Background: Advance care planning (ACP) is recommended to improve compliance with patient end-of-life wishes and to ensure appropriate use of healthcare resources. However, most American adults have neither living wills nor advance directives. Hospital physicians play a critical role in discussing and executing advance care plans, and stronger doctor-patient relationships may help increase rates of ACP. The effect of the doctor-patient relationship on end-of-life planning, though, is not well understood. This study measured the prevalence of ACP in a high-risk patient population and examined if more trusting doctor-patient relationships are associated with increased rates of ACP.
Methods: This study identified 632 Medicare beneficiaries age 65 or older at high risk of hospitalization enrolled in a randomized trial at an urban academic medical center. Patients were surveyed three months after enrollment in the randomized trial, and patients who reported having a personal doctor were asked two follow-up questions about their doctor-patient relationship: (1) how often did the patient feel the doctor put the patient’s best interests first when making recommendations about care, and (2) how often did the patient feel he/she could tell the doctor anything. Answers were never, sometimes, usually, and always. Patients’ medical records were also reviewed for the presence of ACP information (ACPi), defined as text in a medical note or scanned document explaining end-of-life care wishes. Bivariate chi-square test and multivariate logistic regression analysis evaluated the association between doctor-patient relationship strength and ACPi.
Results: The overall survey response rate was 92%. The final sample size was 201 patients after excluding patients with missing survey variables and patients without a record of care from a family or internal medicine practitioner. 156 (78%) patients had ACPi in their medical record. In binary analysis, patients who felt doctors more often put patient interests first were more likely to have ACPi (p=0.036). In multivariate logistic regression analysis controlling for age, gender, race, education, income, health status, randomization scheme, and study enrollment duration, a one-level increase in how often a patient felt his/her doctor put patient interests first was associated with a 122% increase in ACPi presence (p=0.048), and a one-level increase in how often a patient felt he could tell his doctor anything was associated with a 43% increase in ACPi presence (p=0.062), respectively.
Conclusions: Better doctor-patient relationships are positively associated with advance care planning in older patients at high risk of hospitalization. Strengthening the doctor-patient relationship can potentially help improve end-of-life care.