Intended for healthcare professionals

Papers

Adherence to advance directives in critical care decision making: vignette study

BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7422.1011 (Published 30 October 2003) Cite this as: BMJ 2003;327:1011
  1. Trevor Thompson (trevor.thompson{at}bristol.ac.uk), clinical lecturer1,
  2. Rosaline Barbour, professor of health and social care2,
  3. Lisa Schwartz, professor of health care ethics3
  1. 1Division of Primary Health Care, University of Bristol, Bristol BS6 6JL
  2. 2School of Nursing and Midwifery, University of Dundee, Dundee DD1 4HJ
  3. 3Department of Clinical Epidemiology and Biostatistics, McMaster University, 1200 Main Street West Hamilton Ontario, Canada L8N 3Z5
  1. Correspondence to: T Thompson
  • Accepted 4 September 2003

Abstract

Objective To explore health professionals' decision making in a critical care scenario when there is an advance directive.

Design Qualitative study.

Setting Scotland.

Participants Interviewees (n = 12) comprising general practitioners, hospital specialists, and nurses, and six focus groups (n = 34 participants) comprising general practitioners, geriatricians (consultants and specialist registrars), hospital nurses, and hospice nurses.

Results When presented with an advance directive that applied to the same hypothetical scenario, health professionals came to divergent conclusions as to the “right thing to do.” Arguments opposing treatment centred on the supremacy of autonomy as an ethical principle. Other arguments were that the decision to treat was consistent with the terms of the advance directive, or that, notwithstanding the advance directive, the patient's quality of life was sufficient to warrant treatment.

Conclusion Advance directives are open to widely varying interpretation. Some of this variability is related to the ambiguity of the directive's terminology whereas some is related to the willingness of health professionals to make subjective value judgments concerning quality of life.

Footnotes

  • Contributors TT had the original idea for the study, collected the data, and was responsible for the overall running of the project; he will act as guarantor for the paper. RB was the research supervisor and was intimately involved in all stages of design and analysis. LS was involved in the design of the study and was particularly responsible for advice on ethical concepts. All authors contributed to the writing of the manuscript.

  • Funding The empirical work for this paper was undertaken while TT, RB, and LS were based at the Department of General Practice, University of Glasgow, and TT was funded by the Scottish Office as a higher professional training fellow. This study was supported by a grant from the Scientific Board of the Royal College of General Practitioners. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.

  • Competing interests None declared.

  • Ethical approval At the time the study was carried out (November 1999 to February 2000) it was not a formal requirement to obtain ethical approval for non-interventional research with health professionals. All participants gave signed consent.

View Full Text