# Fréquence de rédaction de directives anticipées chez les patients hospitalisés en Martinique

Nadine Simo, Pauline Sesini, Salvatore Metanmo, Joel Raffin, Seendy

Bartholet, Michel Bonnet, Maturin Tabue Teguo, Moustapha Drame

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Nadine Simo, Pauline Sesini, Salvatore Metanmo, Joel Raffin, Seendy Bartholet, et al. Fréquence de rédaction de directives anticipées chez les patients hospitalisés en Martinique. Médecine Palliative, 2026, 10.1016/j.medpal.2026.01.002. hal-05512448

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ORIGINAL ARTICLE

# Frequency of writing advance directives among hospitalized patients in Martinique

## Fréquence de rédaction de directives anticipées chez les patients hospitalisés en Martinique

Nadine Simo<sup>a,*</sup>, Pauline Sesini<sup>b</sup>, Salvatore Metanmo<sup>d</sup>, Joel Raffin<sup>c</sup>, Seendy Bartholet<sup>c</sup>, Michel Bonnet<sup>c</sup>, Maturin Tabue Teguo<sup>e</sup>, Moustapha Drame<sup>f</sup>

Reçu le 25 septembre 2025 ; reçu sous la forme révisée le 16 décembre 2025 ; accepté le 2 janvier 2026

KEYWORDS

Advance directives ;
End-of-life ;
Martinique ;
General practitioner ;
Palliative care ;
Sociodemographic
factors

Abstract

Background. — There is a paucity of data regarding the frequency of advance directives (AD) in Martinique. Yet, the population of Martinique is aging, with high rates of socioeconomic disadvantage, a traditional family model and one of the highest death rates worldwide, resulting in quite particular end-of-life conditions.

Aim. — We aimed to describe the frequency of AD preparation among patients hospitalized in the University Hospital of Martinique, (hospitalization in medical, surgical and home hospitalization departments). The secondary objectives were to identify the sociodemographic and health factors associated with advance directives, as well as to explore the barriers and levers promoting their drafting.

Adresse e-mail : nadine.tabue@yahoo.fr (N. Simo).

https://doi.org/10.1016/j.medpal.2026.01.002

1636-6522/© 2026 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

<footnote><sup>a</sup> Department of Geriatrics, University of the French West Indies, EpiCliV Research Unit, University Hospital of Martinique, Martinique, France</footnote>

<footnote><sup>b</sup> University Hospitals of Martinique, Martinique, France</footnote>

<footnote><sup>c</sup> Department of Geriatrics, University Hospitals of Martinique, Martinique, France</footnote>

<footnote><sup>d</sup> Department of Clinical Research and Innovation-CS 90632, University Hospitals of Martinique-Pierre Zobda-Quitman Hospital, Fort-de-France, 97261 Martinique, France</footnote>

<footnote><sup>e</sup> Inserm 1219, Bordeaux Population Health Research Center, University of Bordeaux, Bordeaux, France</footnote>

<footnote><sup>f</sup> Department of Clinical Research and Innovation, Fort-de-France, University of the French West Indies, EpiCliV Research Unit, University Hospital of Martinique, Martinique, France</footnote>

<footnote>* Corresponding author.</footnote>
**Methods.** — In a cross-sectional study, we recorded data from June to September 2024 using a paper-based questionnaire among 227 patients hospitalized in Martinique University Hospital (medicine, surgery) and at home. Descriptive analysis was performed. Analysis was performed using R software, version 4.4.1. Responses were all categorized and are described as number and percentage for each response option.

**Results.** — Overall, 6.6% of hospitalized patients had AD. Among patients who had not written advance directives, 65% knew that there was legislation on end-of-life, but only 19% knew about advance directives. The main obstacles to AD preparation were lack of knowledge of AD (46.2%), and a refusal to think about one's end-of-life (25.8%). The main reasons motivating patients to prepare AD was to ensure their wishes were respected (86.7%). After the questionnaire has been completed, around 40% of patients said they would write AD later, mainly in order to ensure their wishes were respected at the end-of-life. The family seems to play a key role in end-of-life decisions. Patients prefer to talk to their loved ones about the end-of-life rather than to doctors.

**Conclusion.** — Given the very low frequency of AD in the Martinique population, there is clearly a pressing need to integrate AD into the medical and social paradigm.

