Special Article
Advance Directives for Medical Care — A Case for Greater Use
N Engl J Med 1991; 324:889-895March 28, 1991
- Abstract
- Abstract
Background.
Advance directives for medical care and the designation of proxy decision makers to guide medical care after a patient has become incompetent have been widely advocated but little studied. We investigated the attitudes of patients toward planning, perceived barriers to such planning, treatment preferences in four hypothetical scenarios, and the feasibility of using a particular document (the Medical Directive) in the outpatient setting to specify advance directives.
Methods.
We surveyed 405 outpatients of 30 primary care physicians at Massachusetts General Hospital and 102 members of the general public in Boston and asked them as part of the survey to complete the Medical Directive.
Results.
Advance directives were desired by 93 percent of the outpatients and 89 percent of the members of the general public (P>0.2). Both the young and the healthy subgroups expressed at least as much interest in planning as those older than 65 and those in fair-to-poor health. Of the perceived barriers to issuing advance directives, the lack of physician initiative was among the most
Article Activity
- Article
THE use of life-sustaining medical interventions is often an issue when patients are no longer competent to participate in decisions about their care. Since treatment decisions in these situations may be morally charged,1 costly,2 contested,3 and counter to the wishes of the patient, the use of advance directives4 5 6 as a means of extending the autonomy of patients when they are incompetent has evoked considerable interest. Directives for treatment preferences may be documented in a living will or written advance directive. A proxy decision maker can also be designated and given durable power of attorney for a person's health care. We have advocated comprehensive directives, in which discussion between the patient and the physician can produce both documented treatment preferences based on the patient's response to specific scenarios and a durable power of attorney.7 , 8 Most state legislatures have recently passed statutes on these issues. Forty-seven states and the District of Columbia now have laws covering living wills, durable powers of attorney, or both, 25 of them enacted in the past five years.9 The recent Supreme Court decision in the case of Nancy Cruzan emphasized the need to provide "clear and convincing evidence"10 of the incompetent patient's earlier wishes. In 1990, Congress passed the Patient Self-Determination Act,11 which requires that all hospitals reimbursed by Medicare have a policy on frequently mentioned, and the disturbing nature of the topic was among the least. The outpatients refused life-sustaining treatments in 71 percent of their responses to options in the four scenarios (coma with chance of recovery, 57 percent; persistent vegetative state, 85 percent; dementia, 79 percent; and dementia with a terminal illness, 87 percent), with small differences between widely differing types of treatments. Specific treatment preferences could not be usefully predicted according to age, self-rated state of health, or other demographic features. Completing the Medical Directive took a median of 14 minutes. Conclusions. When people are asked to imagine themselves incompetent with a poor prognosis, they decide against life-sustaining treatments about 70 percent of the time. Health, age, or other demographic features cannot be used, however, to predict specific preferences. Advance directives as part of a comprehensive approach such as that provided by the Medical Directive are desired by most people, require physician initiative, and can be achieved during a regular office visit. (N Engl J Med 1991; 324:889–95.) living wills and that all their patients be asked on admission whether they have a living will. Professional organizations such as the American Medical Association12 , 13 and the American Academy of Neurology14 have also endorsed these forms of planning for terminal illness.
Despite the compelling reasons for advance directives and their professional and public endorsement, we know very little about their actual use. From the few studies reported, physicians generally seem to be favorably disposed to advance directives for medical care,15 16 17 but they seem reluctant to initiate discussion about them18; outpatients and the elderly seem willing to discuss issues concerning life-sustaining treatment19 , 20; and most patients with the acquired immunodeficiency syndrome (AIDS) seem to want advance directives.21 Despite their wide endorsement, however, advance directives are infrequently used. In 1987 only 9 percent of Americans had written advance directives for medical care22; and when patients do have directives, their physicians often do not know of them.23 No studies appear to have addressed the reasons for this gap, the attitudes of a broad range of patients toward comprehensive advance directives, or the role that physicians should take in such planning.
