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PubMed1998

The cancer specific advance directive.

BACKGROUND: Advance directives are an important part of end of life care, but current advance directive documents do not address the specific issues facing cancer patients. The authors' purpose was: 1) to develop a cancer specific advance directive, 2) determine whether oncology outpatients find this directive more acceptable than a generic advance directive, and 3) describe oncology outpatient preferences for life-sustaining treatment. METHODS: A cancer specific advance directive ("The Cancer Living Will"; the full text of the updated version is available at the University of Toronto Joint Centre for Bioethics website [URL: www.utoronto.ca/jcb]) was developed in four steps: 1) literature search, 2) key informant interviews, 3) focus groups, and 4) evaluation of face and content validity. Subsequently, 91 volunteer oncology patients were given copies of the cancer specific advance directive and the generic advance directive ("The University of Toronto Centre for Bioethics Living Will") from which it was adapted. Acceptability of the advance directive was measured by determining the participants' preferred directive. Participants recorded their treatment preferences in both the cancer specific and generic advance directives. RESULTS: Of 60 patients who returned their questionnaires, 50 expressed a preference for the advance directive. Thirty-two patients (64%; 95% confidence interval (CI), 49-77%) preferred the disease specific Cancer Living Will and 18 patients (36%; 95% CI, 23-51%) preferred the generic Centre for Bioethics Living Will. Most participants who preferred the Cancer Living Will did so because it was more specific and relevant to their situation. CONCLUSIONS: The authors have developed and evaluated a cancer specific advance directive that they believe can be recommended for clinical use with cancer patients.

Aged↗
PubMed2005

Attitudes of critically ill Filipino patients and their families toward advance directives.

BACKGROUND: Advance directives are important but often underused tools in critical care. Healthcare professionals' understanding of how culture influences attitudes toward advance directives can improve knowledge and completion of these documents. OBJECTIVE: To understand the attitudes of critically ill Filipino American patients and their families toward advance directives. METHODS: A descriptive, correlational, cross-sectional study with a convenience sample of 22 Filipino American patients and 22 Filipino American family members at a West Coast medical center. All patients were admitted for cardiac surgery or cardiac interventions. Participants were interviewed with the Advance Directive Attitude Survey and A Short Acculturation Scale for Filipino Americans. RESULTS: Family members' scores were significantly more positive than patients' scores on the attitude survey (P = .01). Family members were more American acculturated than were patients (P = .001). Family members with more education had more positive attitudes toward advance directives (P = .02). Only 2 patients (and no family members) had completed an advance directive before the study. Only 27.3% of family members had prior knowledge of advance directives. CONCLUSION: Overall attitudes toward advance directives were positive; however, the completion rate and knowledge of advance directives were low. Participants may have been saying what they thought the researcher wanted to hear in order to avoid disagreement. Such behavior could partly explain the positive attitudes of the Filipino Americans toward advance directives. Further research is warranted to understand how to increase completion rates for advance directives among Filipino Americans.

APACHE↗
PubMed2003

Psychiatric advance directives.

Psychiatric advance directives are gaining attention as the number of consumers seeking metal health services increases. Even though medical advance directives have existed for years, psychiatric advance directives are in their infancy. The goal of these directives is to increase patient autonomy and decrease coercive treatment. Although this concept sounds simple, advance directives have generated heated debates that encompass ethics, law, and medicine. Psychiatric advance directives are also not universally accepted--only 14 states currently recognize such directives. This review article discusses the premise behind psychiatric advance directives and explores possible benefits and obstacles to the use of such directives.

Journal Article↗
PubMed2004

Difficult end-of-life treatment decisions: do other factors trump advance directives?

BACKGROUND: Advance directives are widely promoted as a means to plan for patients' decisional incapacity, yet there is little evidence of their effectiveness. We devised a study to assess physicians' compliance with hypothetical advance directives and further examine their clinical reasoning. METHODS: The study consisted of an analysis of a mailed written survey containing 6 hypothetical cases of seriously ill patients. Each case contained an explicit advance directive with potential conflict between the directive and (1) prognosis, (2) wishes of family or friends, or (3) quality of life. Data were collected on the clinical treatment decisions made by physicians and the reasons for those decisions. Study participants were all internal medicine faculty and resident physicians from a single academic institution. RESULTS: A total of 47% analyzable surveys (117/250) were returned. Decisions by faculty and residents were not consistent with the advance directive in 65% of cases. This inconsistency was similar for faculty and residents (68% and 61%, respectively; P>.05). When physicians made decisions inconsistent with the advance directive, they were more likely to list reasons other than the directive for their decisions (89%; P<.001). CONCLUSIONS: Internists frequently made treatment decisions that were not consistent with an explicit advance directive. In difficult clinical situations, internists appear to consider other factors such as prognosis, perceived quality of life, and the wishes of family or friends as more determinative than the directive. Future work needs to explore the generalizability of these findings and examine how strictly patients desire their advance directives to be followed.