© 2026 The Authors. Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

## MOTS CLÉS

- Directives anticipées ;
- Fin de vie ;
- Martinique ;
- Médecin généraliste ;
- Soins palliatifs ;
- Facteurs sociodémographiques

## Résumé

**Contexte.** — Il existe peu de données concernant la fréquence des directives anticipées (DA) en Martinique. Or, la population martiniquaise vieillit, présente des taux élevés de précarité socio-économique, un modèle familial traditionnel et l'un des taux de mortalité les plus élevés au monde, ce qui se traduit par des conditions de fin de vie assez particulières.

**Objectif.** — Nous avons cherché à décrire la fréquence de la préparation des DA chez les patients hospitalisés à l'hôpital universitaire de Martinique (hospitalisation dans les services de médecine, de chirurgie et d'hospitalisation à domicile). Les objectifs secondaires étaient d'identifier les facteurs sociodémographiques et de santé associés aux directives anticipées, ainsi que d'explorer les freins et les leviers favorisant leur rédaction.

**Méthodes.** — Dans le cadre d'une étude transversale, nous avons recueilli des données entre juin et septembre 2024 à l'aide d'un questionnaire papier auprès de 227 patients hospitalisés à l'hôpital universitaire de Martinique (médecine, chirurgie) et à domicile. Une analyse descriptive a été réalisée. L'analyse a été effectuée à l'aide du logiciel R, version 4.4.1. Les réponses ont toutes été classées et sont décrites en nombre et en pourcentage pour chaque option de réponse.

**Résultats.** — Dans l'ensemble, 6,6 % des patients hospitalisés avaient rédigé des directives anticipées. Parmi les patients n'ayant pas rédigé les directives anticipées, 65 % savaient qu'il existait une législation sur la fin de vie, mais seulement 19 % connaissaient les directives anticipées. Les principaux obstacles à la rédaction de directives anticipées étaient le manque de connaissances à ce sujet (46,2 %) et le refus de penser à sa propre fin de vie (25,8 %). La principale raison qui motivait les patients à préparer des directives anticipées était de s'assurer que leurs souhaits seraient respectés (86,7 %). Après avoir rempli le questionnaire, environ 40 % des patients ont déclaré qu'ils rédigerait des directives anticipées ultérieurement, principalement afin de s'assurer que leurs souhaits seraient respectés en fin de vie. La famille semble jouer un rôle clé dans les décisions de fin de vie. Les patients préfèrent parler de la fin de vie avec leurs proches plutôt qu'avec les médecins.

**Conclusion.** — Compte tenu de la très faible fréquence des directives anticipées dans la population martiniquaise, il existe clairement un besoin urgent d'intégrer les directives anticipées dans le paradigme médical et social.

© 2026 Les Auteurs. Published by Elsevier Masson SAS. Cet article est publié en Open Access sous licence CC BY (http://creativecommons.org/licenses/by/4.0/).
Introduction

Obtaining informed consent from the patient is mandatory
before any medical decisions can be made, be it for cura-
tive or palliative care [1,2]. In order to make provisions
for situations where patients no longer have the capacity
to express their wishes regarding their care, the legisla-
tion in many countries offers the possibility for patients
to prepare advance directives (AD). AD are a document in
which patients may consign, in written form, their wishes
regarding medical decisions for their end-of-life, in case,
in the future, they temporarily or permanently lose capa-
city to communicate or express their preferences [3,4].
In the United States, AD often take the form of a "'living
will'" or power of attorney for healthcare, and make it pos-
sible for patients to avoid unwanted care procedures in
case of severe diseases or loss of capacity [3,5]. AD have
been at the heart of ethics debates in several European
countries in recent decades, notably in relation to end-
of-life situations such as euthanasia and assisted suicide
[6]. It is a subject fraught with challenging and complex
public health, ethical, and legal questions, particularly
when it comes to aligning medical practice and patients'
wishes.

A systematic review published in 2024 [7] brought toge-
ther data from various countries reporting rates of existence
and availability of AD in emergency departments, as well as
the factors influencing the rate of use of AD. In total, 22
studies were included, the majority from the United States
(n = 12), followed by Australia (n = 4), Canada (n = 2), South
Korea, Germany, United Kingdom and Switzerland (1 study
each). The frequency of AD ranged from 19.9 to 27.8% among
adults in general, and from 2.6 to 79% in adults aged over 65
years. The availability of AD differed considerably, ranging
from just 6.8% in adults to 48.8% in those aged over 65%.
A systematic review from 2017 investigating the prevalence
of AD among American adults found an overall prevalence
(of any directive) of 36.7% (ranging from 20.5% for living
wills, to 35.3% for power of attorney for healthcare). This
review suggested that around one in three American adults
completed AD of some sort [5].

