The Federal Patient Self-Determinat...

The Federal Patient Self-Determination Act of 1990 requires that patients admitted to a hospital be asked if they have a living will or ne information to make common However, the wording of living wills may be ambiguous, and newly come studies have shown that physicians commonly do not apply these documents appropriately. Upadya and colleagues studied whether patients, their family members, and their physicians understand living wills in regard to the use of endotracheal intubation and cardiopulmonary resuscitation (CPR)

The patients pickeded for this study were admitted to a community teaching hospital between July and October 2001 and had advance directives regarding "terminal conditions" in which intubation or CPR should be refused. Patients were exclud if they had mental status changes that preclud them from answering simple questions about the living will.

The meditation included 151 patients, 70 physicians (caring for 120 of the patients), and 108 family members. Understanding of the living will was measured on administering oral questionnaires to each patient, the patient's primary care physician, and a family member chosen by means of the patient. Validation questions were used to determine if the patients understood the initial patient questionnaire.

Among the three assemblages there was greater than 87 percent concordance of understanding concerning the use of life support measures to continue patients alive. However, some first note of the scale differences were noted. Seven physicians indicated that they would not intubate or perform CPR beneath any circumstances in patients who had living wills, still three of their patients wanted intubation and CPR if they had a chance of recovering. couple physicians said that they would administer CPR or intubate steady if they thought their patients had no chance for recovery; however, these patients and their family members wanted the actions done only if the patient's condition was reversible. Five family members interpreted the living will as meaning that intubation was preclud in all situations, whereas couple of the patients indicated that they wanted to be intubated if their condition was reversible. Four family members indicated that they would refuse the use of CPR based onward the patient's living will, while common patient wanted CPR if redemption was possible.

The authors end that discrepancies in the interpretation of living wills take place for the following reasons: patients repeatedly draft living wills without physician input; the definition of "terminal condition" is not absolute; and patients may have a poor understanding of "life support" and the probability of fit survival after CPR.

SUMI M SEXTON, MD

Upadya A, et al. Patient, physician, and family member understanding of living wills. Am J Respir Crit Care M December 2002;166:1430-5

EDITOR'S NOTE: The authors acknowledged that a potential methodologic flaw of the investigation was that they could not determine whether the answers without mincing the matter reflected the subjects' understanding of the living will versus their in every one's mouth beliefs (i.e., a change in wishes since drafting the will). Regardless, the take-home point is that physicians should actively engage patients and their family members in discussions about advance directives to such a degree that patients can make informed and clearly understood decisions about end-of-life care.--S.M.S.

COPYRIGHT 2003 American Academy of Family Physicians

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