Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 https://doi.org/10.1186/s12910-021-00646-y RESEARCH Open Access Association between knowledge and attitudes towards advance directives in emergency services Silvia Poveda‑Moral1,2* , Pilar José‑Maria de la Casa3, Pere Sánchez‑Valero4, Núria Pomares‑Quintana3, Mireia Vicente‑García3 and Anna Falcó‑Pegueroles5 Abstract Background: Implementing the routine consultation of patient advance directives in hospital emergency depart‑ ments and emergency medical services has become essential, given that advance directives constitute the frame of reference for care personalisation and respect for patients’ values and preferences related to healthcare. The aim of this study was to assess the levels and relationship of knowledge and attitudes of nursing and medical professionals towards advance directives in hospital emergency departments and emergency medical services, and to determine the correlated and predictor variables of favourable attitudes towards advance directives. Methods: Observational, descriptive, and cross-sectional study. The study was conducted in the emergency depart‑ ment of a second-level hospital and in the emergency medical service. Data collection was performed from January 2019 to February 2020. The STROBE guidelines were followed for the preparation of the study. Results: A total of 173 healthcare professionals responded to the questionnaire. Among them, 91.3% considered that they were not sufficiently informed about advance directives, and 74% acknowledged not having incorporated them into their usual practice. Multinomial analysis indicated a statistically significant relationship between the variable emergency medical service and having more favourable attitudes towards consulting the advance directives in their practical application (OR 2.49 [95% CI 1.06–5.88]; p = 0.037) and compliance in complex scenarios (OR 3.65 [95% CI 1.58 − 8.41]; p = 0.002). Working the afternoon and night shift was a predictor variable for obtaining a higher score with respect to attitudes in complex scenarios. Conclusion: There is an association between the level of knowledge that nursing and medical professionals have about advance directives and the scores obtained on the attitude scales at the time of practical implementation and in complex scenarios. This shows that the more knowledge professionals have, the more likely they are to consult patients’ advance directives and to respect their wishes and preferences for care and/or treatment. Keywords: Advance directives, Hospital emergency department, Emergency medical services, Attitudes, Knowledge Background It is known that scientific and technical advances in recent years have had a positive influence by increasing life expectancy. The improvement of global healthcare in *Correspondence: silviapoveda@euit.fdsll.cat 2 Escola Universitària D’Infermeria I Teràpia Ocupacional de Terrassa (EUIT), our environment has produced a percentage increase in Universitat Autònoma de Barcelona, Calle de La Riba, 90, 08221 Terrassa, the demand for care from emergency services in recent Barcelona, Catalonia, Spain decades [1]. A systematic review that assessed thirty-one Full list of author information is available at the end of the article © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 2 of 15 studies indicated that the most frequent users of hospi- [17], or therapeutic futility, when the professional is una- tal emergency departments and emergency medical ser- ble to recognize that life has its limits and that there are vices were older adults, patients with complex chronic some procedures that violate the autonomy and dignity diseases, patients with psychiatric comorbidities, and of the person. patients with low socioeconomic levels [2]. According to In the context of Spanish law and regulations regard- data from the World Health Organisation, there will be ing ADs, the General Health Law 14/1986 on April 5, two billion individuals aged 60 and over in 2050. This is made explicit the need to regulate actions to enforce a population with increasingly complex pathologies and the right to health protection recognized in the Spanish comorbidities that will require urgent care to treat epi- Constitution. Articles 9 to 11 established the rights and sodes of acute exacerbations [3]. This reality is having an duties of users of the National Health System. The new impact on most health systems. Greater use of hospital legal framework represented a commitment to a model emergency departments can cause saturation and col- more focused on the principle of autonomy of the per- lapse of services. Serving increasingly aging populations son, abandoning the traditional model of care based on means that the assessments made by the professionals medical paternalism. Further, the Convention on Human working at emergency services will be substantially more Rights and Biomedicine (Oviedo Convention) [18], which complex [4–6]. In many cases, chronic and multi-path- came into force on January 1 2000, permitted a step for- ological pictures are accompanied by some type of cog- ward in the recognition of living wills in establishing that nitive impairment that makes it difficult for the patient ‘…the wishes previously expressed regarding a medical to be involved in decision-making [2, 7]. Free choice and intervention by a patient who, at the time of the inter- respect for patient autonomy are important principles in vention, is not able to express himself, will be taken into our health care systems. In fact, current evidence shows consideration’. The legislation on advance directives in that comprehensive, person-centred care helps to reduce Spain and its autonomous communities is very varied. unwanted hospitalisations and increases patients’ self- However, all autonomous communities have a person- care and professionals’ satisfaction [8, 9]. These benefits centred care model in which advance care planning is were already raised in 2013 by the American Geriatrics the framework and there is a national registry that allows Society, together with several North American emer- citizens to officially record their advance directives with gency societies (American College of Emergency Physi- guarantees of confidentiality and accessibility, in addition cians, Emergency Nurses Association, and Society for to freedom and the absence of coercion [19]. Academic Emergency Medicine) [10]. Undoubtedly, being aware of the care and treatment In this context, implementing the routine consultation preferences of patients can help professionals make deci- of patient advance directives (AD) in hospital emergency sions that are better adjusted to the wishes of these indi- departments and emergency medical services becomes viduals, such as the transfers of those who wish to die essential, given that ADs constitute the frame of refer- in their own homes assisted by professionals who are ence for care personalisation and respect for patients’ experts in end-of-life care [20]. Furthermore, it would be values and preferences related to healthcare [11]. ADs possible to reduce unnecessary clinical actions carried allow decision-makers to set goals and preferences for out in the emergency departments and services. future medical care and treatments, which should be As previously mentioned, despite the fact that some respected and met in the absence of patients’ ability to studies have assessed health professionals’ knowledge express themselves [12]. and attitudes towards AD, they did not analyse this issue Previous studies have indicated that it is difficult jointly and comparatively in hospital emergency depart- to know patients’ preferences in emergency services. ments and emergency medical services. Therefore, the According to these studies, ignorance about ADs, reg- main goal of the present study was to assess the levels istration mechanisms, and the normative aspects that and relationship of nursing and medical professionals’ regulate them, as well as the lack of skills of profession- knowledge and attitudes towards AD in hospital emer- als in managing them, constitute the main factors hinder- gency departments and emergency medical services, and ing the consultation and implementation of AD in these to determine the correlated variables. The predictive var- services [13, 14]. Likewise, in addition to posing a clear iables of favourable attitudes towards AD were analysed threat to respect for individuals’ autonomy of decision as a secondary goal of the study. [15], these obstacles described in the literature can gen- erate conflictive situations from an ethical and legal per- Methods spective [16]. They can also lead to a professional practice Study design, settings, and subjects based on "defensive medicine, when professionals are This is an observational, descriptive and cross-sectional afraid of receiving a complaint from patients or relatives study conducted in the Emergency Department of Mollet Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 3 of 15 Hospital (Barcelona), Spain and in an emergency medical definition; (c) proposals for official documentation; (d) service in Catalonia, Spain. The guidelines proposed in proposals for use; (e) proposals for the registration proce- ‘Strengthening the reporting of observational studies in dure; (f ) proposal for attitudes of health professionals at epidemiology’ (STROBE) were followed for the prepara- the time of practical application (APA); and (g) proposals tion of the study. for attitudes of health professionals at the time of practi- The participants included in the study were nursing cal application in complex scenarios (ACS). and medical professionals linked to both services and In order to assess the levels of knowledge about plan- institutions, who had a valid employment contract dur- ning AD in the sample, it was considered relevant to add ing the period of the survey, and who wished to partici- the following question: “Do you know the meaning of pate in the study voluntarily. The professionals excluded advance directives planning?”. were those in the ‘recycling’ period, those who habitually Sociodemographic data were also collected using a worked with the paediatric population, and graduate stu- form attached to the instrument, including sociodemo- dents in internships. The instrument used was delivered graphic and professional variables (sex, age, academic by the service coordinators to the potential participants discipline, service, graduate training and/or master’s in person and/or online through the institutional mail. degree in bioethics, years of experience in the service, The present study was approved by the Clinical and work shift). The response format was open-ended, Board of Emergency Medical Services (Barcelona) dichotomous, and polychotomous. and by the Ethics Committee for Drug Research of the Hospital Clínic Barcelona, with reference number Statistical analysis HCB/2020/0158. Authorisation was obtained from the The compilation of the responses was performed using nursing and medical directorates of both institutions. the SPSS V.24.0 software for ­Windows©. The statistical The guidelines of the Declaration of Helsinki relating analysis of the data was carried out using the R V.4.0.1 to ethical principles in clinical research were followed. software. The normality of continuous variables was The authors of the original questionnaire authorised its determined using QQ plots and the Shapiro-Wilks administration in the present study. With respect to the test. Variables that followed a normal distribution were participants, they received oral and written information presented as means (standard deviation). The differ- concerning the study and the voluntary nature of their ences were calculated