The present study examined patients' attitudes in detail, using a document for specifying comprehensive advance directives (the Medical Directive8) that includes written directives based on four clinical scenarios, each with 13 specified interventions, as well as a provision for granting a durable power of attorney. As part of a larger study we interviewed a group of primary care outpatients (in person) and a sample of the Boston general public (by telephone) in order to answer the following questions: To what extent are patients and potential patients interested in advance directives; and do specific subgroups of patients, such as the elderly or those in poor health, want such directives particularly? Among those who want but do not have directives, what are the perceived barriers? What preferences for life-sustaining treatment do patients and the public express? Does increasing age or poorer health correlate with a desire to forgo life-sustaining interventions? And is comprehensive planning in partnership with a physician in the office setting practical, given the usual time constraints and the varied educational backgrounds of patients?
Methods
Outpatients
Patients under the care of the Internal Medical Associates, a primary care practice at Massachusetts General Hospital, were interviewed. This group practice of 30 primary care physicians registered 20,200 patients making 51,500 visits in 1988. Most patients (90 percent) were residents of the greater Boston area; 43 percent had Medicare coverage and 15 percent were insured by Medicaid.
Interviewers asked every eligible patient who visited the group practice during assigned times whether he or she would participate in the study. Only patients with a major psychiatric diagnosis or a language barrier were excluded. Schedules were designed so that the presence of an interviewer in a given office was in approximate proportion to the number of patients in that practice. At the end of the study period estimates were made of the proportion of patients in each practice who had entered the study. If the physician felt the timing was inappropriate (because of a recent serious diagnosis, for example), the interviewer attempted to make contact by letter, by telephone, or at a subsequent office visit, when the timing was considered better. Patients were introduced to the study by their own physicians; the interviewer then obtained full informed consent. The study was approved by the institutional review board of Massachusetts General Hospital. Responses during interviews were not made part of the patients' medical records. There were five interviewers: one physician, one nurse, and three research assistants trained in the interview process.
Members of the General Public
We studied a group of members of the general public to test whether results from the interviews would be similar in a different population. The Center for Survey Research of the University of Massachusetts at Boston conducted a telephone survey of this group. The center is a research facility whose staff is experienced in administering both personal and telephone surveys. The sample population was drawn at random from persons over 18 years of age who were in annual town lists for the Boston Standard Metropolitan Statistical Area. The Center for Survey Research first sent letters of explanation and a printed list of the interview questions to potential subjects, and then contacted them by telephone to ask whether they would consent to a telephone interview. Five interviewers completed approximately 20 interviews each.
The Questionnaire
The questionnaire contained eight sections, as outlined in the Appendix. The time taken to complete the educational section and the Medical Directive was noted. The Medical Directive described four scenarios: coma with a small chance of full recovery, persistent vegetative state, dementia, and dementia with a terminal illness. For each scenario the respondent was asked whether he or she would want each of a list of possible medical interventions. In the section on barriers to planning, the subjects stated in their own words what they thought such barriers were. One investigator sorted the statements into eight categories at the end of the study; three investigators then independently resorted them into the created categories. Interobserver variation in classification was small; for example, the range for the most frequently cited barrier was 26 to 32 percent of the responses (average, 29). The percentage of respondents in each class was averaged for the three independent classifiers.
Statistical Analysis
Statistical calculations were made with SAS software. Ninety-five percent confidence limits were calculated around point estimates. Comparisons between categorical variables were made with the chi-square test. Comparisons between continuous variables were made with the Wilcoxon rank-sum test for nonparametric distributions.24 Power varied with the size and proportions of the compared groups; to provide an example, the comparison of the desire for an advance directive in the outpatient and general-public cohorts permitted a 95 percent chance of detecting a true 10 percent difference between the populations.
