Intended for healthcare professionals

General Practice

General practitioners' knowledge and use ofliving wills

BMJ 1995; 310 doi: (Published 28 January 1995) Cite this as: BMJ 1995;310:230
  1. Michael Ashby, director of palliative medicinea,
  2. Melanie Wakefield, senior behavioural scientistb,
  3. Justin Beilby, directorc
  1. a Mary Potter Hospice and Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia
  2. b Behavioural Edpidemiology Unit, South Australian Health Commission, Adelaide, South Australia 500
  3. c Research and Health Promotion Unit, Royal Australasian College of General Practitioners (South Australia Faculty), Payneham, South Australia 5069
  1. Correspondence to: Dr Ashby, Calvary Hospital Adelaide, PO Box 231, North Adelaide, South Australia 5006, Australia.
  • Accepted 4 January 1995

Making medical decisions for people who are mentally incompetent, particularly at or near the end of life, is of international interest. In the United Kingdom there are no legal provisions for advance directives or living wills,1 but the High Court recently upheld that a patient's wishes expressed in an advanced directive are legally binding.2

Most of the work on the use of directives and making decisions about health care for others has focused on institutions. The promising role that living wills could have in longer term advance planning, particularly as a part of good family medical practice, has remained largely unexplored.

Living wills have been legal and binding in the state of South Australia for a decade in the format promul-gated under the Natural Death Act 1983. We previously reported the results of a public opinion survey carried out for a parliamentary select committee in 1991 in which the concept of living wills and a medical power of attorney were widely supported, but there were significant concerns about lack of public aware-ness.4 We report the results of a concurrent survey of general practitioners' attitudes to and knowledge of the Natural Death Act.

Subjects, methods, and results

A response rate of 74% (117/158) was obtained to a postal questionaire sent to a random sample of general practitioners. The design and survey methods have been described.5 Only 74 of the respondents were aware of the provision for living wills, 23 of them reporting that they had the forms available in their surgeries. Forty one of the 74 doctors had discussed making a living will with patients, the subject having been raised by the patient in 26 cases and by the doctor in six. Twenty one doctors reported that the patient had completed a living will; the doctor considered it to have been helpful in decision making in 12 cases and to have not been useful in four and was undecided in five.

The general practitioners surveyed were concerned about the concept of living wills and their implementation, notably because of the difficulty in raising the issue with patients and families and the possibilities of having a negative effect on the doctor-patient relation-ship and generating differences of opinion between doctors and families (table).

To improve the practical application of the legislation, 37% (43/117) suggested introducing a bracelet indicating that a person had made a living will. Such wills, however, are unlikely to operate effectively in accident and emergency departments when patients are seen by staff who do not know them. Support for a more medically specific directive was low (14%(17/117)), and opinion was divided (51%(57/112)) on the proposed provision of an agent (enduring power of attorney) to make decisions on a person's behalf when he or she becomes incompetent.

Possible worries and degree of concern about discussing living wills with terminally ill patients who are mentally competent. Values are numbers (percentages) of general practitioners

View this table:


Clearly, lack of knowledge of the Natural Death Act 1983 has been an obstacle to the effective use of living wills in South Australia, and this implies that a carefully executed awareness programme among the public and general practitioners must accompany any legislative change. Although conflict with families is viewed as a common problem, such conflict might arise less often if the person's views have been stated in an advance directive and been discussed within his or her family at the time of making the directive. Any form of living will, advance directive, or agency is intended to clarify what the patient wants and so should be an ally of good medical practice, not a troublesome intruder. General practitioners must be part of their development.

The data were gathered by Harrison Market Research. We thank Megan Ward and Lyn Earnshaw for typing the manuscript.


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