using the Student’s t-test for two participation. To ensure confidentiality, the informa- groups, or ANOVA for more than two groups, correct- tion collected was registered in a database anonymously, ing for multiple comparisons with Tukey test. Variables using numbers instead of the names of the participants. that did not follow a normal distribution were presented with the medians (interquartile range). The differences Sample size calculation were tested using the nonparametric Mann–Whitney The sample was selected by non-probabilistic conveni- U test for two groups, or Kruskal–Wallis for more than ence sampling of a total of 190 professionals. It was cal- two groups, correcting for multiple comparisons using culated using the equation of proportions, estimating a the Benjamin and Hochberg test. Categorical variables confidence level of 95% and an expected proportion of were represented with frequency (percentage) and the losses of 15%. The necessary sample was made up of 128 two groups were compared using the Chi-square test or participants. Finally, 173 nursing and medical profession- Fisher’s exact test. als, representing a participation rate of 91%, participated A Likert-type measurement scale was created from in the study and were asked to fill in the questionnaire the APA and ACS categorical variables, assigning their either on paper or via their computer, mobile phone, and/ degree of agreement or disagreement on a graduated rat- or tablet. ing scale from 1 to 5. Then, ranges of scores were created from the 25th, Questionnaire development 50th, and 75th percentiles to determine the APA and The data collection was performed from January 2019 ACS of professionals who had favourable, intermediate, to February 2020. The questionnaire “Knowledge and or unfavourable attitudes towards AD. The two scores attitudes of health professionals in the process of liv- were considered separately. ing will declaration process”, with a reliability rang- Multinomial logistic regression models were created ing from 0.5 to 0.88, and a Kappa pre-retest stability of to assess the association between variables that were sig- 0.2 [21], was used to assess the participants’ knowledge nificant in the bivariate analysis, taking the total scores and attitudes towards AD. This instrument is made up of APA and ACS classification (unfavourable, intermedi- of forty-one items divided into seven blocks, namely: ate, and favourable attitude) as the response variable. All (a) normative aspects; (b) proposals for conceptual the models were also adjusted for sex, age, education, and Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 4 of 15 work experience. Values of p < 0.05 were considered sta- comparison of the two groups indicated that nurses (68%; tistically significant. n = 80) had a greater tendency to respect the right of the patients to receive appropriate care for prevention and Results pain relief, including sedation, vs. physicians 46% (n = 25) The present study assessed 173 participants, of whom (p = 0.005). Nurses also felt that the physician respon- 119 were nurses and 54 physicians. The median age was sible for care had a moral duty to follow the ADs, with x̃ = 40 years (33.0–47.0); 48 were men and 125 women. 65% (n = 77) of nurses strongly agreeing, compared to Of the total, 57% (n = 99) of the participants worked in 40% (n = 21) of the doctors (p = 0.007). Furthermore, 58% the emergency department of the hospital, 43% (n = 74) (n = 69) of the nursing professionals and 49% (n = 26) of in the emergency medical service, 45% (n = 78) on the the medical professionals considered AD to be very use- morning shift, and 39% (n = 67) had more than fifteen ful as an instrument for healthcare. years’ experience. The remaining sociodemographic The relationship between the level of knowledge and characteristics are detailed in Table 1. the APA and ACS are detailed in Tables 2 and 3. Looking With respect to knowledge, 53% (n = 92) knew that AD at the total number of participants, 37% scored favour- declarations could not replace informed consents, 72% able on the APA questions, 34% scored intermediate, (n = 124) knew that AD declarations were valid through- and the remaining 29% scored unfavourable (Table 2). If out the Spanish territory, 72% (n = 125) knew that an we look at the scores for the ACS questions, 43% scored admitted individual could make an AD declaration, 57% favourable, 23% scored intermediate, and 34% scored (n = 99) acknowledged that health professionals should unfavourable (Table 3). The best scores in the APA and provide information about AD to patients, and only 43% ACS questions were most frequently observed in those (n = 74) knew the meaning of AD planning. On the other who knew about ADs, the official documentation neces- hand, 74% (n = 128) did not know the documentation sary to perform them, the registration procedures, and that should be provided when making an AD declaration, their use in clinical practice. This fact was confirmed with 65% (n = 113) did not know where to register AD, 65% a p value < 0.05. (n = 112) did not know where to consult them, and only The multivariable analysis indicated a statistically sig- 17% (n = 30) knew who could consult them once they had nificant relationship between the variables of service been recorded. In addition, 91% (n = 158) acknowledged and exhibiting greater predisposition on the part of the that they were not sufficiently informed about AD, and professionals to consult the AD of the patients. It was 50% (n = 87) answered N/A when asked about the legal observed that the fact of belonging to the emergency validity of an AD that was not registered. medical service was a predictor variable of a favour- Regarding attitudes, 74% (n = 128) of the profession- able attitude (OR 2.49 [95% CI 1.06–5.88]; p = 0.037) als acknowledged that they had not incorporated con- vs. an