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A study of 192 medical records at a 423 bed hospital in eastern Michigan that found that physicians followed patient's wishes the majority of the time, but did not appropriately document in the medical record evidence that they had communicated with the family regarding advance directives or treatment options. The Patient Self Determination Act of 1990 is also discussed.
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Presented to the Public Administration Faculty in partial^ at^ thefulfillment^ University of^ ofthe^ Michigan-Flint requirements for the Master of Public Administration Degree October 26, 1994
By
Paul Brown
Second Reader
First Reader
The Patient Self Determination Act of 1990 was age (^) ofintended 18 were to informedensure that of theirpatients rights over to the accept communication or refuse between medical the carepatient and toand improve physician 192 medical regarding records thisat a right. 423 bed A hospitalstudy of in eastern physicians Michigan recording found in that the 97%patient's of the medical record expressed honored in their their advance patient's directive. wishes asMore than document fifty in percent the medical of the record physicians that theydid not
withdrawing^ communicated orwith withholding^ the^ patient life^ about support technology. Nineteen percent did not write orders support fortechnology withdrawing in theor (^) medicalwithholding record life as required by the patient's advance directive. This study concluded that physicians followed but^ patient's did not^ wishes appropriately^ the^ majority document^ of^ the in^ time, the medical record evidence that they had communicated advance directives with theor familytreatment regarding options. Statistical correlation analysisbetween physician'sshowed that naturalthere was no origin, type of practice, years in practice, whether^ patient's or^ gender not the^ and physician^ patient's documented^ age^ and patient's^ communication medical^ with record.the^ patient^ in^ the
The following are rules that organizations must follow to comply with the PSDA.
Upon written admission, information patients concerning are to individualbe given rights under the state law, whether statutory or medical judicial, care, toincluding make decisions accepting concerning or refusing medical or surgical treatment.
(^) policiesPatients andare (^) proceduresto be given concerninga provider's the written implementation of those rights.
The organization must document in an individual's or she has executed medical anrecord advance whether directive. or not he
The provider cannot place conditions on the provision individual ofwho care has orexecuted discriminate an advance against an directive.
Providers requirements must of ensure State compliancelaw respecting with advancethe directives.
Providers community muston issues offer concerningeducation foradvance staff and directives. The State of Michigan's response to the requirements of the patient self determination act established the Michigan Durable Power of Attorney for Health Care law (MDPOA). This law gave Michigan residents over the age of 18 the right to sign a legal document identifying a patient advocate. The patient advocate is a person who can make medical treatment decisions for the patient should he or she become incapable of deciding. This document also allows the patient to place her or his wishes regarding health care in writing. These
wishes are expected to be followed by the patient advocate, physicians, caregivers and other health care providers.
The objectives of an advance directive are:
the purposes of this study, life support includes cardiopulmonary resuscitation, mechanical ventilation, and artificially supplied nutrition and hydration.
The Need For Communication In a report published in the Journal of the American Board of Family Practice, Doukas and Brody contend that the Supreme Courts's ruling in the Nancy Cruzan case has changed the Physician/Patient relationship regarding medical decision making.6 The "clear and convincing" standard set by the Supreme Court makes it important for primary care physicians to discuss advance directives with their patients. Several studies have shown this discussion is not taking place. Goold, et al., reported in their 1992 survey that only 10% of patients questioned had discussions with their physicians about life-sustaining treatment.7 The authors found that these 10% were older and had a very poor prognosis. The authors concluded that physicians were more likely to discuss advance directives when their patients were older or had a poor prognosis. However, statistical analysis of the data indicated that age, poor prognosis, and poor quality of life did not consistently prompt physicians to discuss life support decisions with their patients. The study indicated that other factors that may affect physician/patient communication needed exploration. In a survey of 43 chronic hemodialysis patients, Holley, et. al., found that although 77% of their subjects discussed their wishes regarding life support with someone
Lurie and Phely found in their 1992 study of 150 nursing home residents that older individuals, 14.5%, were not likely to have spoken with their physician about their wishes concerning health care should they become incapable of making their own decisions.12 They found, on average, residents with advance directives were 8.4 years younger than those without them. It is apparent from this literature review that physicians are not likely to discuss advance directive issues with their patients. Likewise, patients are just as unlikely to discuss life support issues with their physicians. It can be concluded from these studies that if communication about life sustaining treatment is not taking place, then the chances of physicians complying with patient's wishes are greatly decreased. The use of advance directives is new and very few studies on their effects have been done. It is not possible to know if a broader review would confirm these conclusions until more studies are conducted.
