Directive counsel and morally controversial medical decision-making: findings from two national surveys of primary care physicians.

BACKGROUND: Because of the potential to unduly influence patients' decisions, some ethicists counsel physicians to be nondirective when negotiating morally controversial medical decisions. OBJECTIVE: To determine whether primary care providers (PCPs) are less likely to endorse directive counsel for morally controversial medical decisions than for typical ones and to identify predictors of endorsing directive counsel in such situations. DESIGN AND PARTICIPANTS: Surveys were mailed to two separate national samples of practicing primary care physicians. Survey 1 was conducted from 2009 to 2010 on 1,504 PCPs; Survey 2 was conducted from 2010 to 2011 on 1,058 PCPs. MAIN MEASURES: Survey 1: After randomization, half of the PCPs were asked if physicians should encourage patients to make the decision that the physician believes is best (directive counsel) with respect to "typical" medical decisions and half were asked the same question with respect to "morally controversial" medical decisions. Survey 2: After reading a vignette in which a patient asked for palliative sedation to unconsciousness, PCPs were asked whether it would be appropriate for the patient's physician to encourage the patient to make the decision the physician believes is best. KEY RESULTS: Of 1,427 eligible physicians, 896 responded to Survey 1 (63 %). Physicians asked about morally controversial decisions were half as likely (35 % vs. 65 % for typical decisions, p < 0.001) to endorse directive counsel. Of 986 eligible physicians, 600 responded to Survey 2 (61 %). Two in five physicians (41 %) endorsed directive counsel after reading a vignette describing a patient requesting palliative sedation to unconsciousness; these physicians tended to be male and more religious. CONCLUSIONS: PCPs are less likely to endorse directive counsel when negotiating morally controversial medical decisions. Male physicians and those who are more religious are more likely to endorse directive counsel in these situations.

Duke Scholars

Author Farr A Curlin Medicine, General Internal Medicine