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January 19, 2000

The Hospitalist's Role in Advance-Care Directives—Reply

Author Affiliations

Phil B.FontanarosaMD, Deputy EditorIndividualAuthorMargaret A.WinkerMD, Deputy EditorIndividualAuthorStephen J.LurieMD, PhD, Fishbein FellowIndividualAuthor

JAMA. 2000;283(3):336-337. doi:10-1001/pubs.JAMA-ISSN-0098-7484-283-3-jac90010

In Reply: The loss of information during the transition from outpatient care to the hospital creates ethical dilemmas for physicians and patients. As pointed out by Dr Brickner and Ms Drought, discussions about resuscitation status and end-of-life care are particularly susceptible to confusion. A readily available form that clearly documents a patient's wishes could help resolve ambiguities about the patient's goals for care.1 The preferred intensity of treatment form described by Brickner and Drought represents a creative approach. Such a document may encourage physicians and patients to discuss preferences for care and could guide the content of these conversations. Nonetheless, even a thorough and revealing discussion with a trusted primary care physician may not address an issue such as the massive pulmonary embolus experienced by the patient in our case.

In addition to creative approaches, such as the preferred intensity of treatment form, which attempts to make the content of prior discussions available to the inpatient physician at the point of care, we see no substitute for hospitalists routinely discussing preferences for treatment with every patient for whom they care. Such discussions allow the hospitalist to be certain that the patient has not rethought prior preferences in light of recent events2 and validate the crucial role of the primary care physician. Moreover, compared with outpatient conversations, discussions at the time of admission could focus on specific scenarios.

Hospitalists can do much to resolve ethical dilemmas raised by discontinuity of care. Solutions that respect the central role of the primary care physician but also take advantage of the opportunities presented by a hospital admission may be most likely to respect patient preferences and to promote the highest quality care.

Danis  MSoutherland  LIGarrett  JM  et al.  A prospective study of advance directives for life-sustaining care.  N Engl J Med. 1991;324:882-888.Google Scholar
Rosenfeld  KEWenger  NSPhillips  RS  et al. for the SUPPORT Investigators, Factors associated with change in resuscitation preference of seriously ill patients.  Arch Intern Med. 1996;156:1558-1564.Google Scholar