unfavourable one, taking those of the emergency sultation of AD in their usual practice (Figs. 1, 2). The department of the hospital as reference. Intermediate vs. Table 1 Main characteristics of the participants [ALL] Nursing Medical No No. = 173 No. = 119 No. = 54 Age 40.0 [33.0; 47.0] 39.0 [32.2; 45.0] 42.0 [36.0; 52.0] 172 Previous Master’s or postgraduate degree 8 (4.62%) 6 (5.04%) 2 (3.70%) 173 Years of experience at the service 173 0–5 years 39 (22.5%) 31 (26.1%) 8 (14.8%) 6–10 years 39 (22.5%) 22 (18.5%) 17 (31.5%) 11–15 years 28 (16.2%) 20 (16.8%) 8 (14.8%) + 15 years 67 (38.7%) 46 (38.7%) 21 (38.9%) Service 173 Hospital emergency department 99 (57.2%) 74 (62.2%) 25 (46.3%) Emergency medical service 74 (42.8%) 45 (37.8%) 29 (53.7%) Work shift 173 Morning 78 (45.1%) 54 (45.4%) 24 (44.4%) Afternoon 32 (18.5%) 24 (20.2%) 8 (14.8%) Night 63 (36.4%) 41 (34.5%) 22 (40.7%) Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 5 of 15 Fig. 1 Attitudes of nursing and medical professionals at the time of practical AD application unfavourable attitudes were not statistically significant (ACS), it was observed that belonging to the emergency (OR 1.5 [95% CI 0.63–3.59]; p = 0.357). In addition, it was medical service meant a greater likelihood of obtain- found that with increasing age and years of experience of ing a favourable attitude (OR 3.65 [95% CI 1.58 − 8.41]; the professionals there was not a greater probability of p = 0.002) or intermediate as opposed to an unfavour- obtaining a favourable attitude in APA (Table 4). able one, in comparison to those of the hospital emer- Regarding attitudes of health professionals at the gency department. Working the afternoon shift (OR time of practical application in complex scenarios 3.3 [95% CI 1.1 − 9.84]; p = 0.032) and/or night shift (OR 2[95% CI 0.86–4.68]; p = 0.11) was also a predictor Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 6 of 15 Fig. 2 Attitudes of nursing and medical professionals towards AD in complex scenarios variable for obtaining a higher score in ACS, in com- In the same line as the results found by Mateos et al. parison to working the morning shift (Table 5). [26] and Marco et al. [25, 27], there was good predispo- sition of nursing and medical professionals to respect the autonomy of decision making of the patients they Discussion served and they even considered ADs as a fundamen- The results show that there is still insufficient specific tal tool for making decisions in clinical practice. How- knowledge and skills relating to the management of AD ever, as pointed out by Pérez [28], there was still a lack in the context of emergency services, in line with pre- of knowledge about ADs, their registering mechanisms vious studies [22–25]. Nevertheless, the present study at a practical level, and the normative aspects that regu- provides novel aspects regarding which variables are pre- lated them. According to a phenomenological-herme- dictors of favourable attitudes towards AD. neutic study that interviewed 24 emergency care services Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 7 of 15 Table 2 Relationship between the levels of knowledge and attitudes in practical application (APA) [ALL] Unfavourable Intermediate Favourable p. overall N attitude towards attitude towards attitude AD AD towards AD N = 172 N = 50 (29.1%) N = 58 (33.7%) N = 64 (37.2%) Can the declaration of AD replace Informed Consent? 0.028 171 Yes 40 (23.4%) 8 (16.0%) 9 (15.8%) 23 (35.9%) No 91 (53.2%) 26 (52.0%) 34 (59.6%) 31 (48.4%) N/A 40 (23.4%) 16 (32.0%) 14 (24.6%) 10 (15.6%) Is one of the aims of Law 2/2010 (Spain) to ensure the 0.298 171 autonomy of patients and respect for their will in the dying process, only when there is a living will? Yes 37 (21.6%) 12 (24.0%) 9 (15.8%) 16 (25.0%) No 70 (40.9%) 17 (34.0%) 23 (40.4%) 30 (46.9%) N/A 64 (37.4%) 21 (42.0%) 25 (43.9%) 18 (28.1%) Can persons with a judicial resolution of incapacity register 0.272 170 a living will if it does not specify this in the resolution? Yes 40 (23.5%) 10 (20.0%) 14 (25.0%) 16 (25.0%) No 55 (32.4%) 13 (26.0%) 16 (28.6%) 26 (40.6%) N/A 75 (44.1%) 27 (54.0%) 26 (46.4%) 22 (34.4%) Are living wills valid throughout Spain? 0.039 172 Yes 123 (71.5%) 28 (56.0%) 44 (75.9%) 51 (79.7%) No 8 (4.65%) 4 (8.00%) 1 (1.72%) 3 (4.69%) N/A 41 (23.8%) 18 (36.0%) 13 (22.4%) 10 (15.6%) Are health professionals in Catalonia obliged to inform 0.358 172 about AD? Yes 73 (42.4%) 17 (34.0%) 25 (43.1%) 31 (48.4%) No 33 (19.2%) 13 (26.0%) 8 (13.8%) 12 (18.8%) N/A 66 (38.4%) 20 (40.0%) 25 (43.1%) 21 (32.8%) Can the representative appointed in the living will have his 0.423 172 or her functions limited by the person granting the Living Will whom he or she represents? Yes 87 (50.6%) 24 (48.0%) 27 (46.6%) 36 (56.2%) No 23 (13.4%) 10 (20.0%) 7 (12.1%) 6 (9.38%) N/A 62 (36.0%) 16 (32.0%) 24 (41.4%) 22 (34.4%) The living will must always be taken into account, regard‑ 0.492 172 less of the patient’s state of consciousness Yes 120 (69.8%) 33 (66.0%) 42 (72.4%) 45 (70.3%) No 38 (22.1%) 10 (20.0%) 12 (20.7%) 16 (25.0%) N/A 14 (8.14%) 7 (14.0%) 4 (6.90%) 3 (4.69%) In the case of deceased persons, does only their legal repre‑ 0.809 172 sentative have access to the declaration of a Living Will? Yes 38 (22.1%) 10 (20.0%) 14 (24.1%) 14 (21.9%) No 64 (37.2%) 17 (34.0%) 20 (34.5%) 27 (42.2%) N/A 70 (40.7%) 23 (46.0%) 24 (41.4%) 23 (35.9%) Do you understand the meaning of limitation of therapeu‑ 0.140 172 tic effort? Yes 156 (90.7%) 49 (98.0%) 53 (91.4%) 54 (84.4%) No 7 (4.07%) 0 (0.00%) 3 (5.17%) 4 (6.25%) N/A 9 (5.23%) 1 (2.00%) 2 (3.45%) 6 (9.38%) Have you learned about the meaning and usefulness of the 0.031 172 ACP: Yes 74 (43.0%) 19 (38.0%) 19 (32.8%) 36 (56.2%) No 66 (38.4%) 24 (48.0%) 23(39.7%) 19 (29.7%) Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 8 of 15 Table 2 (continued) [ALL] Unfavourable Intermediate