Patients' attitudes toward advance directives and end-of-life treatment decisions.

Much of the patient education about advance directives described in the literature involves explaining the purpose of advance directives to patients and guiding them through the process of issuing a directive. However, well over half of the subjects in this study claimed to know enough about the directives to issue one, and almost all subjects expressed a preference for issuing directives when healthy. Although health care agencies that wish to adhere to the PSDA must continue to ask all patients if they have issued an advance directive, aggressive patient education programs that press hospitalized patients to consider issuing an advance directive may be perceived by patients as coercive and uncaring. Patient education may be more likely to achieve the goals of the PSDA if it is provided before hospitalization and if patients are encouraged to discuss their care preferences with family members who would be in a position to speak for them at the end of life. Further study of the few patients who choose to issue an advance directive would be informative. When and why they chose to issue the directive should be explored. Patients who report issuing an advance directive but do not provide their physician or hospital with a copy of the directive upon admission should also be studied to determine if this represents a desire not to activate the directive during the current admission or simply confusion about the disposition of this document. Finally, most studies of advance directives have been cross-sectional. Longitudinal study of patients who issue advance directives are needed to determine the effectiveness of these documents in influencing the end-of-life treatment that patients receive.