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Opening the Black Box: How Do Physicians Communicate about Advance Directives?

James A. Tulsky, MD; Gary S. Fischer, MD; Mary R. Rose, MA; and Robert M. Arnold, MD
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From Durham Veterans Affairs Medical Center and Duke University, Durham, North Carolina; and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Acknowledgments: The authors thank Esther Shaw for computer support; Laura Siminoff, PhD, for expert advice on transcript analysis; Marcy Wilson for administrative support; and the 112 patients and physicians who graciously allowed us to observe them during a private moment. Grant Support: By grant HFP82-008 from the Veterans Affairs Health Services Research and Development, grant 5-P60-AG11268 from the National Institute on Aging Claude D. Pepper Older Americans Independence Center, the R.K. Mellon Foundation, and the John A. Hartford Foundation. Drs. Arnold and Tulsky are Project on Death in America Soros Faculty Scholars, and Dr. Tulsky is a Robert Wood Johnson Generalist Physician Faculty Scholar. Requests for Reprints: James A. Tulsky, MD, Health Services Research (152), Veterans Affairs Medical Center, 508 Fulton Street, Durham, NC 27705. Current Author Addresses: Dr. Tulsky: Health Services Research (152), Veterans Affairs Medical Center, 508 Fulton Street, Durham, NC 27705.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1998;129(6):441-449. doi:10.7326/0003-4819-129-6-199809150-00003
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Background: The quality of communication that leads to the completion of written advance directives may influence the usefulness of these documents, but the nature of that communication remains relatively unexplored.

Objective: To describe how physicians discuss advance directives with patients.

Design: Prospective study.

Setting: Five outpatient primary care medicine practices in Durham, North Carolina, and Pittsburgh, Pennsylvania.

Participants: 56 attending internists and 56 of their established patients. Eligible patients were at least 65 years of age or had a serious medical illness.

Measurements: Two raters coded transcripts of audiotaped discussions about advance directives to document how physicians introduced the topic of advance directives, discussed scenarios and treatments, provided information, elicited patient values, and identified surrogate decision makers.

Results: Conversations about advance directives averaged 5.6 minutes; physicians spoke for two thirds of this time. In 91% of cases, physicians discussed dire scenarios in which most patients would not want to be treated, and 48% asked patients about their preferences in reversible scenarios. Fifty-five percent of physicians discussed scenarios involving uncertainty, typically using vague language. Patients' values were rarely explored in detail. In 88% of cases, physicians discussed surrogate decision making and documents to aid in advance care planning.

Conclusions: Although they accomplished the goal of introducing patients to advance directives, discussions infrequently dealt with patients' values and attitudes toward uncertainty. Physicians may not have addressed the topic in a way that would be of substantial use in future decision making, and these discussions did not meet the standards proposed in the literature.

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