Favourable p. overall N attitude towards attitude towards attitude AD AD towards AD N = 172 N = 50 (29.1%) N = 58 (33.7%) N = 64 (37.2%) N/A 32 (18.6%) 7 (14.0%) 16 (27.6%) 9 (14.1%) Do you know the documents necessary to carry out an AD 0.292 172 Yes 79 (45.9%) 21 (42.0%) 25 (43.1%) 33 (51.6%) No 6 (3.49%) 0 (0.00%) 4 (6.90%) 2 (3.12%) N/A 87 (50.6%) 29 (58.0%) 29 (50.0%) 29 (45.3%) Registration of the AD can only be made in person by the 0.600 172 holder Yes 66 (38.4%) 18 (36.0%) 20 (34.5%) 28 (43.8%) No 50 (29.1%) 16 (32.0%) 15 (25.9%) 19 (29.7%) N/A 56 (32.6%) 16 (32.0%) 23 (39.7%) 17 (26.6%) At present, ADs containing, exceptionally, elements con‑ 0.534 172 trary to the legislation in force are accepted Yes 16 (9.30%) 3 (6.00%) 4 (6.90%) 9 (14.1%) No 50 (29.1%) 16 (32.0%) 15 (25.9%) 19 (29.7%) N/A 106 (61.6%) 31 (62.0%) 39 (67.2%) 36 (56.2%) Knows who is entitled to access the content of Ads 0.009 172 Yes 36 (20.9%) 7 (14.0%) 8 (13.8%) 21 (32.8%) No 76 (44.2%) 26 (52.0%) 22 (37.9%) 28 (43.8%) N/A 60 (34.9%) 17 (34.0%) 28 (48.3%) 15 (23.4%) In his/her usual practice, has consulted the AD register 0.009 172 Yes 55 (32.0%) 9 (18.0%) 17 (29.3%) 29 (45.3%) No 111 (64.5%) 37 (74.0%) 40 (69.0%) 34 (53.1%) N/A 6 (3.49%) 4 (8.00%) 1 (1.72%) 1 (1.56%) The professional has an obligation to provide information 0.276 172 on AD Yes 99 (57.6%) 23 (46.0%) 34 (58.6%) 42 (65.6%) No 13 (7.56%) 4 (8.00%) 4 (6.90%) 5 (7.81%) N/A 60 (34.9%) 23 (46.0%) 20 (34.5%) 17 (26.6%) AD consultation is part of his or her regular practice 0.002 172 Yes 26 (15.1%) 4 (8.00%) 3 (5.17%) 19 (29.7%) No 127 (73.8%) 41 (82.0%) 47 (81.0%) 39 (60.9%) N/A 19 (11.0%) 5 (10.0%) 8 (13.8%) 6 (9.38%) Health professionals should always consult the AD 0.229 172 Yes 31 (18.0%) 6 (12.0%) 9 (15.5%) 16 (25.0%) No 95 (55.2%) 27 (54.0%) 32 (55.2%) 36 (56.2%) N/A 46 (26.7%) 17 (34.0%) 17 (29.3%) 12 (18.8%) You think you have enough information about AD 0.508 172 Yes 7 (4.07%) 1 (2.00%) 2 (3.45%) 4 (6.25%) No 158 (91.9%) 47 (94.0%) 52 (89.7%) 59 (92.2%) N/A 7 (4.07%) 2 (4.00%) 4 (6.90%) 1 (1.56%) Knows where an AD is consulted 0.052 172 Yes 46 (26.7%) 11 (22.0%) 11 (19.0%) 24 (37.5%) No 111 (64.5%) 36 (72.0%) 38 (65.5%) 37 (57.8%) N/A 15 (8.72%) 3 (6.00%) 9 (15.5%) 3 (4.69%) Knows the documentation to be provided to register an AD 0.001 172 Yes 31 (18.0%) 3 (6.00%) 7 (12.1%) 21 (32.8%) No 127 (73.8%) 43 (86.0%) 43 (74.1%) 41 (64.1%) N/A 14 (8.14%) 4 (8.00%) 8 (13.8%) 2 (3.12%) Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 9 of 15 Table 2 (continued) [ALL] Unfavourable Intermediate Favourable p. overall N attitude towards attitude towards attitude AD AD towards AD N = 172 N = 50 (29.1%) N = 58 (33.7%) N = 64 (37.2%) The AD is legally valid even if it is not registered 0.064 172 Yes 52 (30.2%) 14 (28.0%) 14 (24.1%) 24 (37.5%) No 34 (19.8%) 11 (22.0%) 7 (12.1%) 16 (25.0%) N/A 86 (50.0%) 25 (50.0%) 37 (63.8%) 24 (37.5%) Find out where you have to go to register an AD 0.440 172 Yes 36 (20.9%) 7 (14.0%) 12 (20.7%) 17 (26.6%) No 113 (65.7%) 34 (68.0%) 38 (65.5%) 41 (64.1%) N/A 23 (13.4%) 9 (18.0%) 8 (13.8%) 6 (9.38%) Will only the AD registered in your Autonomous Commu‑ 0.095 172 nity be valid? Yes 22 (12.8%) 5 (10.0%) 5 (8.62%) 12 (18.8%) No 50 (29.1%) 14 (28.0%) 13 (22.4%) 23 (35.9%) N/A 100 (58.1%) 31 (62.0%) 40 (69.0%) 29 (45.3%) Can a person admitted to hospital register his or her AD? 0.168 172 Yes 124 (72.1%) 31 (62.0%) 44 (75.9%) 49 (76.6%) No 1 (0.58%) 0 (0.00%) 0 (0.00%) 1 (1.56%) N/A 47 (27.3%) 19 (38.0%) 14 (24.1%) 14 (21.9%) The appointment to register AD can only be requested 0.033 171 through the app Salud Responde (Health Responds) Yes 52 (30.4%) 13 (26.5%) 15 (25.9%) 24 (37.5%) No 31 (18.1%) 4 (8.16%) 11 (19.0%) 16 (25.0%) N/A 88 (51.5%) 32 (65.3%) 32 (55.2%) 24 (37.5%) Is the existence of a representative mandatory for ADs? 0.009 172 Yes 85 (49.4%) 17 (34.0%) 26 (44.8%) 42 (65.6%) No 15(8.72%) 4 (8.00%) 7 (12.1%) 4 (6.25%) N/A 72 (41.9%) 29 (58.0%) 25 (43.1%) 18 (28.1%) Only physicians are authorised to consult the AD register? 0.474 172 Yes 72 (41.9%) 20 (40.0%) 20 (34.5%) 32 (50.0%) No 4 (2.33%) 1 (2.00%) 2 (3.45%) 1 (1.56%) N/A 96 (55.8%) 29 (58.0%) 36 (62.1%) 31 (48.4%) Are there other groups in addition to physicians who are 0.242 172 authorised to consult the register? Yes 50 (29.1%) 14 (28.0%) 13 (22.4%) 23 (35.9%) No 36 (20.9%) 8 (16.0%) 12 (20.7%) 16 (25.0%) N/A 86 (50.0%) 28 (56.0%) 33 (56.9%) 25 (39.1%) Do you know who can consult the AD once it has been 0.474 172 entered in the Register? Yes 30 (17.4%) 8 (16.0%) 7 (12.1%) 15 (23.4%) No 57 (33.1%) 16 (32.0%) 19 (32.8%) 22 (34.4%) N/A 85 (49.4%) 26 (52.0%) 32 (55.2%) 27 (42.2%) professionals [13], the lack of knowledge of professionals making decisions in accordance with the wishes and pref- can act as a barrier and make it difficult to routinely con- erences of individuals and as a fundamental tool to miti- sult ADs in the emergency services. This further empha- gate potential ethical and legal conflicts arising from the sises the need to make efforts to raise awareness among practice of care in these situations. emergency professionals of the importance of know- A noteworthy finding of the present study is the asso- ing and consulting patients’ ADs as a central element in ciation between the level of knowledge that nursing Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 10 of 15 Table 3 Relationship between the levels of knowledge and attitudes in complex scenarios (ACS) [ALL] Unfavourable Intermediate Favourable p. overall N attitude towards attitude towards attitude AD AD towards AD N = 172 N = 59 (34.3%) N = 39 (22.7%) N = 74 (43%) Can the declaration of AD replace Informed Consent? 