The role of the general practitioner in advance directives

Abstract

Patients have a right to self-determination, however, patients lacking mental capacity are not able to make autonomous decisions. Their right to self-determination can be preserved through the use of advance directives. Advance directives allow patients to make their preferences on future treatments in advance, just in case they lose the capacity to make the same decisions in the future. In spite of their commendable purpose, it is often argued that problems related to the creation and implementation of advance directives nullify their usefulness. A greater involvement of the general practitioner in the process of advance care planning is believed to be the answer. Obstacles to the creation of advance directives are generally attributable to problems affecting advance care discussions between patients and doctors. Primarily these include a lack of sufficient time for such discussions, doctor’s lack of training, and a fear of quashing the patient’s hope. Barriers attributable to the patient include lack of trust in the health provider, a lack of knowledge on the subject, and fear of creating familial conflict. Problems related to the implementation of advance directives affect one or more of three essential criteria: existence, applicability and validity. Uncertainties relating to any of the three criteria may preclude the use of advance directives. The attributes of general practice, such as continuity of care, patient-centredness and family orientation, and ease of accessibility, are all factors which position the general practitioner as the best answer to most of these problems. For advance directives to be effective they need legal-backing. Laws regulating advance directives are widespread, and while many include provisions that try to ensure the patient’s rights are protected, the general practitioner’s potential role is largely disregarded. An argument is made that giving greater importance to the general practitioner’s facilitating role within advance directive legislation can improve their successful creation and implementation.