Results
The Cohorts
From an initial screened pool of 702 patients from the 30 physicians' practices, 405 were studied. Between 4 and 13 percent of the patients from each physician's practice participated in the study, with the exception of two practices that contributed only eight (0.9 percent) and two (0.1 percent) patients. Patients refused to be interviewed in 196 cases (28 percent), and 76 ( 11 percent) were ineligible, 44 (6 percent) because of a language barrier and 32 (5 percent) because of a major psychiatric diagnosis. Patients who refused to be interviewed often reported too little time on the day of the visit as their reason. The timing was inappropriate for 38 patients (often due to a recent change in health); 13 were recontacted, and 25 (4 percent) were lost to follow-up. Ultimately, 65 percent of the eligible population was studied. From the Boston general public, 102 of an initial pool of 135 subjects were interviewed; 4 (3 percent) were ineligible, and 29 (21 percent) refused. About 28 percent of the people called by the Center for Survey Research about other sensitive topics, such as AIDS or drug use, have refused to participate in telephone surveys.
The demographic features of the outpatient cohort reflected those of the general-public cohort, except that a higher proportion of the patients were at the extremes of the educational spectrum (25 percent of the patients as compared with 16 percent of the members of the general public had postgraduate education, and 14 percent as compared with 4 percent had only a grade-school education). The cohort from the Boston general public was somewhat more likely to be white and Roman Catholic than the national population.
Do Patients Want Advance Directives?
The interviewers asked the patients whether they wanted any of three forms of advance directives — a conversation with their physician, a living will, or a durable power of attorney. The question was asked after the patients had completed the Medical Directive section of the questionnaire, to ensure a good understanding of what is involved in such planning for medical care. At least one of the three forms of advance directives was desired by 93 percent of the patients (Table 1Table 1
Views of Planning for Medical Care in the Study Cohorts.). Contrary to our expectation that patients would be more interested than the general public in advance directives, we found that 89 percent of the members of the general public also wanted one or more of the three forms of planning (not a statistically significant difference). A large majority of respondents from the two populations thus believed that some form of advance directive was desirable.When asked whether issuing advance directives for themselves or making decisions for incompetent sick relatives or friends was easier, 77 percent of the outpatients and 86 percent of the members of the general public said that making decisions for themselves was easier. This view is compatible with the finding that a large majority of people desire some form of planning for medical care.
The desire for planning was not usefully associated with age, health, or other demographic features in either cohort (examples from the outpatient cohort are shown in Table 2Table 2
Correlations of Age and Health with Preferences for Planning.). When associations reached statistical significance, the proportion of subjects in any category who desired planning was still large. Thus, one could not reasonably target patients for advance directives according to age, health status, or other demographic features without neglecting a sizable proportion of the people who desire planning.How Many Subjects Had Actually Completed Advanced Directives?
Despite the large proportion of respondents who said they desired some form of planning, few had actually made explicit arrangements before the interview. Although 57 percent of the patients wanted a document specifying future care, only 7 percent had one; although 78 percent wanted a proxy decision maker, only 8 percent had designated one in writing; and although 59 percent wanted a discussion with their physicians, only 5 percent reported having had such a discussion. Overall, of those who wanted to issue some form of advance directive only 15 percent of the outpatients and 18 percent of the sample of the Boston general public had undertaken one or more of the forms of planning. In contrast, 57 percent of the patients and 74 percent of the general public reported having a will concerning the disposal of their estate.
