title: Opening the black box: how do physicians communicate about advance directives?
abstract: BACKGROUND
  The quality of communication that leads to the completion of written advance directives may influence the usefulness of these documents, but the nature of that communication remains relatively unexplored.
  
  
  OBJECTIVE
  To describe how physicians discuss advance directives with patients.
  
  
  METHODS
  Prospective study.
  
  
  METHODS
  Five outpatient primary care medicine practices in Durham, North Carolina, and Pittsburgh, Pennsylvania.
  
  
  METHODS
  56 attending internists and 56 of their established patients. Eligible patients were at least 65 years of age or had a serious medical illness.
  
  
  METHODS
  Two raters coded transcripts of audiotaped discussions about advance directives to document how physicians introduced the topic of advance directives, discussed scenarios and treatments, provided information, elicited patient values, and identified surrogate decision makers.
  
  
  RESULTS
  Conversations about advance directives averaged 5.6 minutes; physicians spoke for two thirds of this time. In 91% of cases, physicians discussed dire scenarios in which most patients would not want to be treated, and 48% asked patients about their preferences in reversible scenarios. Fifty-five percent of physicians discussed scenarios involving uncertainty, typically using vague language. Patients' values were rarely explored in detail. In 88% of cases, physicians discussed surrogate decision making and documents to aid in advance care planning.
  
  
  CONCLUSIONS
  Although they accomplished the goal of introducing patients to advance directives, discussions infrequently dealt with patients' values and attitudes toward uncertainty. Physicians may not have addressed the topic in a way that would be of substantial use in future decision making, and these discussions did not meet the standards proposed in the literature.
authors.affiliation: Durham Veterans Affairs Medical Center and Duke University, North Carolina 27705, USA.
authors.forename: J A
authors.initials: JA
authors.lastname: Tulsky
authors.forename: G S
authors.initials: GS
authors.lastname: Fischer
authors.forename: M R
authors.initials: MR
authors.lastname: Rose
authors.forename: R M
authors.initials: RM
authors.lastname: Arnold
mesh_terms: D000328:Adult; D032722:Advance Care Planning; D016223:Advance Directives; D000368:Aged; D001294:Attitude to Health; D003142:Communication; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010347:Patient Care Planning; D010361:Patients / Q000523:psychology; D010819:Physician's Role; D010817:Physician-Patient Relations; D011446:Prospective Studies; D012151:Resuscitation; D012945:Social Values; D035501:Uncertainty