profession
Living wills' lack of specifics limits their usefulness
■ Patients often opt for more end-of-life care when given detailed circumstances -- at odds with responses to a general question, a new study says.
Living wills fail to capture patients' end-of-life care wishes because they do not ask about the real-life scenarios patients are likely to face as they get close to death, according to a new study.
Researchers from Thomas Jefferson University in Pennsylvania examined interview responses of 202 Philadelphia-area patients age 70 and older for the study in the May 22 Journal of Palliative Medicine.
Patients first were asked a question used in many Pennsylvania living wills, probing whether to "withdraw life-sustaining treatment that serves only to prolong the process of dying." Patients then were queried about their desires about more specific scenarios, such as whether to use antibiotics to treat their pneumonia if they also have Alzheimer's disease. There was a 23% average correlation between the responses.
"This study points out that if you talk to people in more detail, there's more nuance to their decisions than just results from a simple question about what they want in a living will document," said Charles F. von Gunten, MD, PhD, editor-in-chief of the Journal of Palliative Medicine and provost of the Institute for Palliative Medicine at San Diego Hospice. The study is online (link).
The study comes on the heels of previous research showing that living wills and other advance directives often do not explicitly cover the full spectrum of clinical realities patients face as they die.
An April 1 study in the New England Journal of Medicine, however, found that two-thirds of 3,746 patients with living wills or durable powers of attorney received care consistent with their wishes. Nearly all those who requested only comfort care, for example, received it (link).
About 70% of Americans tell pollsters that they do not have living wills. The American Medical Association strongly supports advance directives and the durable power of attorney for health care.
Even if living wills fail to cover every medical contingency, they still hold value for physicians, patients and families doing end-of-life care planning, according to Dr. von Gunten.
"It's the conversations that these documents stimulate that is the most important," he said. "When physicians bring this up, the question is not, 'What do you want us to do?' and write it down, but, 'Why?' What are the principles? What are your values that lie behind your preferences? It's those values that are likely to help others make decisions for the patient, rather than just reading a document."