0.359 171 Yes 40 (23.4%) 12 (20.3%) 9 (23.7%) 19 (25.7%) No 91 (53.2%) 28 (47.5%) 23 (60.5%) 40 (54.1%) N/A 40 (23.4%) 19 (32.2%) 6 (15.8%) 15 (20.3%) Is one of the aims of Law 2/2010 (Spain) to ensure the 0.678 171 autonomy of patients and respect for their will in the dying process, only when there is a living will? Yes 37 (21.6%) 9 (15.3%) 9 (23.7%) 19 (25.7%) No 71 (41.5%) 26 (44.1%) 15 (39.5%) 30 (40.5%) N/A 63 (36.8%) 24 (40.7%) 14 (36.8%) 25 (33.8%) Can persons with a judicial resolution of incapacity register 0.057 170 a Living Will if it does not specify this in the resolution? Yes 40 (23.5%) 13 (22.0%) 8 (21.6%) 19 (25.7%) No 56 (32.9%) 15 (25.4%) 9 (24.3%) 32 (43.2%) N/A 74 (43.5%) 31 (52.5%) 20 (54.1%) 23 (31.1%) Are Living Wills valid throughout Spain? 0.006 172 Yes 124 (72.1%) 35 (59.3%) 26 (66.7%) 63 (85.1%) No 8 (4.65%) 3 (5.08%) 2 (5.13%) 3 (4.05%) N/A 40 (23.3%) 21 (35.6%) 11 (28.2%) 8 (10.8%) Are health professionals in Catalonia obliged to inform 0.348 172 about AD? Yes 72 (41.9%) 20 (33.9%) 16 (41.0%) 36 (48.6%) No 33 (19.2%) 12 (20.3%) 10 (25.6%) 11 (14.9%) N/A 67 (39.0%) 27 (45.8%) 13 (33.3%) 27 (36.5%) Can the representative appointed in the living will have his 0.710 172 or her functions limited by the person granting the living will whom he or she represents? Yes 87 (50.6%) 27 (45.8%) 18 (46.2%) 42 (56.8%) No 23 (13.4%) 9 (15.3%) 5 (12.8%) 9 (12.2%) N/A 62 (36.0%) 23 (39.0%) 16 (41.0%) 23 (31.1%) The living will must always be taken into account, regardless 0.099 172 of the patient’s state of consciousness Yes 121 (70.3%) 39 (66.1%) 25 (64.1%) 57 (77.0%) No 37 (21.5%) 11 (18.6%) 12 (30.8%) 14 (18.9%) N/A 14 (8.14%) 9 (15.3%) 2 (5.13%) 3 (4.05%) In the case of deceased persons, does only their legal repre‑ 0.414 172 sentative have access to the declaration of a living will? Yes 37 (21.5%) 12 (20.3%) 11 (28.2%) 14 (18.9%) No 64 (37.2%) 20 (33.9%) 11 (28.2%) 33 (44.6%) N/A 71 (41.3%) 27 (45.8%) 17 (43.6%) 27 (36.5%) Do you understand the meaning of limitation of therapeutic 0.762 172 effort? Yes 156 (90.7%) 55 (93.2%) 36 (92.3%) 65 (87.8%) No 7 (4.07%) 1 (1.69%) 1 (2.56%) 5 (6.76%) N/A 9 (5.23%) 3 (5.08%) 2 (5.13%) 4 (5.41%) Learn about the meaning and usefulness of the ACP 0.487 172 Yes 74 (43.0%) 25 (42.4%) 16 (41.0%) 33 (44.6%) No 66 (38.4%) 21 (35.6%) 19 (48.7%) 26 (35.1%) N/A 32 (18.6%) 13 (22.0%) 4 (10.3%) 15 (20.3%) Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 11 of 15 Table 3 (continued) [ALL] Unfavourable Intermediate Favourable p. overall N attitude towards attitude towards attitude AD AD towards AD N = 172 N = 59 (34.3%) N = 39 (22.7%) N = 74 (43%) Knows the documents necessary to carry out an AD 0.367 172 Yes 79 (45.9%) 24 (40.7%) 17 (43.6%) 38 (51.4%) No 6 (3.49%) 4 (6.78%) 0 (0.00%) 2 (2.70%) N/A 87 (50.6%) 31 (52.5%) 22 (56.4%) 34 (45.9%) The registration of the AD can only be made in person by 0.823 172 the holder Yes 66 (38.4%) 24 (40.7%) 13 (33.3%) 29 (39.2%) No 49 (28.5%) 16 (27.1%) 14 (35.9%) 19 (25.7%) N/A 57 (33.1%) 19 (32.2%) 12 (30.8%) 26 (35.1%) At present, ADs containing, exceptionally, elements contrary 0.716 172 to the legislation in force are accepted Yes 16 (9.30%) 5 (8.47%) 3 (7.69%) 8 (10.8%) No 51 (29.7%) 17 (28.8%) 15 (38.5%) 19 (25.7%) N/A 105 (61.0%) 37 (62.7%) 21 (53.8%) 47 (63.5%) Knows who is entitled to access the content of Ads 0.679 172 Yes 36 (20.9%) 9 (15.3%) 10 (25.6%) 17 (23.0%) No 77 (44.8%) 28 (47.5%) 18 (46.2%) 31 (41.9%) N/A 59 (34.3%) 22 (37.3%) 11 (28.2%) 26 (35.1%) In his/her usual practice, he or she has consulted the AD 0.052 172 register Yes 55 (32.0%) 14 (23.7%) 15 (38.5%) 26 (35.1%) No 111 (64.5%) 40 (67.8%) 23 (59.0%) 48 (64.9%) N/A 6 (3.49%) 5 (8.47%) 1 (2.56%) 0 (0.00%) The professional has an obligation to provide information 0.193 172 on AD Yes 98 (57.0%) 27 (45.8%) 26 (66.7%) 45 (60.8%) No 14 (8.14%) 8 (13.6%) 2 (5.13%) 4 (5.41%) N/A 60 (34.9%) 24 (40.7%) 11 (28.2%) 25 (33.8%) AD consultation is part of his or her regular practice 0.369 172 Yes 26 (15.1%) 8 (13.6%) 4 (10.3%) 14 (18.9%) No 127 (73.8%) 41 (69.5%) 32 (82.1%) 54 (73.0%) N/A 19 (11.0%) 10 (16.9%) 3 (7.69%) 6 (8.11%) Health professionals should always consult the AD 0.295 172 Yes 31 (18.0%) 11 (18.6%) 9 (23.1%) 11 (14.9%) No 94 (54.7%) 28 (47.5%) 24 (61.5%) 42 (56.8%) N/A 47 (27.3%) 20 (33.9%) 6 (15.4%) 21 (28.4%) You think you have enough information about AD 0.430 172 Yes 7 (4.07%) 2 (3.39%) 2 (5.13%) 3 (4.05%) No 157 (91.3%) 52 (88.1%) 37 (94.9%) 68 (91.9%) N/A 8 (4.65%) 5 (8.47%) 0 (0.00%) 3 (4.05%) Knows where an AD is consulted 0.680 172 Yes 46 (26.7%) 13 (22.0%) 13 (33.3%) 20 (27.0%) No 111 (64.5%) 39 (66.1%) 24 (61.5%) 48 (64.9%) N/A 15 (8.72%) 7 (11.9%) 2 (5.13%) 6 (8.11%) Knows the documentation to be provided to register an AD 0.065 172 Yes 31 (18.0%) 6 (10.2%) 6 (15.4%) 19 (25.7%) No 127 (73.8%) 45 (76.3%) 32 (82.1%) 50 (67.6%) N/A 14 (8.14%) 8 (13.6%) 1 (2.56%) 5 (6.76%) Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 12 of 15 Table 3 (continued) [ALL] Unfavourable Intermediate Favourable p. overall N attitude towards attitude towards attitude AD AD towards AD N = 172 N = 59 (34.3%) N = 39 (22.7%) N = 74 (43%) The AD is legally valid even if it is not registered 0.557 172 Yes 52 (30.2%) 17 (28.8%) 10 (25.6%) 25 (33.8%) No 34 (19.8%) 15 (25.4%) 6 (15.4%) 13 (17.6%) N/A 86 (50.0%) 27 (45.8%) 23 (59.0%) 36 (48.6%) Find out where you have to go to register an AD 0.061 172 Yes 36 (20.9%) 8 (13.6%) 11 (28.2%) 17 (23.0%) No 112 (65.1%) 37 (62.7%) 25 (64.1%) 50 (67.6%) N/A 24 (14.0%) 14 (23.7%) 3 (7.69%) 7 (9.46%) Will only the AD registered in your Autonomous Commu‑ 0.951 172 nity be valid? Yes 22 (12.8%) 7 (11.9%) 5 (12.8%) 10 (13.5%) No 51 (29.7%) 16 (27.1%) 11 (28.2%) 24 (32.4%) N/A 99 (57.6%) 36 (61.0%) 23 (59.0%) 40 (54.1%) Can a person admitted to hospital register his or her ADs? 0.001 172 Yes 124 (72.1%) 35 (59.3%) 25 (64.1%) 64 (86.5%) No 1 (0.58%) 1 (1.69%) 0 (0.00%) 0 (0.00%) N/A 47 (27.3%) 23 (39.0%) 14 (35.9%) 10 (13.5%) The appointment to register AD can only be requested 0.011 171 through the app Salud Responde (Health Responds) Yes 52 (30.4%) 14 (24.1%) 16 (41.0%) 22 (29.7%) No 31 (18.1%) 7 (12.1%) 3 (7.69%) 21 (28.4%) N/A 88 (51.5%) 37 (63.8%) 20 (51.3%) 31 (41.9%) Is the existence of a representative mandatory for ADs? 0.480 172 Yes 85 (49.4%) 25 (42.4%) 20 (51.3%) 40 (54.1%) No 15 (8.72%) 4 (6.78%) 3 (7.69%) 8 (10.8%) N/A 72 (41.9%) 30 (50.8%) 16 (41.0%) 26 (35.1%) Only physicians are authorised to consult the AD register? 