AD are not set in stone, but can evolve over time [8].
In France, the legislation underpinning the use of AD was
first introduced in 2005 (the so-called ''Leonetti'' law),
which addressed patients' rights at the end-of-life and
sought to provide a legislative framework for end-of-life
decisions, while prohibiting ''unreasonable therapeutic obs-
tinacy''. This legislation was revised in 2016, in the so-called
''Claeys-Leonetti'' law, and strengthened the scope of AD,
in particular by stipulating that AD be binding for the physi-
cian, except in situations where the patient's life is at stake
or immediate medical intervention is needed [9,10]. A sur-
vey performed in France in 2022 [11], among a sample of
1003 adults over the age of 18 found that only 433 respon-
dents were familiar with the term ''advance directives.''
Of those, 18% had prepared advance directives. The fac-
tors associated with AD preparation in that study were age,
level of information, and personal experience with end-of-
life situations. The same study also revealed that French
people want to have control over the decisions surrounding
their end-of-life, and a vast majority reported that they

were in favour of an accompaniment that respected their
dignity. However, a widespread lack of knowledge about the
procedures involved, and the absence of a clear framework
mean that the application of these dispositions for end-of-
life situations remains limited. For organisational reasons,
the aforementioned study among French adults recruited
only adults living in mainland France, and did not recruit
in France's overseas territories, such as the French West
Indies (FWI). In the FWI, there is marked aging of the popu-
lation, with a higher proportion of adults over 75 years
(15% vs 11% in mainland France) [12]. In 2021, there were
considerably more deaths at home in the FWI (42.9%) com-
pared to mainland France (26.6%) [13,14]. The traditional
family model in the FWI means that there is strong involve-
ment of families in caring for older persons. However, the
rapid aging of the population, combined with social changes,
are jeopardizing this model of care, raising new challenges
for the future management of end-of-life situations in our
region [14,15].

In this context, the main objective of the present study
was to describe the frequency of AD among patients in Marti-
nique, one of the FWI islands. Secondary objectives were to
describe the socio-demographic and health-related factors
associated with the frequency of AD.

Methods

Study population

As part of this initial work, our objective was to take stock
of the issue of advance directives within the hospital envi-
ronment in Martinique. It is for this reason in particular
that we did not choose to target any particular department.
We conducted a descriptive cross-sectional study in medi-
cal departments (endocrinology, gastroenterology, geria-
trics, hematology, infectious diseases, general medicine,
neurology, respiratory medicine, rheumatology, internal
medicine, palliative care), surgical departments (digestive,
gynecological, and orthopedic surgery), and also in the only
home hospitalization unit (HAD) at the University Hospi-
tal of Martinique, as it encourages the drafting of advance
directives because it combines an intimate and secure envi-
ronment for the patient. Sensitive conversations related to
the end-of-life become easier and more accepted. It creates
a calming environment with a strengthened caregiver-
patient relationship, as the patient has time to reflect and
ask questions without pressure. The patient profile is cha-
racterized by advanced or chronic conditions and palliative
situations, which often lead to anticipating end-of-life deci-
sions and clarifying the patient's wishes. HAD creates a
clinical setting that makes it relevant and useful to draw
up advance directives based on patient profiles. Data was
collected from June to September 2024. The departments
in which the interviews were conducted were selected based
on the agreement of the department heads or, failing that,
the physicians concerned. The profile of patients receiving
palliative care in home hospitalisation differs from that of
patients hospitalised in conventional medicine. In addition,
the nature of the home environment allows us to reflect on
patients who have written their advance directives at home.
In Martinique, there is only one home hospitalisation service (managed by a private hospital), which facilitates the representativeness of this type of hospitalisation.

To be eligible to participate, patients had to be aged 18 years or older, and hospitalized in any one of the above-mentioned units. We excluded subjects who did not have a general practitioner (GP) declared to the national health-care system, those who did not have an officially designated surrogate, those who had neurocognitive deficits preventing them from answering the questionnaire, and those who refused to consent. The assessment of the neurocognitive deficit criterion was done by nurses and physicians on the ward at the time of data collection, for those in hospital, and by the designated surrogate for patients in hospital-at-home care.

