Laura A. Siminoff

Patient Knowledge and Physician Predictions of Treatment Preferences After Discussion of Advance Directives

OBJECTIVE: To determine patient knowledge about life-sustaining treatments and physician understanding of patient preferences for proxies and treatments after outpatient discussions about advance directives.DESIGN: Cross-sectional interview-based and questionnaire-based survey.SETTING: Two university general internal medicine practices, two Department of Veterans Affairs general internal medicine practices, and one university-based geriatrics practice, in two different cities.PATIENTS: Fifty-six patients of primary care internists.INTERVENTION: Physicians discussed “advance directives” (ADs) with one randomly selected patient during an outpatient visit.MEASUREMENTS AND MAIN RESULTS: After the discussions, physicians identified the patient’s proxy and predicted the patient’s preferences for treatment in 20 scenarios. Patients provided treatment preferences in the 20 scenarios, the name of their preferred surrogate decision maker, and their understanding of cardiopulmonary resuscitation and mechanical ventilation. Of the 39 patients who discussed resuscitation, 43% were able to identify two important characteristics; 26% identified none; 66% did not know that most patients need mechanical ventilation after undergoing resuscitation. None of the 43 patients who had a discussion about mechanical ventilation had a good understanding of it; 67% did not know that patients generally cannot talk while on ventilators; 46% expressed serious misconceptions about ventilators. There was poor agreement between physicians and their patients regarding treatment preferences in 18 of 20 scenarios (κ −0.04 to 0.31). Physicians correctly identified the proxy 89% of the time (κ 0.78).CONCLUSIONS: Patients leave routine AD discussions with serious misconceptions about life-sustaining treatments. Physicians are unable to predict treatment preferences but do learn about patients’ preferences for surrogate decision makers.

Offering the option of randomized clinical trials to cancer patients who overestimate their prognoses with standard therapies

We have shown that cancer patients routine (and understandable) overestimations of their prognoses with standard therapy may inhibit their accrual to randomized clinical trials for which standard therapies are the alternative. Patients appreciation of the rationale for a trial, and the potential benefit of trial participation, can only be enhanced if they understand their prognoses with standard therapy. However, clinical investigators may be reluctant to provide specific information that deflates patients estimates of their prognoses. The routine withholding of information regarding the modest benefits of standard therapies may avoid patient distress, but such physician behavior is paternalistic and may deleteriously affect trial accrual. On the other hand, the routine communication of prognostic information will cause significant distress among patients and will perhaps be destabilizing to that minority of patients who would otherwise shun this information or truly cannot psychologically tolerate it. A middle ground between these extremes is the stepwise disclosure of potentially distressing information, wherein specific prognostical information is offered by physicians to patients and actually provided or communicated only after patients first understand the nature of it and then indicate their interest in receiving it. A practical disadvantage of this approach is its additional demand on physicians time. Therefore, if impracticality is to be avoided and yet the approach fostered, clinical investigators might consider developing trial-specific, written or audiovisual materials for patient education about general background information. These could be employed prior to patient-physician dialogue and so enable physicians to focus on more sensitive subjects, such as prognosis with standard therapy.

ETHICAL ISSUES IN ORGAN PROCUREMENT: A Review for Intensivists

The current state of organ procurement and the ethical issues raised by the procurement process are reviewed in this article. After an examination of the legislative framework governing organ procurement, the intensivists role in donation is discussed, including (1) donor identification, (2) asking the family to donate, and (3) obtaining consent. Recent proposals for changing the organ procurement system are analyzed, including increasing family donation or increasing the donor pool.

Discussions about Limiting Treatment in a Geriatric Clinic

Objective: Obtain detailed information about the frequency and content of discussions about withholding treatment between doctors and elderly outpatients.