0.374 172 Yes 72 (41.9%) 21 (35.6%) 15 (38.5%) 36 (48.6%) No 4 (2.33%) 1 (1.69%) 2 (5.13%) 1 (1.35%) N/A 96 (55.8%) 37 (62.7%) 22 (56.4%) 37 (50.0%) Are there other groups in addition to physicians who are 0.115 172 authorised to consult the register? Yes 49 (28.5%) 13 (22.0%) 16 (41.0%) 20 (27.0%) No 36 (20.9%) 12 (20.3%) 4 (10.3%) 20 (27.0%) N/A 87 (50.6%) 34 (57.6%) 19 (48.7%) 34 (45.9%) Do you know who can consult the AD once it has been 0.161 172 entered in the Register? Yes 29 (16.9%) 5 (8.47%) 10 (25.6%) 14 (18.9%) No 57 (33.1%) 19 (32.2%) 11 (28.2%) 27 (36.5%) N/A 86 (50.0%) 35 (59.3%) 18 (46.2%) 33 (44.6%) and medical professionals have regarding AD and the them as a routine consultation in these departments. A scores obtained on the APA and ACS scales. This result study conducted in Germany with emergency physicians indicates that the more knowledgeable professionals revealed that the therapeutic decisions of the profession- are about AD, the more inclined they are to consult the als were influenced by the existence of ADs in 77% of AD of patients and respect their wishes and preferences the cases [29]. In this way, professionals’ consultation of regarding care and/or treatment and, therefore, apply patient ADs could be determined by the knowledge they Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 13 of 15 Table 4 Sociodemographic factors that affect attitudes towards AD in its practical application (APA) Intermediate attitude p value Favourable attitude towards p value towards AD AD OR (95% CI) OR (95% CI) Intercept 0.15 (0.01; 2.09) 0.158 0.08 (0.01; 1.21) 0.069 Sex: Woman 1.09 (0.43; 2.81) 0.852 1.47 (0.56; 3.81) 0.433 Age 1.06 (0.98; 1.14) 0.151 1.05 (0.97; 1.13) 0.238 Discipline: Medicine 0.86 (0.33; 2.25) 0.759 1.34 (0.52; 3.42) 0.547 Years of experience: 6–10 0.6 (0.19; 1.85) 0.371 0.95 (0.29; 3.14) 0.932 Years of experience: 11–15 0.77 (0.19; 3.13) 0.715 0.93 (0.21; 4.19) 0.928 Years of experience: + 15 0.73 (0.13; 4.02) 0.713 1.74 (0.3; 10) 0.535 Service: Emergency medical service 1.5 (0.63; 3.59) 0.357 2.49 (1.06; 5.88) 0.037 AD advance directives, CI confidence interval Table 5 Sociodemographic factors that affect attitudes towards AD in complex scenarios (ACS) Intermediate attitude p value Favourable attitude towards p value towards AD AD OR (95% CI) OR (95% CI) Intercept 0.31 (0.02; 5.3) 0.417 0.11 (0.01; 1.43) 0.092 Sex: Woman 1.2 (0.44; 3.3) 0.726 1.34 (0.55; 3.26) 0.516 Age 1.02 (0.94; 1.1) 0.716 1.04 (0.97; 1.12) 0.272 Discipline: Medicine 0.93 (0.35; 2.48) 0.883 0.57 (0.24; 1.37) 0.208 Years of experience: 6–10 0.5 (0.14; 1.72) 0.272 0.63 (0.2; 2.01) 0.433 Years of experience: 11–15 1.36 (0.27; 6.94) 0.71 1.46 (0.32; 6.68) 0.622 Years of experience: + 15 0.48 (0.07; 3.05) 0.436 0.69 (0.13; 3.55) 0.659 Service: Emergency medical service 1.58 (0.61; 4.09) 0.341 3.65 (1.58; 8.41) 0.002 Afternoon shift 1.78 (0.51; 6.16) 0.364 3.3 (1.1; 9.84) 0.032 Night shift 1.88 (0.73; 4.85) 0.193 2 (0.86; 4.68) 0.11 AD advance directives, CI confidence interval have about AD. However, the lack of knowledge could their daily practice and in complex situations. Firstly, the represent greater variability of response to the same sce- fact that the professionals who worked in the emergency nario at the clinical level, especially in a vital risk situa- service had more favourable attitudes towards patient tion that entails urgent action [26–28]. This variability ADs than those professionals of the emergency depart- in the decision-making process could represent a risk of ment is a new piece of information. Perhaps the fact of patient rights’ protection, especially with regard to their caring for patients in critical situations or at the end of autonomy in choosing the treatments or interventions life is a key element to explain the interest or a favourable according to their preferences [29–31]. attitude towards AD. On the other hand, it should be noted that no relation- Secondly, the nurses and physicians on the evening ship was observed between the age and experience of the and night shifts of the emergency medical services and professionals with attitudes at the time of practical appli- the emergency departments were the ones most willing cation (APA) or at in complex scenarios (ACS). These to respect the ADs of the persons attended in a complex results are in disagreement with other reports, which situation involving a vital risk to the person, as would be indicated that older professionals and those with greater the case of cardio-respiratory arrest. This result may be experience in the service being the ones who were more explained by the lack of time and the heavy workloads to compliant with the ADs of the patients they attended [28, which the professionals working the morning shift are 32]. subjected, which may be a clear obstacle to respecting There are two important findings that have not been the wishes and preferences of the person in a situation of presented in previous studies and which are directly incapacity to make decisions [13, 22, 28, 32]. This could related to the attitudes of professionals towards ADs in also be explained by the fact that in the evening and night Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 14 of 15 shifts there are fewer professionals to consult, so that departments and emergency medical services. To this professionals working in these shifts may find the ADs end, it is necessary firstly to train and sensitize nurses helpful to