Unclear wording adds to patient confusion over living wills

Most patients don't realize that directives take effect only after a diagnosis of terminal illness.

By Andis Robeznieks, AMNews staff. Dec. 23/30, 2002.

Few patients arrive at a hospital with their preferences for end-of-life care formally expressed in living wills or advance directives. But even when they do, these preferences may be packaged in documents that are not clearly understood or available.

In a study published in the Dec. 1 American Journal of Respiratory and Critical Care Medicine, Connecticut researchers at Bridgeport Hospital in Bridgeport and the Yale University School of Medicine in New Haven examined if patients, family members and physicians were all on the same page regarding cardiopulmonary resuscitation and endotracheal intubation/mechanical ventilation.

The researchers found that only 206 patients (4.3%) out of the 4,800 admitted to the 325-bed teaching hospital between July and October 2001 had living wills and that "living wills did not reflect fully patients' expectations of receiving or not receiving life-sustaining modalities."

Of those 206 patients, researchers were able to interview only 151, and of those, only 88 had complete data.

Of the 88, more than half wanted to block intubation or ventilation if the chances of recovery were less than 10%, and about 15% wanted to block it even if the chances were 50-50.

Constantine A. Manthous, MD, one of the authors of the study, said most living wills would not grant this request, and he was "startled" by how few people knew this.

"Living wills, as they are currently written, don't 'kick in' until a physician or physicians come to the conclusion that the patient is terminal," said Dr. Manthous, director of internal medicine training at Bridgeport Hospital and assistant clinical professor at Yale University School of Medicine. "As our study demonstrates, the most common misunderstanding regarding living wills is that they apply to non-terminal circumstances, which they don't. [...]