Implementing advance directives in the primary care setting

Area of Science:

• Geriatric Medicine
• Healthcare Policy
• Medical Education

Background:

• Advance directives are crucial for patient autonomy but are underutilized.
• Barriers to advance decision-making persist, particularly in primary care settings.
• Physician-led interventions are being explored to improve advance directive completion.

Purpose of the Study:

• To assess the effectiveness of a combined educational and administrative intervention for physicians.
• To determine if physicians can overcome barriers to discussing advance directives with elderly patients.
• To evaluate the impact of practical training on physician behavior regarding advance decision-making.

Main Methods:

• A 5-week legal training course on advance directives was provided to primary care internists in home care (HC) and nursing home (NH) services.
• Administrative support allowed physicians extra time for patient discussions.
• The intervention was modified to include all active patients and practical training, including observed and led discussions.

Main Results:

• Physicians successfully approached and facilitated advance directive completion in a significant percentage of eligible patients (65% in HC, 90% in NH).
• Relatives were commonly chosen as proxies, and patients frequently directed withholding of life-sustaining treatments.
• High completion rates were achieved, indicating patient willingness to engage in advance decision-making when prompted by physicians.

Conclusions:

• Physician reluctance to discuss advance directives can be overcome with targeted interventions.
• Practical experience and observed discussions are more effective than legal education alone in changing physician behavior.
• A physician-directed intervention is sufficient to achieve high rates of advance directive completion among elderly patients.