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Clinical Decisionmaking

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Advance care planning standards could be improved by giving patients more flexibility in conveying their wishes to others

Advance directives are an effort to maintain a patient's "voice" in their end-of-life care if they become unable to make their own decisions. These directives have become increasingly detailed and specific, often containing patient preferences for a variety of specific medical treatments in a number of hypothetical medical scenarios. However, this may run counter to what many elderly people would prefer.

A recent study has found that although most elderly individuals prefer to maintain some control over certain aspects of their end-of-life medical care, they appear to have little interest in "micromanaging" their own death. The study was conducted by researchers from the University of California, Irvine; Kent State University; and the Family Practice Center of Akron. For the study, the researchers analyzed data from interviews and questionnaire responses of 337 elderly outpatients and their designated surrogate decisionmakers.

Of the patients and surrogate decisionmakers who desired an advance directive, the largest proportion (50 and 44 percent, respectively) preferred one that contained only general statements about values or goals for care (for example, a dignified death or maintaining the ability to think clearly) that patients would want guiding medical decisions. Fewer patients and surrogates desired an advance directive that included both general statements and precise treatment directions, and fewer still preferred one that included only precise directions regarding specific medical treatments.

A substantial proportion of each group believed that surrogates should have "a lot" or "complete" leeway in making medical decisions, whereas only 9 percent believed the surrogate should have "no" leeway. On average, patients believed surrogates should have significantly more leeway in decisionmaking than surrogates believed they should have. Surrogates also demonstrated a number of other significant misunderstandings of the values and process preferences that patients wanted to guide their end-of-life medical treatment.

The authors conclude that because very few individuals desire the kind of tight control over medical care implied in the standard approach to advance directives, patient autonomy would be best served by emphasizing patient-surrogate discussion of process preferences and leeway in end-of-life decisionmaking. This research was supported in part by the Agency for Healthcare Research and Quality.

See "Micromanaging death: Process preferences, values, and goals in end-of-life medical decision making," by Nikki Ayers Hawkins, Ph.D., Peter H. Ditto, Ph.D., Joseph H. Danks, Ph.D., and William D. Smucker, M.D., in the Gerontologist 45(1), pp. 107-117, 2005.

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