Advance Directives from the Point of View of Primary Care Physicians in Spain
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Letter to the Editor Advance Directives from the Point of View of Primary Care Physicians in Spain Beatriz Navarro, PsyD, 1 Jesu ´s Lo ´ pez-Torres, MD, 2 Fernando Andre ´ s-Pretel, BCS, 1 Ignacio Pa ´ rraga, MD, 3 Alicia Ferna ´ ndez de Pen ˜ aranda, BMed, 4 Jose ´ Daniel Go ´ mez, BMed, 2 and Consolacio ´ n Armero Borja, BMed 2 To the Editor: A dvance directives have been regulated in Spain since 2002 via a law that defines the advance directives document as one by which a person of legal age, who is capable and free, manifests his or her will in advance so that it is fulfilled should the person lose the capacity to make medical decisions about his or her care and treatment. In case of death, the advance directive states what is to be done with the person’s body or organs. Despite the time elapsed since advance directives were enacted, the general population has not made widespread use of them. One barrier to their widespread use may be that health care professionals have limited knowledge about advance directives. The main ob- jective of this study was to assess the knowledge and attitudes of family physicians toward advance directives. A cross-sectional descriptive study (n = 298 family phy- sicians) was conducted in the health areas of Albacete and Guadalajara. The variables studied (self-informed) were sociodemographic and work characteristics and knowledge of, attitudes toward, and use of advance directives. Mean age was 47 years (58.5% men). Almost 70% of participants reported knowing about advance directives and the formalization procedure for them. Most participants agreed that most patients do not know about the document (93.0%) and that ‘‘formalizing the document helps the patient to make decisions about end-of-life issues’’ (84.3%), as well as helping the physician (83.4%), and the family (88.2%). Most participants felt that the opportunity to formalize the document should be explained to every patient, and not only to elderly or sick people. We found that 6.3% had completed their own advance directives document, and that 62.7% had lived through a situation related to the death of someone close in which such document could have been of help. A total of 59.1% of the sample reported feeling unable to address the issue of advance directives during consultation. The variables associated with a positive attitude toward advance directives were: reporting that the document would have been of help in the death of someone close (odds ratio [OR]:3.27), feeling able to address the issue during con- sultation (OR:2.12), and having worked as a family physi- cian for less than 10 years (OR:3.12). The vast majority of the family physicians know of the advance directives document and the procedure to formalize it; however, they also acknowledge that the information available to them is insufficient for them to properly advise their pa- tients. These results are consistent with those obtained previ- ously by other authors, because even though 90.4% of the physicians knew of the advance directives concept and 100% knew the formalization and registry procedure, 1 only 10.8% of them knew it in detail and 82.5% indicated that they knew little or nothing about the subject. 2 The results of this study show that primary care physicians have a positive attitude toward advance directives. A large percentage of participants agreed that there should be information campaigns about the docu- ment. In their study, Huges and Singer 3 determined that the majority of family physicians considered educational programs about advance directives to be necessary. Although the study was performed 2 decades ago, it seems that this need is still present in the context of primary care. In our study the majority of physicians reported that all patients should be informed about the possibility to for- malize this document. These results are consistent with those obtained previously by other authors. 4 The great ma- jority of respondents agreed or strongly agreed that the ad- vance directives document helps the physician, the patient, and family members with the decision-making process. These results are consistent with those obtained previously in other studies, such as the study by Santos Unamuno et al, 2 in which 97% of family physicians agreed that advance directives facilitate decision making. Studies in the United States show similar results and indicate that advance di- rectives help to improve health care treatment decisions. 3 More than half of the participants in our study (59.1%) did not feel able to discuss advance directives during con- sultation. The issue has been addressed in prior studies, noting that the problem is not a negative attitude of physi- cians toward the advance directives document, but rather the feeling of not having the necessary skills to address the issue with patients. 5 1 Research Unit, Primary Care Head Office of Albacete, Health and Social Care Foundation of Castilla-La Mancha, Albacete, Spain. 2 Health Care Centre Area IV, Health System of Castilla-La Mancha, Albacete, Spain. 3 Health Care Centre of La Roda, Health System of Castilla-La Mancha, Albacete, Spain. 4 Department Teaching Unit, Family and Community Medicine, Health System of Castilla-La Mancha, Guadalajara, Spain. POPULATION HEALTH MANAGEMENT Volume 17, Number 3, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/pop.2013.0104 197
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Transcript of Advance Directives from the Point of View of Primary Care Physicians in Spain
Letter to the Editor
Advance Directives from the Point of Viewof Primary Care Physicians in Spain
Beatriz Navarro, PsyD,1 Jesus Lopez-Torres, MD,2 Fernando Andres-Pretel, BCS,1
Ignacio Parraga, MD,3 Alicia Fernandez de Penaranda, BMed,4 Jose Daniel Gomez, BMed,2
and Consolacion Armero Borja, BMed2
To the Editor:
Advance directives have been regulated in Spainsince 2002 via a law that defines the advance directives
document as one by which a person of legal age, who iscapable and free, manifests his or her will in advance so that itis fulfilled should the person lose the capacity to makemedical decisions about his or her care and treatment. In caseof death, the advance directive states what is to be done withthe person’s body or organs. Despite the time elapsed sinceadvance directives were enacted, the general population hasnot made widespread use of them. One barrier to theirwidespread use may be that health care professionals havelimited knowledge about advance directives. The main ob-jective of this study was to assess the knowledge and attitudesof family physicians toward advance directives.
