Perceptions of "good palliative care" orders: a discursive study of cancer patients' comments

Patients' perceptions regarding Good Palliative Care (GPC) orders, a form of advance directives, were sought, and issues inherent in their promotion as policy were identified. Semi-structured interviews with 23 oncology-clinic outpatients, focused on end-of-life decision making, were tape-recorded, transcribed, and analyzed using discursive-analytical techniques. Most patients were unfamiliar with the term GPC orders, preferring the familiar "do-not-resuscitate" orders. GPC orders were negatively perceived as vague, beyond the individual's control, implying dependency on others, and failing to reduce suffering. Positive perceptions of GPC orders saw them as counteracting the impersonality of medical procedure and asserting the value of the whole patient within a social context. Participants' comments on a draft copy of a GPC order form suggest that they view consultation as beneficial, but that a standardized form may be impersonal and inappropriate. The structure and content of the GPC order form constitute it as a quasilegal document that may confuse and disempower patients, and function to protect the interests of the medical profession in the guise of promoting patient autonomy. The potential benefits attributed to GPC orders are achievable without the adoption of a blanket policy that depersonalizes and bureaucratizes the dying process, and may be less than sensitive to individual patients' needs.