Physician Attitudes Towards Advance Directives In 1992, Solomon et al, sent questionnaires to 687 physicians and 759 acute care nurses. Of the 61% who responded, 47% said they continued to provide unwanted treatments to patients though they agreed that patients ought to have the right to refuse treatments that were burdensome.13 An accompanying comment by Vladeck blames hospital structure. No one is apparently in charge of treatment decisions. The most logical and necessary changes in policy and procedures for treatment decisions somehow fail to get implemented. Hughes reported in 1992 that of the 643 physicians he surveyed, family physicians favor advance directives but use them rarely. Most family physicians support offering advance directives to terminally ill or chronically ill patients, but not to everyone.14 Somewhat in the same vein, T.R. Fried found that of the 62% of the physicians who responded to his survey, 41% would not remove a mechanical ventilator from a patient who specifically requested it. The reasons most often cited for this behavior was that it would not be "ethically acceptable" and "it would not be accepted by the courts."15 The conclusions of both studies were that many physicians, almost half, are unaware of current ethical and legal opinions on the withholding and withdrawing of life support systems. Fried found when they are aware of them, some physicians continue to practice contrary to patient's
Andre recommends that medical schools teach more social science and better communications skills. She also feels that the demand on students' time does not allow them time for reflection and thinking. Another factor which affects physician's behavior towards life sustaining treatment is the type of advance directive. To explore this issue, Mower and Baraff questioned 444 physicians at a teaching institution. They found that 84% of the physicians surveyed would discontinue therapy if it was specifically requested in an advance directive. This compared to 73% who would discontinue therapy that was not specifically stated when the patient had signed a generally stated advance directive.18 If the treatment specific advance directive was accompanied with family support and prior patient-physician discussion, 100% of the physicians said they would remove requested therapy. It was also found that physicians would not act on all treatments equally. Nearly all would remove mechanical ventilation, 82% intravenous fluids, 80% antibiotics, 70% simple tests, and 13% said they would remove pain medications upon request. The authors concluded that physicians were willing to remove high tech and burdensome treatment, but were less willing to remove low tech or "ordinary” care. Current literature has offered many theories and reasons why physicians are reluctant to follow patient's
wishes regarding life sustaining treatment. These theories include the physician's medical training and "learned” attitudes toward patient care. There also appears to be inadequate ethical and legal education which perpetuates an ignorance toward current ethical and legal opinions. Of all the literature reviewed, no comprehensive studies were found that tried to link physician's practice specialty, length of medical service, and cultural background to their attitudes towards withholding and withdrawing life sustaining treatment.
and families to make decisions to withdraw life sustaining treatment from family members who have lived a " long and fruitful life ” than for someone younger, even if their prognosis is extremely poor.19 These factors may be important in physician's behaviors regarding advance directives. It is reasonable to speculate that there may be a relationship between physicians' cultural background, their professional experience, and their behaviors toward communication with patients and the patient's families regarding end of life and life support decisions.2 0 To test this relationship, four hypotheses were explored.
Subjects A retrospective study of 192 medical records was performed. The records were randomly selected from a list of 323 patients who had been admitted between September 1991 and December 1992 to a medium sized (423 beds) hospital in eastern Michigan. Each patient had indicated a DNR (Do Not Resuscitate) status upon admission. Patient records indicating a DNR status were chosen for study for the following reasons:
Physician's Name The attending Physician was chosen for this study. He
