Doctors Tend to Ignore Living Wills

Study finds family members or hopeful prognoses can sway decisions

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HealthDay Reporter

THURSDAY, Aug. 5, 2004 (HealthDayNews) -- When people sign a living will, they assume their wishes about dying will be respected, but a new study adds to a growing body of evidence that suggests the instructions are often ignored.

When given hypothetical situations involving imaginary patients with living wills, nearly two-thirds of 117 doctors surveyed said they wouldn't follow the orders. They were most likely to diverge from the documents when confronted with family members with differing views, or if there were hopeful prognoses for the patients.

The findings aren't surprising, said experts who study end-of-life issues.

"There have been many studies over the course of the last decade which suggest that advance directives, especially living wills, are not particularly helpful," said Alan Meisel, a professor of law and bioethics at the University of Pittsburgh.

The problem, he said, is that "it's impossible for people to fine-tune what they want and don't want in the way of medical care in advance. They never know what the situations will be. They're particularly complex and constantly changing."

In the study, researchers sent surveys to 250 doctors and asked them how they would handle six hypothetical situations involving seriously ill patients who weren't capable of making decisions about their care. The researchers came from the Jerry L. Pettis Memorial Veterans Affairs Medical Center and Loma Linda University School of Medicine in California. The 117 doctors who responded were all from the Loma Linda University Medical Center and affiliated hospitals.

The findings appeared in a recent issue of The Archives of Internal Medicine.

In 65 percent of the cases, the doctors surveyed said they wouldn't follow the advance-directive orders left by the patients. In difficult clinical situations, internists appeared to consider other factors such as prognosis, perceived quality of life, and the wishes of family or friends as more important than the directive, wrote the study authors.

"There are two obvious reasons why a doctor might not follow an advance directive," said Dr. Howard Brody, a bioethicist at Michigan State University. "Reason one is that the doctor is a jerk and is practicing unethical medicine. The second reason is that advance directive is unfollowable."

Often, patients simply don't anticipate what might happen in the hospital room, Brody said, or they issue vague directives. "People say things like 'no heroics.' What does that mean? What's heroic and isn't heroic?"

In some cases, he added, patients may write directives ordering that they not be placed on ventilators, mechanical devices which help them breathe. But when the patients actually enter the hospital, doctors may violate the orders because the patients only need to be on a ventilator for a few days.

"Then it looks like the doctor is not following the patient's directive, but if you'd actually been able to talk to the patient and explain, the patient might totally agree with that," Brody said.

So what are people to do when they hope to control their care when they can't speak for themselves?

Robyn Shapiro, director of the Bioethics Center at the Medical College of Wisconsin, recommends that guardians be appointed to make sure the wishes of patients are followed. This is particularly important because the law doesn't always provide enough "teeth" to guarantee that doctors follow the orders, she said.

Shapiro also advises people to speak to both their doctor and their family members about their preferences ahead of time. Legal documents are just "one tool in the kit to try to protect patients' rights to direct their own medical courses," she said.

More information

Learn more about living wills and other advance directives from HealthFinder.

SOURCES: Alan Meisel, professor of law, and Dickie, McCamey & Chilcote professor of bioethics, University of Pittsburgh School of Law; Howard Brody, M.D., Ph.D., university distinguished professor, Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Lansing; Robyn Shapiro, J.D., professor, and director, Bioethics Center, Medical College of Wisconsin, Milwaukee; July 26, 2004, Archives of Internal Medicine

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