Barriers to Producing Advance Directives
The reasons why patients who wanted advance directives had not completed their arrangements are shown in Table 3.Table 3
Perceived Barriers to Discussion among Patients Wanting Planning. The two most frequently cited barriers were the patient's expectation that the physician should take the initiative and the sense that such issues were only relevant for those who were older or in worse health. Of those who cited age and health, 95 percent were in good-to-excellent health, ≤65 years old, or both. Of these younger or healthier patients, 94 percent wanted one or more of the three forms of planning, and 64 percent reported increased desire for discussion with their physicians at the end of the interview. Among the least frequently cited barriers were the sensitivity of the topic for the patient (5 percent) and general opposition to advance directives (2 percent). No patient cited lack of knowledge of living wills; 70 percent of the patients and 78 percent of the Boston general public reported before they had completed the educational section of the survey that they understood what a living will was.When the participants were asked at the end of the interview (thus after the educational section and the Medical Directive) whether it had altered their desire for planning, an increased desire for a living will was reported by 45 percent of the outpatients and 63 percent of the members of the general public; only 1 and 2 percent, respectively, reported less inclination. An increased desire for discussion with their physicians was reported by 44 percent of the patients.
What Preferences Do People Express Regarding Life-Sustaining Treatments?
When responding to the intervention options in the four scenarios of the Medical Directive, 71 percent of patients' responses and 64 percent of those of the general public were refusals. Acceptance of intervention constituted 17 and 19 percent, respectively, of the responses in the two cohorts; 3 and 6 percent of the responses involved the choice of a trial period of intervention; and 8 and 10 percent of the responses were "undecided." There was no answer for 1 percent of the responses in both cohorts (Table 4Table 4
Reported Treatment Preferences in the Four Scenarios of the Medical Directive.*).Averaged over all four scenarios, the rate of patient refusal for each intervention was as follows: major surgery, 76 percent; dialysis and artificial nutrition, 74 percent; mechanical respiration, cardiopulmonary resuscitation, and blood transfusion, all 73 percent; minor surgery and intravenous fluids, both 71 percent; antibiotics, 68 percent; and simple tests, 64 percent.
In the two scenarios not involving coma, 78 percent of the outpatients wanted pain medication even if it indirectly accelerated death; 7 percent wanted the use of pain medication to stop short of accelerating death. The remainder were undecided, did not answer, or refused pain medication.
The patients' preferences for accepting or refusing treatments differed among the scenarios. The rate of refusal was lowest for coma with a chance of recovery (55 percent of the responses), intermediate for dementia (73 percent), and highest for persistent vegetative state (79 percent) and dementia with terminal illness (82 percent).
Can Preferences Be Predicted According to Demographic Features or State of Health?
The preferences of the outpatients and the sample of the Boston general public regarding interventions showed little association with demographic features or self-rated health status (assessed only among the outpatients because there were few sick people in the general-public cohort). Associations that did reach statistical significance were nonetheless weak. In the scenario of dementia, for example, in which 71 percent of those in excellent-to-good health as compared with 59 percent of those in fair-to-very-poor health refused antibiotics (P<0.05), the association was weak and did not extend to other treatments or other scenarios. Young patients refused some interventions more often than the elderly in several cases. In the scenario of a persistent vegetative state, for example, 83 percent of those 65 or younger refused mechanical respiration, whereas 75 percent of those over 65 refused the intervention (P<0.05). However, the association was not found consistently, was not greater in other examples, and may have represented a chance association due to multiple statistical comparisons. Thus, any attempt at a common-sense prediction of a patient's preferences based on age, health, or other demographic features would not have a high chance of corresponding to the patient's stated wishes.
Are Advance Directives Practical in Office Practices?
We found that most patients had some basic knowledge of the issues involved in planning for medical care. The patients' reported awareness of two famous law cases involving the termination of care, those of Karen Ann Quinlan and Paul Brophy, was 93 and 64 percent, respectively; for the Boston general public the figures were 96 and 62 percent. When asked whether a friend or relative had ever needed decisions about life-sustaining treatment made for him or her, 53 percent of the outpatients and 51 percent of the members of the general public reported such personal experience. As a check on comprehension, we asked the patients, after the educational section of the survey and the Medical Directive had been completed, seven simple factual questions (Appendix). Ninety-two percent of their answers were correct.
