Background The degree of consensus between a physician and patient after a discussion of advanced directives has not been examined. The purpose of this study was to explore levels of agreement following an inpatient discussion of a patient's preferences for resuscitation.
Methods We conducted semistructured open-ended interviews with resident physicians and hospitalized patients and/or a family member following a discussion of advanced directives. We asked patients and surrogate decision makers their decision about attempted resuscitation. Both physicians and patient/surrogates were asked to describe the discussion they had about preferences for resuscitation. We asked how the resident interpreted the decision, whether they perceived that the patient/surrogate understood the issue, and whether the physician felt that the patient's or surrogate's decision was reasonable. The patient's medical record was reviewed for physician documentation and orders reflecting an advanced directive. Transcribed interviews were analyzed via grounded theory, a method for identifying themes in qualitative interviews. Thematic coding used ATLAS.ti qualitative data management software.
Results Forty-eight interviews with 24 physician and patient/surrogate dyads were included in the analysis-14 with patients alone, 5 with a patient and family member, and 5 with a surrogate decision maker. Analysis of the interviews revealed that 11 of 24 dyads included some degree of discordance between the participants. This manifested in several ways. Two patients did not recall speaking with anyone about this topic. In four cases, the preferences the patient stated during the interview differed from the physician's interpretation or were not reflected accurately in the medical record. Five cases featured the physician questioning the decision of the patient or surrogate decision maker. Six physicians felt that the patient or surrogate had difficulty understanding the discussion, which potentially impacted their decision making. Three patients and surrogates admitted their inability to adequately comprehend this exchange. Following a discussion of advanced directives, there were varied levels of agreement between the participants. Differences were noted in the perceived outcome of the discussion as well as the physician's belief that the decision was not in the patient's best interest or based on an inaccurate understanding. These findings highlight the importance of improved education on communication skills, especially about end-of-life decision making.
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