consider approaches to improve the validity and applicability of ACDs. In addition, there is a need for ethical and legal education to support doctors' knowledge and confidence in ACP and enacting ACDs. SN - 2044-6055 UR - https://www.unboundmedicine.com/medline/citation/31676659/Doctors'_perspectives_on_adhering_to_advance_care_directives_when_making_medical_decisions_for_patients:_an_Australian_interview_study_ L2 - https://bmjopen.bmj.com/lookup/pmidlookup?view=long&pmid=31676659 DB - PRIME DP - Unbound Medicine ER -