We assessed the time taken to read the educational section and complete with the interviewer the Medical Directive's four scenarios, each with 13 intervention choices. Patients took a median of 14 minutes (range, 8 to 44; interquartile range, 10 to 15). There was a small difference when this result was stratified according to level of education. Patients who had not graduated from high school took a median of 17 minutes, and those who had graduated took a median of 12 minutes (P<0.01).
Discussion
Desire for Advance Directives
The outpatients and the Boston public were favorably inclined toward planning for medical care; 89 and 93 percent, respectively, desired some form of planning at the end of the structured interview. Even if the extreme possibility is considered — that all screened and eligible patients who did not participate would have declined planning — 78 percent of the patients would still have wanted it. The large gap between the 93 percent of the outpatients who wanted planning and the 15 percent who had already undertaken it in some form represents fertile ground for physician initiative. The proportions were lower for individual forms of planning (e.g., 65 percent of the patients wanted an advance directive). Patients may thus be best helped if physicians make all three alternatives available — that is, discussion with the physician, written directives, and the designation of a proxy.
Can certain populations be targeted for planning? As mentioned, planning is commonly assumed to be particularly relevant for older and sicker people. However, the patients' preferences in this study indicated that a large proportion of patients in all health-status and age groups desire planning. Indeed, younger patients desired advance directives and discussion more often than older patients. This finding may reflect a generational difference or perhaps different perceptions about quality of life.25 Our finding stands in comparison with the finding of Lo et al.20 that more elderly patients (71 percent) than younger patients (43 percent) had thought about surrogate decision makers. This discrepancy could be explained by the differences in the questions asked ("would you like to have" vs. "have you thought about"). The discrepancy can also be used to emphasize that even differences of this degree are not enough to warrant targeting the old alone. Another difficulty with the assumption that planning should focus on the sick or old is illustrated by the great proportion of law cases that have involved young, previously healthy patients (including Quinlan and Cruzan). Although the probability that the young and healthy will become incompetent is low, the advantages of advance directives can be high, should incompetence occur. In this regard, planning is similar to screening and other forms of preventive health care.
The outpatients and the members of the general public had similar opinions about their desire for planning. The one statistically significant difference between them was that a larger proportion of the general public wanted a written advance directive, and this may have been an artifact of multiple comparisons. Overall, our findings can probably be generalized beyond Massachusetts General Hospital, although differences outside the Boston area are still possible. Our conclusion that most outpatients and members of the general public favor advance directives is consistent with, but goes beyond, previous reports on more limited populations, such as the elderly or patients with AIDS.19 , 20
Surmountable Barriers to Planning
The barriers to planning, as perceived by patients, could be substantially overcome by physicians. Contrary to a common clinical perception that patients may not want to discuss the topic, one of the barriers most frequently cited by patients was their expectation that physicians would initiate the discussion. The patient's own discomfort with the topic was cited very infrequently. These findings are consistent with and expand on those previously reported.19
Another frequently cited barrier was the expectation that the subject of planning would be raised only at a time of ill health or old age. This expectation must be juxtaposed with the finding that most patients who cited this barrier reported a desire to plan for medical care at the end of the interview. It is reasonable to deduce that those who assumed that such planning was for older or sicker patients were nevertheless educated by the interview and came to desire it themselves. As a result of the structured interview the desire for planning increased in a high proportion of subjects. This finding parallels the positive experience reported by patients who undertake planning26 and by physicians who undertake the process with patients.17 There thus seem to be strong indications that physicians could overcome one of the most important barriers by initiating discussions of advance directives with their patients.
What Life-Sustaining Treatments Do People Want?