The questionnaire was administered by a study investigator (SP) in a direct individual interview with each patient (or their surrogate). For patients hospitalized in the University Hospital, the interviews were performed at the patient's bedside. For patients in hospital-at-home, the interviews were performed at the patient's home.

This study was approved by the Thesis Commission of the Department of Primary Care of the University of Antilles-Guyane, and by the Institutional Review Board of Martinique (IRB number 2024/052). The study also received approval from the French National Data Privacy Commission (CNIL), Commission nationale de l'informatique et des libertés). Written informed consent was obtained from all participants after providing information about the study.

All interviews were individual and confidential, and data were rendered anonymous for analysis.

## Data collection

Paper questionnaires were used for all patients. The questionnaire is attached as additional material. The questions asked about socio-demographic and medical characteristics, namely: sex, age, marital status; any children; socio-professional category; highest level of education; perceived health; presence of a chronic disease (i.e., disease entitling to long-term 100% reimbursement by the social security system); presence of palliative care; recent hospital admissions. The patients' opinions about end-of-life, and their knowledge and opinion of AD were also collected. Data were coded and entered into Microsoft Excel by the lead investigator (SP).

## Statistical analysis

The number of subjects required was determined using NQUERY 9.3.3 software (Statistical Solutions Ltd, 2023). For the results of our study to be meaningful, we needed to include a sample of 227 patients. The sample size was calculated taking into account an error risk (α) of less than 5% and a confidence interval of 95%. The prevalence of patients who had written advance directives ranged from 13% to 23%, with an expected prevalence of 18% (value observed in mainland France in 2022).

Analysis was performed using R software, version 4.4.1. Responses were all categorized and are described as number and percentage for each response option. For most questions, more than one option could be chosen. For the purposes of comparisons, patients were grouped according

to the presence or absence of AD, and were compared using the chi square or Fisher's exact test, as appropriate. A P-value < 0.05 was considered statistically significant.

## Results

### Characteristics of the study population

In total, 227 patients completed the questionnaires. The characteristics of the study population are shown in Table 1. Age ranged from 18 to 80 years, 47% were aged > 65 years, and 50% were women (n = 113). The majority of participants (91.6%) were interviewed in the University Hospital of Martinique, while the remaining 8.4% were in hospital-at-home. In response to the question asking "In general, would you say your health is...,", the majority responded "fair" (44.1%) or "poor" (38%).

Overall the frequency of AD was 6.6% (n = 15 patients; 10 were men). All 15 patients with AD were in-hospital; no patient in hospital-at-home had prepared AD.

All 15 patients who had prepared AD had previously thought about their wishes and preferences for end-of-life care. Among those who had not prepared AD, 48% had never thought about end-of-life preferences or wishes. Overall, 65% were aware that end-of-life decisions are governed by law, but only 19% were familiar with AD.

The reported obstacles to AD are illustrated in Fig. 1. The main barriers cited by the respondents who had no AD were a lack of knowledge of AD (46.2%), a refusal to think about end-of-life (25.8%), a feeling that end-of-life matters do not apply to them (20.8%), and the fact that the general practitioner had never raised the issue (23.1%).

Among those who had not prepared AD (n = 212), the factors that would motivate them to prepare them in the future are shown in Fig. 2. The main factors were to ensure respect of end-of-life wishes (40%). We noted that 36% had no particular motivation to prepare AD, 34% would like to avoid the burden of painful decisions falling on their family, 32% oppose unreasonable therapeutic obstinacy, and 16% would prepare AD for fear of pain or suffering at the end-of-life.

Among patients who have written their advance directives, 53.3% prefer to keep their end-of-life wishes and preferences at home and 53.3% in a secure digital database. Only 6.7% wish to entrust them to their primary care physician. Among patients who have not written their advance directives, the preferred location is at home (43.4%), with only 18.4% wishing to keep them in a secure digital database and 14.2% with their primary care physician. The preferred location for storing end-of-life wishes, depending on whether or not advance directives have been written, is shown in Fig. 3.

