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15 Nov 2019

A new Australian study has shed light on why doctors sometimes struggle to comply with patient choices documented in Advance Care Directives.

An Advance Care Directive (ACD) is a written record of patient preferences for future care. The directive can record values, life goals and preferred outcomes, or directions about care and treatments. ACD can also formally appoint a substitute decision-maker.

They are often used to plan for future health care and a time when patients may be longer able to communicate decisions for themselves.

The study, published in BMJ Open, uncovers the complexity and difficulty experienced by doctors when enacting ACDs, and the deep conflict in weighing up whether to follow a patient directive.

The findings challenge the widely-held assumption that personal autonomy and choice trumps all in medical treatment decision making.

The qualitative research led by Advance Care Planning Australia, presented 21 doctors from a Melbourne hospital with real-life scenarios to explore how doctors use ACDs to guide medical treatment decision making, when faced with different patients and circumstances.

Interestingly, the study found that overall, doctors appeared more motivated to act in what they considered to be the patient’s best interest, rather than upholding the individual’s autonomy or following a legally-binding directive, which potentially puts doctors and health services at risk.

Doctors were more likely to rely on their own judgement and override patient choice when:

  • ACDs are not current, were too vague or incoherent;
  • ACDs were not easily accessible at the point of care;
  • they encounter family opposition; and
  • faced with a patient with a condition the doctor deemed to be potentially reversible.

The study found that doctors sometimes doubted the validity of ACDs, questioning how well equipped non-medically trained people were to make nuanced and complex medical decisions and whether a person could make such important decisions and informed choices in advance.

“The findings suggest that more work needs to be done to support doctors in what can be very ethically and legally complex, challenging and time-pressured decision-making,” said Linda Nolte, Program Director of Advance Care Planning Australia.

“We can’t underestimate the real-world dilemmas doctors’ sometimes face in enacting Advance Care Directives, but equally we can’t lose sight of the fact that Advance Care Directives are legally-binding documents. Competent adults have the right to make decisions in advance as to how they wish to be cared for. And quite rightfully they expect that everyone involved in their care will do their utmost to respect their choices.

“The study also highlights the need for people to ensure their advance care planning documents are accurate, up-to-date, complete and easily accessible, otherwise the treating doctor may not be able to comply with the directive.”

Advance Care Planning Australia offers a free national advisory service for health professionals and the public on phone number 1300 208 582.

Published: 15 Nov 2019