The preferences of the outpatients and members of the general public in this study present us with baseline data on what patients would want if faced with various types of illness involving incompetence. It is not possible to say whether patients generally receive more or less intervention than their preferences would dictate. The reported preferences do challenge some common assumptions about care for the incompetent ill, however. First, there was no substantial difference between the rate of refusal of technically advanced interventions and that of artificial nutrition and intravenous fluids. In the literature on ethics and in legal opinions there has been a strong distinction between such interventions. In this regard, the opinion of the patients and the general public is in concert with legal rulings that permit patients to forgo artificial nutrition and fluids.27 , 28 Similarly, antibiotics were refused in a substantial majority of responses, only slightly less often than other measures frequently categorized as extraordinary. Even cardiopulmonary resuscitation, a measure that the medical profession considers distinct from others, was not distinguished from other life-sustaining measures in the four scenarios by rates of refusal. These findings suggest that distinctions between medical care and artificial nutrition and hydration, between ordinary and extraordinary medical care, and between short-term and protracted life-sustaining measures are not seen in the actual preferences of patients and the public. Finally, pain medications were usually requested even when they might indirectly hasten death; physicians should be alert to the very high premium patients place on remaining free of pain.
Substituted Decision Making Is Not a Good Alternative to Advance Directives
Our data indicate that preferences regarding interventions cannot be inferred from a patient's age, health, or other demographic features. When stratified according to these criteria, differences in preferences rarely reached statistical significance, and when they did the differences were small. It can be argued that physicians and relatives may base their proxy decisions on some less tangible feature of the patient to better effect. This argument, however, is not supported by two other studies in which spouses and physi-
Section
Health status
Advance directives and barriers to planning with the physician
Education about directives and health care
Medical Directive scenarios
Patient's knowledge and comprehension
Advance directives and proxies
Demographics
View of planning for medical care at end of survey
Appendix: The Questionnaire
Sample Items
Would you say your overall health is very poor, poor, fair, good, or excellent?
Have you ever discussed with your doctor what life-sustaining treatments you would want if you became so ill you could not make choices for yourself? (yes or no)
Would you like to have such a discussion with your doctor? (yes [skip next question] or no)
Why would you not wish to have such a discussion?
Living wills permit people to state ahead of time how they would like to be treated if they become severely ill and are unable to express their own wishes. A living will can state preferences for any degree of intervention depending on the circumstance. Some people also choose a friend or relative to make health care decisions for them if they become unable to do so themselves.
When people's hearts stop or their breathing fails it is sometimes possible to revive them with cardiopulmonary resuscitation (CPR). Depending on the circumstances, between 5 and 50 percent of people can be resuscitated with CPR. For patients with serious illness the chance of surviving CPR is nearer 5 percent.
Coma with a small chance of full recovery, persistent vegetative state, dementia with no other life-threatening illness, and dementia with a terminal illness. (Interventions considered ranged from CPR to antibiotics. Response options were "want," "do not want," "treatment trial," and "undecided.")
Are living wills intended to help dispose of possessions after a person becomes very sick? (yes or no)
CPR saves more than 90 percent of people from dying, (true or false)
Have you ever heard of Paul Brophy, a Massachusetts firefighter who lost his mental functions and was kept alive by artificial feeding but who had previously stated that he did not want to be kept alive by advanced medical technology? (yes or no)
Have you formally named a person, in a signed document, to make health care decisions for you, should you be unable to do so yourself? (yes or no)
Would you want to name such a person? (yes or no)
What is the highest year of school you completed?
Has participation in this survey changed either of the following: your desire to have a living will or your inclination to talk about the issue with your physician? (yes or no)
Do you think you might make out a living will for yourself? (yes, no, or undecided) cians failed to predict patients' desires for resuscitation accurately.29 , 30 It is thus reasonable to conclude that in the absence of direct discussion with patients, substituted decision making is not likely to correspond with their preferences.
Our data challenge the common assumption that younger age weighs in favor of aggressive medical intervention. We found that younger people did not want interventions more often than the elderly. Whatever the reason, the difference in preferences between the young and the old was not great. At a minimum, our data lend emphasis to the medical ethos of personal care tailored to the individual patient, whose values and preferences often cannot be adequately predicted by statistical norms. More specifically, our data may also support the use of advance directives for all, including young and healthy patients.