Among patients who have written their advance directives, 100% have already thought about their wishes and preferences regarding the end-of-life. Almost all of them have discussed this with their loved ones (93.3%), 33.3% with their primary care physician, and 66.7% with another healthcare professional. Among patients who had not written their advance directives, 48.1% had already thought about their wishes and preferences regarding the end-of-life, 33% had discussed it with their loved ones, only 3.8% with their primary care physician, and 1.9% with another healthcare
<table><caption>**Table 1** Socio-demographic characteristics of the study population according to the presence of absence of advance directives.</caption><thead><tr><th>Characteristic</th><th>AD<br>n = 15<sup>a</sup></th><th>No AD<br>n = 212<sup>a</sup></th><th>Overall<br>n = 227<sup>a</sup></th><th>P-value<sup>b</sup></th></tr></thead><tbody><tr><td>Age (years)</td><td></td><td></td><td></td><td>0.6</td></tr><tr><td>18–44 years</td><td>1 (1.4%)</td><td>40 (97.6%)</td><td></td><td></td></tr><tr><td>45–64 years</td><td>5 (6.3%)</td><td>74 (93.6%)</td><td></td><td></td></tr><tr><td>65–79 years</td><td>6 (8.3%)</td><td>66 (91.7%)</td><td></td><td></td></tr><tr><td>80 years and more</td><td>3 (3.3%)</td><td>32 (91.4%)</td><td></td><td></td></tr><tr><td>Sex</td><td></td><td></td><td></td><td>0.2</td></tr><tr><td>Male</td><td>10 (67%)</td><td>104 (49%)</td><td>114 (50%)</td><td></td></tr><tr><td>Female</td><td>5 (33.3%)</td><td>108 (50.9%)</td><td></td><td></td></tr><tr><td>Living alone</td><td>5 (33%)</td><td>115 (54%)</td><td>120 (53%)</td><td>0.12</td></tr><tr><td>Has children</td><td>3 (20%)</td><td>40 (19%)</td><td>43 (19%)</td><td>> 0.9</td></tr><tr><td>Professionally active</td><td>5 (33%)</td><td>91 (43%)</td><td>96 (42%)</td><td>0.5</td></tr><tr><td>Level of education</td><td></td><td></td><td></td><td>0.068</td></tr><tr><td>Less than high school diploma</td><td>6 (40%)</td><td>135 (64%)</td><td>141 (62%)</td><td></td></tr><tr><td>Poor state of health</td><td>8 (53%)</td><td>79 (37%)</td><td>87 (38%)</td><td>0.2</td></tr><tr><td>Department</td><td></td><td></td><td></td><td>0.8</td></tr><tr><td>Surgery</td><td>3 (20%)</td><td>58 (27%)</td><td>61 (27%)</td><td></td></tr><tr><td>Medicine</td><td>12 (80%)</td><td>154 (73%)</td><td>166 (73%)</td><td></td></tr><tr><td>Long-term disease</td><td>13 (87%)</td><td>151 (71%)</td><td>164 (72%)</td><td>0.6</td></tr><tr><td>Previous received palliative care</td><td>3 (20%)</td><td>23 (11%)</td><td>26 (11%)</td><td>0.4</td></tr><tr><td>Ongoing palliative care</td><td>3 (100%)</td><td>21 (91%)</td><td>24 (92%)</td><td>> 0.9</td></tr><tr><td>Acute hospitalisation in last 3 years</td><td>10 (67%)</td><td>106 (50%)</td><td>116 (51%)</td><td>0.3</td></tr><tr><td>Number of hospitalisations</td><td>5 (50%)</td><td>54 (51%)</td><td>59 (51%)</td><td>> 0.9</td></tr></tbody></table>

All 15 patients who had prepared AD had previously thought about their wishes and preferences for end-of-life care. Among those who had not prepared AD, 48% had never thought about end-of-life preferences or wishes. Overall, 65% were aware that end-of-life decisions are governed by law, but only 19% were familiar with AD. The reported obstacles to AD are illustrated in figure 1. The main barriers cited by the respondents who had no AD were a lack of knowledge of AD (46.2%), a refusal to think about end-of-life (25.8%), a feeling that end-of-life matters do not apply to them (20.8%), and the fact that the general practitioner had never raised the issue (23.1%).

<figure><img src="image_4.png" /><figcaption>**Figure 1.** Barriers to the preparation of AD (among those who reported not having AD) (n = 212).</figcaption></figure>

Freins à la rédaction des Directives Anticipées Chez les patients n'ayant pas rédigé leurs Directives Anticipées.

