Annals of Internal Medicine--
COMPUTERS BREAK IMPASSE IN PATIENT-DOCTOR TALKS ABOUT ADVANCE DIRECTIVES

INDIANAPOLIS -- Advance directives for end-of-life care are a delicate topic to broach; there are no clear guidelines on when it is best or who should initiate the conversation, so usually no one does. But a study published in the Jan. 15 issue of the Annals of Internal Medicine gives physicians a model to follow to prompt the discussion.

Reporting on a two-year study, Indiana University School of Medicine faculty at Regenstrief Institute for Health Care found that nearly eight times as many physicians would address the delicate topic of advance directives* with terminally ill or elderly out-patients when reminded through the physicians' electronic computer record system. Without the reminder, only 4 percent of physicians in the study brought up the topic with patients.

"The study suggests that a highly technical aspect of health care -- computers in medicine -- has been able to affect something that isn't highly technical but is highly personal and important -- end-of-life care discussions," says the study's principle investigator, William Tierney, M.D., professor of medicine at IU School of Medicine, and senior investigator at Regenstrief Institute and the Roudebush VA Health Services Research and Development.

"The effectiveness of the computer reminders contrasts with the lack of effectiveness of the Congressional Patient Self-Determination Act (of 1990) and of efforts at intensive patient education, both of which have had little or no effect," the authors state in the article.

Other research has shown that both patients and physicians believe advance directives to be important, but there apparently is a gap in communication as to who should initiate the conversation.

"Our reminders broke the impasse. Doctors initiated discussions in response to the reminders and the patients were appreciative," says Dr. Tierney.

Study participants included 147 primary care physicians and 1,009 patients from the Regenstrief Health Center of Wishard Health Services who were over the age of 75 or who were age 50 and older with a serious illness. Twenty-four percent of the physicians who received computer generated reminders went on to discuss end-of-life care decisions with their patients. And, half of the patients who had discussions of this nature with their physician completed an advance directive.

Reasons physicians would not have initiated the discussion with patients include time constraints, the patient being too ill, reluctance on the part of the patient to discuss such issues, or a lack of belief in advance directives by the physician.

Researchers say they believe the key to the high rate of discussion and completion of advance directives was that the discussion occurred during regularly scheduled primary care visits when patients were not acutely ill and were visiting a physician they knew and trusted.

Dr. Tierney hopes the study may provide an impetus for physicians to discuss advance directives with patients and reduce the number of end-of-life decisions that are made without patient involvement.

This $750,000 study was funded by the Agency for Health Care Policy and Research, a division of the U.S. Department of Health and Human Services. IU faculty who are scientists at Regenstrief Institute for Health Care are national leaders in the research and development of computers as resources in the improvement of medical care.

* Advance directives are official medical documents that help patients direct their health care if they are seriously ill and unable to make their wishes known.

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