guide decision-making in difficult situations. and physicians in the emergency departments with In this line, further studies should examine this find- new training programs that promote the acquisition of ing more deeply and with larger samples in order to knowledge on the management of advance directives in determine which factors make professionals of emer- a practical and experiential way. Secondly, it is crucial gency medical services more likely to consult and respect that both organisations and institutions become aware of patient ADs and which ones hinder morning shift profes- the importance of improving AD consultation processes sionals in respecting people’s wishes and preferences. in order to increase the quality of care, reduce conflicts Finally, the results show that those working the even- in these services, and respond appropriately to patients’ ing and night shift, and those who worked in the emer- needs and expectations. gency medical services, were more likely to consult and respect patient ADs. These variables must be taken into Abbreviations account when designing strategies to improve AD man- AD: Advance directives; APA: Attitudes of health professionals at the time agement in intra-hospital and extra-hospital emergency of practical application; ACS: Attitudes of health professionals at the time of services. Undoubtedly, this can contribute to improving practical application in complex scenarios. the care and clinical attention of patients and to respect Acknowledgements for patient autonomy. The authors are grateful to all nursing and medical professionals who selflessly participated in the present study. Limitations Authors’ contributions Among the limitations of the present study we should SPM and AFP planned the study. PJM, PSV, NPQ and MVG conducted a survey. note that the sample size was moderate, although it SPM and AFP analysed the data. All research members actively participated in the drafting of the article. SPM submitted the study. All authors read and exceeded those of other similar studies [26, 29]. Also, it approved the final manuscript. is worth mentioning the heterogeneous representative- ness of the two groups, since the highest response rate Funding This study was funded by Víctor Grífols i Lucas Fundation (reference number: was obtained in nursing. However, the proportion of the BEC-2018-009) through a 2018 Bioethics research grant. The responsibility for two professional groups was certainly not the same in the this research lies exclusively with the authors who have carried out the study clinical setting. For this reason, only the trend followed with total independence from the funder. by the professionals’ responses was shown in the presen- Availability of data and materials tation of the results by professional category. The results The data used and/or analyzed during the current study are available from the by sex were not compared either, since the highest par- corresponding author on reasonable request. ticipation in the study was that of women, an issue that should be taken into account if an analysis of the results Declarations is to be carried out in terms of sex. Finally, it is worth Ethics approval and consent to participate mentioning that we obtained a minimal proportion of The present study was approved by the respective ethics committees of losses for some variables in the questionnaire, and this Ethical Commitee of Clínic Hospital (Barcelona) and comittee of Emergency Medical Services (Barcelona), with reference number HCB/2020/0158. may have influenced the interpretation of the results. Authorisation was obtained from the nursing and medical directorates of both institutions. The guidelines of the Declaration of Helsinki relating to Implications for clinical practice ethical principles in clinical research were followed. The authors of the original questionnaire authorised its administration in the present study. With respect Systematic consultation of patients’ ADs in emergency to the participants, they received oral and written information concerning the departments and emergency medical services would, study and the voluntary nature of their participation. To ensure confidentiality, firstly, make it possible to adjust treatments and inter- the information collected was registered in a database anonymously, using numbers (P1/G1, P2/G2, etc.) instead of the names of the participants. ventions to patients’ wishes and preferences, thus favour- ing person-centred care. Secondly, it would improve Consent for publication decision-making by professionals in complex and rapid Not applicable. response situations and, thirdly, it would reduce conflict Competing interests situations with patients and relatives that arise from not The author(s) declared no potential conflicts of interest with respect to the knowing the advance directives. research, authorship and/or publication of this article. Author details Conclusion 1 School of Nursing, Faculty of Medicine and Health Sciences, University These results highlight the need to redefine and iden- of Barcelona, Barcelona, Spain. 2 Escola Universitària D’Infermeria I Teràpia Ocupacional de Terrassa (EUIT), Universitat Autònoma de Barcelona, Calle de tify new frameworks of action to help implement rou- La Riba, 90, 08221 Terrassa, Barcelona, Catalonia, Spain. 3 Fundación Sani‑ tine consultation of advance directives in emergency taria de Mollet, Mollet del Vallés, Spain. 4 Coordinador Territorial Servicio de Poveda‑Moral et al. BMC Med Ethics (2021) 22:75 Page 15 of 15 Emergencias Médicas, Generalitat de Catalunya, Barcelona, Catalonia, Spain. 17. Denniss DL. Legal and ethical issues associated with Advance Care Direc‑ 5 School of Nursing. Faculty of Medicine and Health Sciences. Consolidated tives in an Australian context. Intern Med J. 2016;46(12):1375–80. 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