Advance Directives from the Point of View of Primary Care Physicians in Spain

To the Editor:

Advance 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 objective of this study was to assess the knowledge and attitudes of family physicians toward advance directives.

A cross-sectional descriptive study (n=298 family physicians) 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 consultation (OR:2.12), and having worked as a family physician 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 patients. These results are consistent with those obtained previously 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 document. 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 formalize this document. These results are consistent with those obtained previously by other authors. ⁴ The great majority of respondents agreed or strongly agreed that the advance 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 directives 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 consultation. The issue has been addressed in prior studies, noting that the problem is not a negative attitude of physicians toward the advance directives document, but rather the feeling of not having the necessary skills to address the issue with patients. ⁵

In conclusion, physicians agree that advance directives help them, the patients, and their families in the decision-making process. Both knowledge and experience are associated with physicians' attitudes toward the advance directives document.