Doctors Often Unaware of Living Wills, Study Finds : Medicine: In three out of four cases, physicians did not know patients had prepared instructions on their care in event of incapacitation, researchers say.
Faced with the possibility of spending one’s last days in a blurry limbo engendered by high medical technology, Americans have increasingly turned to living wills and other documents to make their wishes known in advance. But like a message in a bottle, such documents are seldom heeded because doctors usually are not aware of them, according to studies of elderly people in New York and California who produced so-called advance directives.
The New York City study, published in this week’s Journal of the American Medical Assn., found that the advance medical directives of three-quarters of the elderly patients admitted to a New York City hospital were not available to physicians or even known to exist when crucial therapeutic decisions were being made.
California researchers found the same thing. California Medical Review Inc., which oversees the state Medicare administration, recently found that 78 of 567 elderly patients surveyed said they had completed an advance directive. But three-quarters of those documents could not be found in the medical records.
The findings come as a surprise because living wills, durable powers of attorney and the like have become increasingly common. Most significantly, they express one’s wish not to prolong life unnecessarily with technology, thus helping people exercise that most thoroughly modern civil right, the right to die.
Dr. R. Sean Morrison, a geriatrician at Mt. Sinai Medical Center in New York City, who led the new study, said he didn’t expect the failure rate to be quite so high. “It’s a tragedy if someone goes to the trouble of completing an advance directive and we in the medical community don’t find out about it,” he said.
Dr. Leslie J. Blackhall, an internal medicine specialist at USC’s Pacific Center for Health Policy & Ethics, said, “The important thing this shows is that these documents are no good if they’re sitting in someone’s drawer.” She added, “They’re effective only insofar as they facilitate discussion between patients and family members and patients and doctors.”
Morrison recalled a “vivid example of what can happen when communication breaks down.” It involved an elderly woman who completed a somewhat unusual living will: She wanted extraordinary life-sustaining measures to be used if she became comatose.
Only days after documenting her wishes, she was admitted to the hospital and slipped out of consciousness. Her doctors, unaware of her living will, consulted a family member, who signed a “do not resuscitate” order. She died, a victim of the Information Age’s ultimate irony: Her final wish was ignored because her doctor didn’t access it.
“One encouraging finding of this study,” the researchers wrote, “was that advance directives appeared to be correctly invoked and used in circumstances where they were recognized.”
Much blame for the oversights documented by the New York researchers goes to hospital clerks. While all the patients studied had filled out advance directives, in 39% of admissions, clerks said there wasn’t one; in 27%, they said they couldn’t tell if there was one, and in 27%, they made no mention of advance directives whatsoever.
A 1990 U.S. law called the Patient Self-Determination Act requires hospitals receiving federal health care funds to ask patients if they have completed advance directives and, if not, explain that they have the right to do so.
That has heightened awareness of directives, Morrison said. But admissions clerks, already burdened by paperwork, may simply hand a patient an easily overlooked questionnaire in a stack of forms--fulfilling the letter of the law, he added, but not its spirit.
Morrison suggested two reforms. First, nursing homes should better document patients’ wishes and add any directives to records that accompany patients to the hospital. Second, hospitals should shift the burden away from admissions clerks, perhaps by appointing counselors to deal with advance directives and by encouraging doctors to overcome their traditional reticence over asking patients about life-sustaining measures.
Morrison pointed out that hospitals are good at obtaining vital patient information when they need it. “I’ve noticed that they have no trouble finding out if someone has health insurance,” he said.
The California Medical Assn. says that in the last decade it has given out 5 million forms conveying durable power of attorney, which appoints a family member or loved one to make health care decisions in the event one becomes incapacitated.
Researchers and health care advocates urge people who have completed advance directives to discuss the documents with their family members and doctors, and make sure the directives are stored with medical records. “If you just fill out a piece of paper and never tell anyone about it,” Blackhall said, “that’s a big problem.”
