Emergency clinicians' attitudes and decisions in patient scenarios involving advance directives

To identify the decisions and attitudes of emergency clinicians in hypothetical scenarios involving advance directives (ADs).

An online survey distributed to members of the Australasian College for Emergency Medicine elicited decisions on commencing full treatment (CFT), limiting treatment or palliation in hypothetical clinical scenarios. Quantitative data were summarised using number and percentage.

388 surveys yielded a 13.0% response rate, including 190 fellows (51.9%) and 176 trainees (48.1%). For a 75-year-old patient with major trauma and unknown comorbidities requiring laparotomy, most participants (355/365, 97.3%) chose CFT. When an AD limiting treatment was made available, CFT decreased substantially (63/364, 17.3%), and the modal response was palliation (175/364, 48.1%). The most frequently reported influential factor in this decision was ethical obligation (82/383, 21.4%). For an elderly nursing-home resident with dementia, metastatic cancer and possible septic shock, 10.7% (39/366) chose CFT, changing little (21/365, 5.8%) with a directive requesting full treatment. The patient's presentation and history (189/375, 50.4%) overrode legal obligations (14/375, 3.7%) in influencing the decision. For a 55-year-old man with prostate cancer, hypoxia and acute respiratory distress (potentially requiring ventilatory support) saying, 'I just want to end it all,' most (233/366, 63.7%) chose CFT. A directive requesting limitation resulted in fewer decisions on CFT (43/368, 11.7%). Clear documentation was most important (100/362, 27.6%) in influencing this decision.

Hypothetical treatment decisions involving ADs made by emergency clinicians appear to be more influenced by ethical and clinical factors than by legal obligations.