Geriatricians' views of advance decisions and their use in clinical care in England: qualitative study

Background: an anticipatory decision document records a person's wishes regarding medical treatment at a time when they have capacity to make choices, to be enacted when this capacity is lost. In England and Wales an advance decision to refuse treatment (ADRT, or advance decision), a legally binding document, is currently rarely used. A disparity is suggested to exist between physicians' support for anticipatory decisions in principle and their lack of impact on decision-making in practice. Objective: to elicit geriatricians' views on advance decisions and their use in decision-making in England. Design: a qualitative approach was taken. Semi-structured interviews were conducted with 10 geriatricians. An inductive approach was used for data analysis. Results: geriatricians held positive views on anticipatory decisions in principle. In practice, they reported being highly likely to follow a decision which was in line with their clinical view. They would also favour an ADRT which was prescriptive in terms of the situation and treatment to which it applied. However, geriatricians expressed concerns in relation to patient understanding of the role and limits of these documents. Participants expressed discomfort in following an ADRT which, in their professional opinion, did not represent the patient's best interests, despite it being a legally binding document. A conflict between doctors' beneficence and patients' autonomy was apparent, with geriatricians differing in their views on how ADRTs should fit into medical decision-making; particularly how far anticipatory decisions can represent ongoing patient autonomy. Conclusion: despite their status in law, an ADRT which conflicts with a geriatrician's clinical opinion may not be implemented, in breach of the Mental Capacity Act. To avoid this, they must be seated within wider advance care planning. © The Author 2011. Published by Oxford University Press on behalf of the British Geriatrics Society.