<footnote>a n (%).</footnote>

<footnote>b Pearson's Chi-squared test; Fisher's exact test.</footnote>
Reasons for drafting Advance Directives Action of Advance
Directives

<figure><img src="image_5.png" /><figcaption>**Figure 2.** Factors that would motivate patients who currently do not have AD to prepare them in the future (n = 212).

*Freins à la rédaction des Directives Anticipées Chez les patients n'ayant pas rédigé leurs Directives Anticipées.*</figcaption></figure>

<figure><img src="image_6.png" /><figcaption>**Figure 3.** Preferred place for storing end-of-life wishes, depending on whether or not advance directives have been drawn up.

*Lieu préférentiel de conservation des souhaits de fin de vie en fonction de la rédaction ou non des Directives Anticipées.*</figcaption></figure>

professional. Reflection and discussion about the end-of-life
(EOL) is presented in Fig. 4.

Discussion

Frequency of AD

This study reveals that only 6.6% of patients hospitalized
in Martinique had prepared AD. This rate is considerably
lower than that reported in mainland France (18%) and in
other international studies (49%) [16]. In our analysis, the
heterogeneity of services probably contributed to the low
number of advance directives drafted, particularly due to

differences in the profiles of patients treated. Each depart-
ment treats patients with distinct clinical characteristics,
levels of vulnerability, and needs. This diversity of care
contexts may thus reduce the overall frequency of drafting.

In one survey performed in mainland France in 2022 about
the end-of-life, in a general population of adults aged over
18 years, around 18% of adults had prepared AD, of whom
a third were aged 65 years or older [11]. This difference
could be explained by the profile of the patients included,
since in that study, 90% of patients had a level of educa-
tion higher than a high-school diploma, and the recruitment
was done using quota methods in the general population.
The frequency of AD is reported to be even higher in other
international studies, notably in North America, where one
<figure><img src="image_7.png" /><figcaption>**Figure 4.** Reflection and discussion of end-of-life issues for individuals with or without advance directives.
*Réflexion sur la fin de vie en fonction de la rédaction ou non des Directives Anticipées.*</figcaption></figure>

study from 2023 [17] reported a frequency of 49% in certain intensive care units. This difference in reported AD rates compared to our study can again be at least partially explained by the profile of included patients. Indeed, patients admitted to the intensive care unit often have life-threatening conditions. Another study, from Switzerland, found that the rate of AD preparation had increased from 44 to 55% since the emergence of COVID-19 [18]. In other European countries, notably England, the rate of preparation of AD reportedly reached up to 76.9% in long-term residential care facilities [19].

In terms of certain aspects of AD preparation, our results are coherent with these international findings. However, contrary to other studies, our results do not suggest a relationship between preparation of AD and advanced age [20,21], marital status [22], higher level of education, or professional activity [23,24]. A previous study suggested that individuals with a higher level of education were more inclined to prepare AD [7].

Regarding potential sex differences, our study found that among those who had prepared AD, men were more represented (66.7%), which contrasts with previous findings. A 2017 systematic review on the prevalence of AD among American adults [5] reported that approximately one in three had completed some form of AD. In that review, the overall prevalence was 36.7%, observed mainly in a predominantly female, Caucasian population aged 65 years and older and residing in nursing homes. This discrepancy with our results may be explained by differences in the study populations (patients versus healthy adults) as well as by the recruitment settings (nursing homes, hospices or palliative care units, inpatient services, or outpatient clinics).

Thinking about end-of-life

Our study provides an opportunity to raise the awareness of the population about this topic, not only among the population of Martinique, but also in mainland France. In our study, 51.5% of the population had thought about their preferences for the end-of-life, a figure that is slightly higher than that reported from metropolitan France (44%). This

may be explained by the fact that the persons interviewed in our study were in hospital, and had a perceived state of health that was overall quite poor [25]. AD are also strongly dependent on the cultural and social context [26]. A study from Canada among older adults at the end-of-life [27] provided insights into the opinions of older patients hospitalized for acute or chronic diseases, and their families, whereby 80% of the older patients (or their families) had thought about or discussed the end-of-life, but only 48% had completed AD. However, the rates for both Martinique and mainland France remain markedly lower than in other countries in Europe, such as Belgium, where a study about AD in primary care found that only 16.33% of citizens have simply never thought about an advance directive [27,28]. This difference can be explained by more pronounced sociocultural reluctance to discuss end-of-life issues, particularly in Martinique, and less awareness of advance planning.

