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Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

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Opening the black box: how do physicians communicate about advance directives?

J A Tulsky¹, G S Fischer, M R Rose

¹Durham Veterans Affairs Medical Center and Duke University, North Carolina 27705, USA.

Annals of Internal Medicine

|September 12, 1998

Summary

Physicians often introduce advance directives but rarely explore patient values or attitudes toward uncertainty. These discussions, though brief, may not adequately prepare patients for future medical decisions.

Keywords:

Empirical Approach Professional Patient Relationship

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Area of Science:

Medical Communication
Bioethics
Patient-Physician Interaction

Background:

The quality of communication during advance directive completion influences document usefulness.
The nature of physician-patient communication regarding advance directives is understudied.

Purpose of the Study:

To describe how physicians discuss advance directives with patients.

Main Methods:

Prospective study involving 56 internists and 56 established patients across five primary care practices.
Audiotaped discussions were coded by two raters to analyze the introduction of advance directives, scenario discussions, information provision, value elicitation, and surrogate identification.

Main Results:

Advance directive conversations averaged 5.6 minutes, with physicians dominating the discussion.
Physicians frequently presented dire scenarios (91%) and discussed surrogate decision-making (88%), but less often explored patient preferences in reversible scenarios (48%) or patient values (rarely).
Discussions about uncertainty were common (55%) but often used vague language.

Conclusions:

Physician discussions introduce advance directives but seldom delve into patients' values or attitudes toward uncertainty.
Current communication practices may not sufficiently equip patients for future decision-making.
Physician-patient communication regarding advance directives did not meet established literature standards.