• W M Tierney, P R Dexter, G P Gramelspacher, A J Perkins, X H Zhou, and F D Wolinsky.
• Department of Medicine, Indiana University School of Medicine, Indianapolis, USA.wtierney@iupui.edu
• J Gen Intern Med. 2001 Jan 1;16(1):32-40.

BackgroundDiscussions of end-of-life care should be held prior to acute, disabling events. Many barriers to having such discussions during primary care exist. These barriers include time constraints, communication difficulties, and perhaps physicians' anxiety that patients might react negatively to such discussions.ObjectiveTo assess the impact of discussions of advance directives on patients' satisfaction with their primary care physicians and outpatient visits.DesignProspective cohort study of patients enrolled in a randomized, controlled trial of the use of computers to remind primary care physicians to discuss advance directives with their elderly, chronically ill patients.SettingAcademic primary care general internal medicine practice affiliated with an urban teaching hospital.ParticipantsSix hundred eighty-six patients who were at least 75 years old, or at least 50 years old with serious underlying disease, and their 87 primary care physicians (57 residents, 30 faculty general internists) participated in the study.Measurements And Main ResultsWe assessed patients' satisfaction with their primary care physicians and visits via interviews held in the waiting room after completed visits. Controlling for satisfaction at enrollment and physician, patient, and visit factors, discussing advance directives was associated with greater satisfaction with the physician (P =.052). At follow-up, the strongest predictor of satisfaction with the primary care visit was having previously discussed advance directives with that physician (P =.004), with a trend towards greater visit satisfaction when discussions were held during that visit (P =.069). The percentage of patients scoring a visit as "excellent" increased from 34% for visits without prior advance directive discussions to 51% for visits with such discussions (P =.003).ConclusionsElderly patients with chronic illnesses were more satisfied with their primary care physicians and outpatient visits when advanced directives were discussed. The improvement in visit satisfaction was substantial and persistent. This should encourage physicians to initiate such discussions to overcome communication barriers might result in reduced patient satisfaction levels.

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