title: Intricate decision making: ambivalences and barriers when fulfilling an advance directive.
abstract: BACKGROUND
  Despite a recent statutory ruling stating the binding nature of advance directives (ADs), only a minority of the population has signed one. Yet, a majority deem it of utmost importance to ensure their wishes are followed through in case they are no longer able to decide. The reasons for this discrepancy have not yet been investigated sufficiently.
  
  
  METHODS
  This article is based on a survey of patients using a well-established structured questionnaire. First, patients were asked about their attitudes with respect to six therapeutic options at the end of life: intravenous fluids, artificial feeding, antibiotics, analgesia, chemotherapy/dialysis, and artificial ventilation; and second, they were asked about the negative effects related to the idea of ADs surveying their apprehensions: coercion to fulfill an AD, dictatorial reading of what had been laid down, and abuse of ADs.
  
  
  RESULTS
  A total of 1,260 interviewees completed the questionnaires. A significant percentage of interviewees were indecisive with respect to therapeutic options, ranging from 25% (analgesia) to 45% (artificial feeding). There was no connection to health status. Apprehensions about unwanted effects of ADs were widespread, at 51%, 35%, and 43% for coercion, dictatorial reading, and abuse, respectively.
  
  
  CONCLUSIONS
  A significant percentage of interviewees were unable to anticipate decisions about treatment options at the end of life. Apprehensions about negative adverse effects of ADs are widespread.
authors: Department of Gynecology and Obstetrics, Center of Integrated Oncology, University Hospital Bonn, Bonn.
authors: Lars
authors: L
authors: Schröder
authors: Institute of Medical Biometry, Epidemiology and Informatics, Johannes Gutenberg University, Mainz.
authors: Gerhard
authors: G
authors: Hommel
authors: Department of Gastroenterology and Oncology, Ketteler Hospital, Offenbach; Institute for Ethics and History of Medicine, Johann Wolfgang Goethe University, Frankfurt, Germany.
authors: Stephan
authors: S
authors: Sahm
keywords: advance directive; advanced care planning; decision making; living will; patient’s desires; therapy at the end of life