title: Advance directives and the impact of timing. A qualitative study with Swiss general practitioners.
abstract: BACKGROUND
  Advance directives are seen as an important tool for documenting the wishes of patients who are no longer competent to make decisions in regards to their medical care. Due to their nature, approaching the subject of advance directives with a patient can be difficult for both the medical care provider and the patient. This paper focuses on general practitioners' perspectives regarding the timing at which this discussion should take place, as well as the advantages and disadvantages of the different moments.
  
  
  METHODS
  In 2013, 23 semi-structured face-to-face interviews were performed with Swiss general practitioners. Interviews were analysed using qualitative content analysis.
  
  
  RESULTS
  In our sample, 23 general practitioners provided different options that they felt were appropriate moments: either (a) when the patient is still healthy, (b) when illness becomes predominant, or (c) when a patient has been transferred to a long-term care facility. Furthermore, general practitioners reported uncertainty and discomfort regarding initiating the discussion.
  
  
  CONCLUSIONS
  The distinct approaches, perspectives and rationales show that there is no well-defined or "right" moment. However, participants often associated advance directives with death. This link caused discomfort and uncertainty, which led to hesitation and delay on the part of general practitioners. Therefore we recommend further training on how to professionally initiate a conversation about advance directives. Furthermore, based on our results and experience, we recommend an early approach with healthy patients paired with later regular updates as it seems to be the most effective way to inform patients about their end-of-life care options.
authors.affiliation: Institute for Biomedical Ethics, University of Basel, and Institute of Primary Health Care, University of Basel, Switzerland.
authors.forename: Ina Carola
authors.initials: IC
authors.lastname: Otte
authors.affiliation: Institute of Primary Health Care, University of Basel, Switzerland.
authors.forename: Corinna
authors.initials: C
authors.lastname: Jung
authors.affiliation: Institute for Biomedical Ethics, University of Basel, Switzerland.
authors.forename: Bernice Simone
authors.initials: BS
authors.lastname: Elger
authors.affiliation: Institute of Primary Health Care, University of Basel, Switzerland.
authors.forename: Klaus
authors.initials: K
authors.lastname: Bally
mesh_terms: D000328:Adult; D016223:Advance Directives / Q000523:psychology*; D003142:Communication; D003657:Decision Making; D005260:Female; D058005:General Practitioners / Q000523:psychology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D013997:Time Factors