Variables that influence the medical decision regarding Advance Directives and their impact on end-of-life care

ABSTRACT The objective of this study was to identify the variables that influence physicians to implement Advance Directives and assess their impact on end-of-life care. It is a narrative literature review of 25 articles published between 1997 and 2018, in the following databases: CAPES, EBSCOhost, BDTD, VHL, Google Scholar, MEDLINE®/PubMed. The keywords utilized were: “advance directives”, “living wills”, “physicians”, “attitude”, “decision making”, “advance care planning”. The main factors that influenced physicians to implemente the directives were patients prognosis, medical paternalism, and patients understanding of their medical condition. Respect for autonomy, lack of knowledge and experience with directives, legal concerns, family influence, cultural and religious factors also contributed to medical decision. Most studies (86%) showed that having a directive led to lower rates of invasive interventions in the last days of patient´s life. Physicians were interested in respecting their patients’ autonomy and agreed that having an advance directive helped in the decision-making process; however, they stated other factors were also taken into account, mainly prognosis and reversibility conditions. Having directives contributed to reducing the use of life support therapies and adoption of comfort measures.

摘要 本研究旨在识别影响医师实施预立医疗指示（Advance Directives）的相关变量，并评估其对临终关怀的影响。本研究为叙事性文献综述，纳入了1997年至2018年间发表于CAPES、EBSCOhost、BDTD、VHL、Google Scholar、MEDLINE®/PubMed数据库的25篇文献。本次研究所使用的关键词为："预立医疗指示（advance directives）"、"生活遗嘱（living wills）"、"医师"、"态度"、"决策制定"、"预立医疗照护计划（advance care planning）"。影响医师实施上述预立医疗指示的核心因素包括患者预后、医疗家长主义（medical paternalism）以及患者对自身病情的认知水平。尊重患者自主原则、缺乏相关指示的应用知识与实践经验、法律顾虑、家属影响、文化与宗教因素同样对医疗决策产生了显著作用。绝大多数研究（占比86%）结果显示，患者拥有预立医疗指示可降低其生命终末期有创干预的实施比例。医师群体普遍认同尊重患者自主原则，并认可预立医疗指示有助于优化临床决策流程，但同时表示医疗决策仍需综合考量其他因素，主要包括患者预后与病情可逆性条件。推行预立医疗指示有助于减少生命支持疗法的使用，并推动舒适护理措施的落地实施。