Knowledge of AD

Regarding the knowledge of AD, the population of respondents in our study appeared to have a low level of knowledge about AD. Indeed, we found that 67% of the population were not familiar with AD. Among those who had not prepared AD, 64% reported knowing that there is a legal framework for end-of-life issues, and 19% were familiar with the term AD. The very low number of patients who had actually prepared AD is likely due to the complexity of the task [29]. Patients often have a limited understanding of medical diagnostics, prognosis and possible interventions or therapeutic approaches. Consequently, it is difficult for them to estimate or envisage the progression of their disease, or to know when is the right time to raise the question of AD [30]. In contrast to our findings, 24% of French people in mainland France reported that they knew the term AD, but among these, only 59% were actually able to describe the aims of AD accurately [31]. Our study suggests that a lack of knowledge about AD, and a reluctance to talk about the end-of-life are two major barriers to the writing of AD. This underlines the need to raise awareness and communicate more about the subject, as there appear to be unmet informational needs.
Motivation to prepare AD

The motivations for preparing AD that were reported in our study were largely similar to those of a previous qualitative study performed in 2019 in the Alpes-Maritimes region of France, notably the respect of personal choices, opposition to unreasonable therapeutic obstinacy, and fear of pain or suffering at the end-of-life [18]. In this regard, the issues that motivate a desire to prepare AD seem to be largely convergent between Martinique and mainland France. Although many people have clear ideas about what they do not want at the end-of-life, many reported having difficulty fixing specific limits for the future. The aims that were mentioned, such as avoiding suffering, ensuring respect of their wishes, sparing their families the burden of decision-making, stating their opposition to unreasonable therapeutic obstinacy, or fear of pain and suffering, are all general expectations that people have when formulating AD, but remain vague and unspecific. Comparatively, in the literature, studies in other context have found other specific objectives for AD, such as the desire to avoid inappropriate prolongation of dying [32].

Study strengths and limitations

This study has several methodological strengths. It is, to our knowledge, the first quantitative, observational, epidemiological, cross-sectional, and multicenter study conducted in Martinique specifically designed to measure the frequency of MA. Data collection through individual interviews helped minimize missing or erroneous data while ensuring that patients and their representatives clearly understood the questionnaire. The quality of data collection can therefore be considered high.

However, some limitations should be noted. First, a selection bias is possible, as all participants were hospitalized (or receiving home hospitalization), excluding healthy individuals or those hospitalized in other types of facilities, who might have different behaviors and attitudes regarding advance directives. For this reason, our study may overestimate the frequency of AD compared to the general population. In addition, relying on the trusted person to collect certain information constitutes a potential methodological bias, as their responses may not accurately reflect the patient's actual preferences, due to partial knowledge of the patient's wishes or the influence of the emotional context. Finally, the absolute number of patients with AD was small (n = 15), limiting the power of any statistical comparisons.

Conclusion

In this study of patients hospitalized in medical and surgical units and hospital-at-home in Martinique, we found that 6.6% of patients had prepared AD, a rate that is substantially lower than that observed in mainland France. This low proportion could be partially explained by a general lack of knowledge of AD, and a cultural reluctance to talk about the end-of-life. There is a compelling need to integrate AD into the medical and social paradigm in Martinique. Greater integration of AD could contribute to improving communication

between physicians and their patients about end-of-life preferences and decision-making, and could prompt reflection and discussion about preferences for future care. It would be important for researchers to examine the issue of barriers to advance directive writing and develop strategies to improve the prevalence of advance directive writing. With a view to improving the drafting of advance directives, decision-makers must implement active policies, such as measures to encourage the drafting of advance directives or reflective measures dedicated to patients or healthcare professionals.

The submitted work complies with the ethical recommendations of the Declaration of Helsinki

The protocol complies with clinical trial regulations, in particular:

* this study has been approved by the Thesis Committee of the University Department of General Medicine of the Antilles-Guyana and by the Institutional Review Board (IRB) of Martinique;

* it was also authorised by the CNIL (Commission Nationale de l'Informatique et des Libertés).

Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.medpal.2026.01.002.

Disclosure of interest

The authors declare that they have no competing interest.

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