A cross-sectional descriptive study (n = 298 family phy-sicians) was conducted in the health areas of Albacete andGuadalajara. The variables studied (self-informed) weresociodemographic and work characteristics and knowledgeof, attitudes toward, and use of advance directives.
Mean age was 47 years (58.5% men). Almost 70% ofparticipants reported knowing about advance directives andthe formalization procedure for them. Most participantsagreed that most patients do not know about the document(93.0%) and that ‘‘formalizing the document helps the patientto make decisions about end-of-life issues’’ (84.3%), as wellas helping the physician (83.4%), and the family (88.2%).
Most participants felt that the opportunity to formalize thedocument should be explained to every patient, and not onlyto elderly or sick people. We found that 6.3% had completedtheir own advance directives document, and that 62.7% hadlived through a situation related to the death of someoneclose in which such document could have been of help. Atotal of 59.1% of the sample reported feeling unable toaddress the issue of advance directives during consultation.
The variables associated with a positive attitude towardadvance directives were: reporting that the document wouldhave been of help in the death of someone close (odds ratio[OR]:3.27), feeling able to address the issue during con-
sultation (OR:2.12), and having worked as a family physi-cian for less than 10 years (OR:3.12).
The vast majority of the family physicians know of theadvance directives document and the procedure to formalize it;however, they also acknowledge that the information availableto them is insufficient for them to properly advise their pa-tients. These results are consistent with those obtained previ-ously by other authors, because even though 90.4% of thephysicians knew of the advance directives concept and 100%knew the formalization and registry procedure,1 only 10.8% ofthem knew it in detail and 82.5% indicated that they knew littleor nothing about the subject.2 The results of this study showthat primary care physicians have a positive attitude towardadvance directives. A large percentage of participants agreedthat there should be information campaigns about the docu-ment. In their study, Huges and Singer3 determined that themajority of family physicians considered educational programsabout advance directives to be necessary. Although the studywas performed 2 decades ago, it seems that this need is stillpresent in the context of primary care.
In our study the majority of physicians reported that allpatients should be informed about the possibility to for-malize this document. These results are consistent withthose obtained previously by other authors.4 The great ma-jority of respondents agreed or strongly agreed that the ad-vance directives document helps the physician, the patient,and family members with the decision-making process.These results are consistent with those obtained previouslyin other studies, such as the study by Santos Unamuno et al,2
in which 97% of family physicians agreed that advancedirectives facilitate decision making. Studies in the UnitedStates show similar results and indicate that advance di-rectives help to improve health care treatment decisions.3
More than half of the participants in our study (59.1%)did not feel able to discuss advance directives during con-sultation. The issue has been addressed in prior studies,noting that the problem is not a negative attitude of physi-cians toward the advance directives document, but rather thefeeling of not having the necessary skills to address the issuewith patients.5
1Research Unit, Primary Care Head Office of Albacete, Health and Social Care Foundation of Castilla-La Mancha, Albacete, Spain.2Health Care Centre Area IV, Health System of Castilla-La Mancha, Albacete, Spain.3Health Care Centre of La Roda, Health System of Castilla-La Mancha, Albacete, Spain.4Department Teaching Unit, Family and Community Medicine, Health System of Castilla-La Mancha, Guadalajara, Spain.
POPULATION HEALTH MANAGEMENTVolume 17, Number 3, 2014ª Mary Ann Liebert, Inc.DOI: 10.1089/pop.2013.0104
197
In conclusion, physicians agree that advance directiveshelp them, the patients, and their families in the decision-making process. Both knowledge and experience are as-sociated with physicians’ attitudes toward the advancedirectives document.
Author Disclosure
This research was funded through a grant from theCastilla-La Mancha Health Research Foundation (FISCAM).
References
1. Champer A, Caritg F, Marquet R. Conocimientos y actitudesde los profesionales de los equipos de atencion primariasobre el documento de voluntades anticipadas. Aten Primaria2010;42:463–469.
2. Santos de Unamuno C, Forn MA, Perez R, Corrales A,Ugarriza L, Sales C. ¿Estamos preparados los medicos defamilia para ayudar a nuestros pacientes a hacer el testa-mento vital? RCA 2007;22:262–265.
3. Hughes DL, Singer PA. Family physicians’ attitudes towardadvance directives. CMAJ 1992;146:1937–1944.
4. Bachiller Baeza A, Hernandez de Miguel S, MartınezQueipo M, Delgado Martınez R, Domınguez Cano V. Tes-tamento vital: la opinion medica en la provincia de Valla-dolid. Metas de Enfermerıa 2004;7:24–27.
5. Wissow LS, Belote A, Kramer W, Compton-Phillips A,Kritzler R, Weiner JP. Promoting advance directives amongelderly primary care patients. J Gen Intern Med 2004;19:944–951.
Address correspondence to:Beatriz Navarro, PsyD
Research UnitResearch Unit (Unidad de Investigacion)
Call Laurel S/N02006 Albacete
Spain
E-mail: [email protected]
198 NAVARRO ET AL.
