Why doctors override advanced care directives: ‘err on the side of treating’ 

End of life

By Michael Woodhead

12 Nov 2019

While doctors want to respect patient autonomy, many find it difficult to comply with the choices they have expressed in Advance Care Directives (ACD), an Australian study shows.

When faced with complex and often conflicting options in patient care, doctors tend to go with their clinical judgement and override an ACD, interviews with physicians at the Austin Hospital have revealed.

In response to vignettes of hypothetical end of life care decisions, doctors were motivated to act in what they considered to be the patient’s best interest, even if this meant direct contravention of their written instructions, according to study findings, published in in BMJ Open.

Most of the doctors expressed little concern about possible legal risks of their preference to override an ACD, saying they felt obliged to “err on the side of treatment.”

The research led by Advance Care Planning Australia, sought feedback on the real-life scenarios from 21 consultants and registrars in specialties including oncology, haematology, cardiology, gastroenterology and respiratory medicine.

One example was of a 65-year old man with ventricular fibrillation whose ACD included a “not for resuscitation” instruction that he be to allowed to “pass away in peace’ if it was unlikely he would recover to resume his daily routine of playing golf.

But many of the doctors said they would ignore this ACD instruction and likely provide urgent emergency treatment because the patient had a condition deemed to be potentially reversible.

Some doctors were reluctant to implement patients requests that they considered to be unreasonable, unusual or inconsistent with what a ‘normal’ person might want.

“‘[The patient] has an excellent prognosis … So you would be mischievous not to treat him,” said one.

Doctors cited numerous others reasons why they may not adhere to an ACD, including concerns that the document was invalid for being out of date out of date, unsuited to the current context or written in vague language.

“How I interpret independence is different to how someone else might value his independence’ because values are different from person to person,” wrote one respondent.

Participants also doubted whether some patients had made an informed choice when they drew up the ACD, and whether they had understood the implications of their stated preferences.

“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 [they] are legally-binding documents,” she added.

“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,” said Ms Nolte.

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