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Letter |
Key Words: Suicide • End-of-Life Decisions • Advance Directives
SIR: Dr. Blank and Dr. Sullivan's commentary and special article on patient choice in end-of-life decisions are important works that create an opportunity for the field of geriatric psychiatry to enter into the nation's debate about end-of-life care.1,2 As psychiatric physicians, we often become consultants in evaluating a patient's decisional capacity late in the course of a terminal illness, when the patient's autonomy is compromised by the dying process. Sullivan's primary argument was that "to respect the patient as a person, patient autonomy should be respected to the degree that it is intact."1 Dr. Blank's commentary provides "clinical context" and a vivid and highly personalized example of how an advance directive "helped bring his integrity into consideration" during the last days of her father-in-law's life.2
The level of discourse surrounding patients' decisional capacity and end-of-life care has risen sharply as the result of the SUPPORT study, in which a multidimensional intervention failed to improve five targeted end-of-life outcomes: the presence and timing of Do-Not-Resuscitate orders, patient–doctor communication, doctors' knowledge of patient care preferences, number of intensive-care-unit days before death, and amount of pain.3 As part of the important debate that followed the study's publication, the investigative team eventually questioned the fundamental assumptions of the study, asserting that
the course of care for the seriously ill hospitalized patient is the result of individual, patient-level decision-making that could be improved by better counseling and information. Instead, the course of care may well be shaped largely by how the care system is organized and by the interpersonal meanings ascribed to various cues and signals that shape the predictable patterns of care.4
Psychiatrists, and perhaps geriatric psychiatrists in particular, have important roles in this arena, as we are often asked to assist the family and treatment team in assessing decisional capacity of severely ill patients. To help frame our assessments, many of us use Grisso and Applebaum's four-component construct of decisional abilities (understanding, appreciation, reason, and expressed choice).5 Kim and colleagues recommend using these four constructs to approach the assessment of competence in cognitively impaired patients.6 This involves a two-step process that assesses an individual's decisional abilities, after which the evaluator makes a judgment about the person's capacity or competence to make an autonomous decision. Kim and colleagues7 further emphasize that the judgment of the assessor requires both the assessment of an individual's decisional abilities and the contextual factors surrounding a particular decision, such as a risk–benefit ratio, and the judgment style of the evaluator.
Not well studied, however, has been the cognitive and behavioral psychology of decision-making regarding advance care planning. Several years ago, my colleagues and I conducted a cross-sectional survey of community-dwelling adults participating in a planned educational program to promote advance directives.8 To the best of our knowledge, this was the first such study examining whether health psychology variables, such as coping strategies, health locus of control, mood, and personal spiritual experiences influenced advance care planning for community-dwelling adults not under the stress of an acute illness. About 32% of the sample had an advance directive. In the multivariate analyses, variables associated with higher odds of possessing an advance directive included advancing age and white ethnicity. Characteristics associated with lower odds of having an advance directive were higher relative distancing coping scores and higher relative seeking-social-support scores. The bivariate analysis also found that individuals with higher planful problem-solving coping strategies were more likely to have an advance directive. Interestingly, health locus of control and religious/spiritual measures were not found to be predictive of having an advance directive.8
These data underscore the idea that variables other than health status are important factors in securing an advance directive, especially in a non-critically ill population, where patient autonomy is high. The data also underscore Sullivan's assertion that improving the quality of care for dying individuals requires a much deeper analysis of individual choice and should include community values and the quality of care that is delivered in our health systems.2 The research settings and clinical conditions relevant to advance care planning should move beyond hospital or long-term care settings and into the community. It is in the community where the field might discover more about the contextual, health psychology, and cultural preferences surrounding high-stakes and highly personalized decision-making on end-of-life care.
REFERENCES
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