The Practicality of Advance Directives
We found that completing advance directives with a physician need not be a lengthy procedure. The discussion can be structured with use of documents such as the Medical Directive, which three quarters of patients can complete in 15 minutes or less. In our study, there was very little difference in the time patients with widely different levels of education needed to complete the form. Thus, directives can be completed as part of a structured discussion during a normal office visit. Our study did not, however, examine the necessary follow-up discussions. Furthermore, 15 minutes may be a full office visit for many internists. We reiterate our suggestion that the cost of a planning visit should be reimbursed by third-party payers.8 The visit involves a small amount of time well invested7 and is justified by ethical considerations.1 , 5 , 10
Although we await the results of the prospective portion of this study to report on the stability of patients' preferences over time and through illness, we suggest that the empirical case in favor of planning for medical care with a comprehensive document is already strong enough to warrant recommending that physicians initiate routine discussion of planning with their patients.
Supported by a grant (ROl HS06120) from the Agency for Health Care Policy and Research. Dr. L. Emanuel is an American College of Physicians Teaching and Research Scholar, and Dr. Barry is a Henry J. Kaiser Family Foundation Faculty Scholar in General Internal Medicine.
We are indebted to Jack Fowler for helpful suggestions on the design of the questionnaire and comments on the manuscript; to Albert Mulley, Lee Goldman, and Thomas Delbanco for help in designing the study; to Lynn Peterson and Dan Singer for helpful critiques of the manuscript; to Yuan-Lih Yeh and Terry Field for help with data analysis; to Gayle Long, Steve Amato, Sonya Kinney, and Pam Sapeto; to all the primary care physicians whose patients participated in the study; and to the administrative staff of the General Internal Medicine Unit at Massachusetts General Hospital.
Source Information
From the General Internal Medicine Unit, Massachusetts General Hospital, Boston (L.L.E., M.J.B., J.D.S., L.M.E.); Beth Israel Hospital, Boston (E.J.E.); and the Program in Ethics and the Professions, Harvard University, Cambridge, Mass. (L.L.E., E.J.E.).
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- Citing Articles (180)
Citing Articles
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Rebecca L. Sudore, Dean Schillinger, Sara J. Knight, Terri R. Fried. (2010) Uncertainty About Advance Care Planning Treatment Preferences Among Diverse Older Adults. Journal of Health Communication 15:sup2, 159-171
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Glenn J. Wagner, Deborah Riopelle, Jillisa Steckart, Karl A. Lorenz, Kenneth E. Rosenfeld. (2010) Provider Communication and Patient Understanding of Life-Limiting Illness and Their Relationship to Patient Communication of Treatment Preferences. Journal of Pain and Symptom Management 39:3, 527-534
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Khalid F. Almoosa, Linda M. Goldenhar, Ralph J. Panos. (2009) Characteristics of discussions on cardiopulmonary resuscitation between physicians and surrogates of critically ill patients. Journal of Critical Care 24:2, 280-287
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Rebecca Garavan, Hannah M McGee, Rachel Winder, Desmond O'Neill. (2009) WHEN AND HOW OLDER PEOPLE DISCUSS PREFERENCES FOR LONG-TERM CARE OPTIONS. Journal of the American Geriatrics Society 57:4, 750-751
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J. Savulescu, G. kahane. (2009) Brain Damage and the Moral Significance of Consciousness. Journal of Medicine and Philosophy
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Christopher R. Gilbert, Cecilia M. Smith. (2009) Advanced Lung Disease: Quality of Life and Role of Palliative Care. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine 76:1, 63-70
CrossRef17
Adam D. Schickedanz, Dean Schillinger, C. Seth Landefeld, Sara J. Knight, Brie A. Williams, Rebecca L. Sudore. (2009) A Clinical Framework for Improving the Advance Care Planning Process: Start with Patients' Self-Identified Barriers. Journal of the American Geriatrics Society 57:1, 31-39
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