Emergency clinicians' attitudes and decisions in patient scenarios involving advance directives.
BACKGROUND
To identify the decisions and attitudes of emergency clinicians in hypothetical scenarios involving advance directives (ADs).


METHODS
An online survey distributed to members of the Australasian College for Emergency Medicine elicited decisions on commencing full treatment (CFT), limiting treatment or palliation in hypothetical clinical scenarios. Quantitative data were summarised using number and percentage.


RESULTS
388 surveys yielded a 13.0% response rate, including 190 fellows (51.9%) and 176 trainees (48.1%). For a 75-year-old patient with major trauma and unknown comorbidities requiring laparotomy, most participants (355/365, 97.3%) chose CFT. When an AD limiting treatment was made available, CFT decreased substantially (63/364, 17.3%), and the modal response was palliation (175/364, 48.1%). The most frequently reported influential factor in this decision was ethical obligation (82/383, 21.4%). For an elderly nursing-home resident with dementia, metastatic cancer and possible septic shock, 10.7% (39/366) chose CFT, changing little (21/365, 5.8%) with a directive requesting full treatment. The patient's presentation and history (189/375, 50.4%) overrode legal obligations (14/375, 3.7%) in influencing the decision. For a 55-year-old man with prostate cancer, hypoxia and acute respiratory distress (potentially requiring ventilatory support) saying, 'I just want to end it all,' most (233/366, 63.7%) chose CFT. A directive requesting limitation resulted in fewer decisions on CFT (43/368, 11.7%). Clear documentation was most important (100/362, 27.6%) in influencing this decision.


CONCLUSIONS
Hypothetical treatment decisions involving ADs made by emergency clinicians appear to be more influenced by ethical and clinical factors than by legal obligations.
Emergency Practice Innovation Centre, St Vincent's Hospital, 41 Victoria Pde, Fitzroy 3065, Melbourne, Victoria, Australia.
Rebecca E
RE
Wong
Tracey J
TJ
Weiland
George A
GA
Jelinek
D000328:Adult; D016223:Advance Directives / Q000523:psychology*; D000368:Aged; D001291:Attitude of Health Personnel; D044362:Australasia; D002983:Clinical Competence; D003657:Decision Making; D004635:Emergency Medicine; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010820:Physicians / Q000523:psychology*; D012017:Referral and Consultation; D016414:Resuscitation Orders / Q000523:psychology*; D011795:Surveys and Questionnaires