Table 4

Exemplars illustrating the interplay between perceived susceptibility and empowerment in advance directive form completion

Patient exemplarsPerceived susceptibilityEmpowermentImplications for practice*
Case 1: terminally ill, frail elderly woman, living in her own home with community care. High reliance on family for social and practical support.
“Well, they oughtn't try to resuscitate me. Because, ah, it'd be coming back to a lot more pain and a lot more suffering… but, ah, my family isn't very happy about that… So where it'll finish up I have no idea.”
++++Provide practical assistance
(eg, book interpreter, make appointments, home visit, provide forms and written information)
Facilitate emotional support
(eg, family meeting with doctor, goal setting within family context, plan longer appointments)
Case 2: independent-minded 80-year old man with no acute medical illnesses. Supportive sons living locally.
“I just go on in life and do what I want to do.”
++++Prompting by doctor
(eg, discuss complications and prognosis of illness, brief prompt as part of consultation)
Scheduled opportunities for reflection (eg, post-hospital admission, change in treatment, new diagnosis, death of family member)
Case 3: recently retired professional, with a past history of cancer, reflecting on the end-of-life care received by his mother.
“I am conscious that things really need to be put in some order and this was just… another document, that helped tie up everything together.”
++++Balancing point
This is an opportunity to reinforce perceived susceptibility triggers (eg, listen and validate concerns, provide concrete information about illness trajectories and possible treatment options) and promote empowerment (eg, probe for specific goals and wishes, provide guidance on appropriate wording, witness signature, disseminate and store copies)
  • *The suggested implications for practice list a broad set of strategies that may be relevant to patients with a similar interplay.