Swiss physicians’ perspectives on advance directives in elective cardiovascular surgery

Advance directives (AD) are a written document in which patients express their wishes regarding care and treatments in case they would become incompetent. When patients lose competency due to coma or confusion, for instance, AD can help physicians take crucial medical decisions. This tool to enhance autonomy was developed for more than 20 years, but their number remains low. The planned cardiovascular surgery context is interesting because of the vital nature of the surgery and the strong associated emotion despite a very low mortality rate. The objective of this study was to investigate physicians’ perspectives and attitudes towards AD in order to determine potential targets for improvement.

Fig. 1. Physicians’ opinion about the optimal moment to establish advance directives.

General practitioners and specialists potentially involved in the care of patients planned for major cardiovascular surgery in a Swiss canton were sent questionnaires to return via a prepaid envelop. The results were kept anonymous, but a code allow the sending of two remainders.

164/409 (40%) questionnaires were completed. Men: 116 (71%). Medical specialties: Internists: 73 (45%); General Practitioners: 50 (31%); Intensivists (specialist of acute care and resuscitation): 22 (13%); Cardiologists: 18 (12%).

138/162 (85%) physicians thought that AD were useful and 124/161 (77%) were ready to help patients write AD. Their reasons were to allow patients to decide on their fate [115/124 (93%)] and to increase their ease in expressing their wishes [108/124 (87%)]. Men and cardiologists were least likely to provide help. Factors associated with lower interest in promoting AD were not logistical but personal such as “the topic can induce fear” [21/34 (62%)] or “the topic can induce unease” [16/34 (47%)], and physicians’ lack of knowhow [15/34 (44)]. 22/160 (14%) physicians had never heard about AD, especially men. Most of the sources of physicians’ information about AD were patients / colleagues / friends (69/160, 43%) and post-medical school courses (67, 42%), followed by the medical journals (46, 29%), the medical school (21, 13%) and the media / Internet (20, 13%). Table 1 informs on physicians’ opinion about the optimal moment to establish AD. The criteria considered as necessary for the recognition of valid AD documents are summarized in Table 2.

Fig. 2. Physicians’ opinion about the conditions for valid advance directives.

Despite the rather low response rate, this study has highlighted the possible gaps between an ideal practice of advanced care planning and the reality of the current one. The majority thought that AD were useful and would help patients write them, in order to respect their autonomy. Although at the first place when talking of cardiovascular patients, not all cardiologists felt involved in advance care planning. Logistic factors such as lack of time or of remuneration were not paramount, but personal-related factor were often cited, such as feelings of inducing fear or harm patients. This overview of physicians’ opinions shed some light on potential ways to increase the prevalence of AD, such as a better use of the media, a greater emphasis of what AD are and the benefit they can bring to patients when incompetent at medical school, as well as about communication skills, support at the postgraduate training (mentoring, consultant) or active delegation (specific trained people). Studies on the opinions of patients and relatives would complement current understanding of the complexity of implementing AD in practice. Integrating all this data may help elaborate future strategies to enhance advance care planning.

Fabienne Gigon PhD, Ms.
Intensive Care Unit, Department APSI
Geneva University Hospitals
Geneva, Switzerland

 

Publication

Swiss physicians’ perspectives on advance directives in elective cardiovascular surgery.
Gigon F, Merlani P, Ricou B.
Minerva Anestesiol. 2015 Oct

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