Advance Directives↗
PubMed1993

Why are elderly people not using advance directives?

Although advance directives for health care are widely advocated, usage rates among the elderly are low. Reported is a study testing comparative educational strategies to increase the use of advance directives among elderly persons ages 65 to 93. Follow-up interviews (n = 293) with intervention participants and controls showed that only 1 of 6 different strategies increased use. Neither lack of information nor simple procrastination were found as primary barriers to completion of advance directives. Most intervention participants preferred to defer to family surrogates and avoid executing advance directives. Level of education was a factor in use. Proposed is a restructuring of the advance directives process to accommodate elderly persons' wishes to authorize family members for surrogate health decision making, a policy that would assist the majority of people, including those who either wish to avoid or fail to execute advance directives.

Advance Care Planning↗
PubMed1998

Making advance directives meaningful.

Advance directives have been criticized as impractical and/or ineffective, but very little of the criticism differentiates among diverse types of advance directives. The thesis of this article is that carefully drawn documents can be effective. The inadequacy of the advance directive mechanism to date flows in part from documents that are too vague and uninformative. People preparing advance directives are usually seeking to define a level of intolerable indignity at which death becomes preferable. By focusing on the elements of indignity that commonly trouble dying persons, drafters of advance directives can prepare forms that are relevant and meaningful to most people. The author examines the efforts of some existing forms to define intolerable indignity and suggests a different approach. That approach is a unique values profile geared to helping people describe what is, for them, an intolerably deteriorated status.

Advance Care Planning↗
PubMed2001

Factors influencing rural Wisconsin elders in completing advance directives.

PURPOSE: Advance directives can assist in end-of-life decision-making. This study explores the factors that influence completion of advance directives. METHODS: Qualitative study using in-depth interviews of 10 patients over age 60 in a rural office practice. RESULTS: Major themes: (1) patient autonomy: the patient and family role as decision maker, the physician as educator; (2) barriers that deter patients from completing advance directives include fear and confusion about these documents; and (3) quality of life is an important value in end-of-life decision-making. CONCLUSIONS: Decision making about advance directives is a personal and family issue, but physician efforts to initiate the process and educate patients are important, especially if done routinely in the office or preferably in community settings. The main difference between those who do and don't complete advance directives is an understanding of the documents and their purpose.

Advance Directives↗
PubMed2003

Could lack of clarity in written advance directives contribute to their ineffectiveness? A study of the content of written advance directives.

Since 1991, advance directives have failed to have a significant impact on end of life care. One reason is that despite widespread interest in these documents, few individuals have chosen to issue advance directives. Another reason reported in several studies is that the conditions under which the patient intended the directives to apply are unclear as are some of the treatments requested or declined. The purpose of this study was to describe instructions commonly included in written advance directives concerning the conditions under which the directives should apply and the treatments that are requested or declined. Five hundred consecutive closed medical records were reviewed from the medical and surgical departments of an urban hospital. These records produced 40 (8%) advance directive documents. Patient instructions indicating when the directives should take effect and which treatments should be declined or provided were summarized. Nurses and other health professionals can use this information to assist in patients in making their advance directives as clear as possible and to make patients more aware of the potential limitations of these types of written instructions.

Advance Directives↗
PubMedDate not supplied

Assessing competence to complete psychiatric advance directives with the competence assessment tool for psychiatric advance directives.

The Competence Assessment Tool for Psychiatric Advance Directives (CAT-PAD), a new instrument designed to assess competence to complete a psychiatric advance directive (PAD), is described. Initial psychometric properties and data regarding participant performance on the instrument are detailed. Study participants were 80 outpatients with at least two psychiatric crises in the previous 2 years. The CAT-PAD has three scales that assess decisional capacities regarding the nature and value of PADs and a specific treatment choice: Understanding, Appreciation, and Reasoning. Construct and discriminant validity were evaluated using the AD-Maker competence questions, symptom and functioning scales, and clinical and demographic characteristics. Reliability was strong for the Understanding and Reasoning scales and total score, and adequate for the Appreciation scale. Construct validity was demonstrated in relation to the AD-Maker competence questions and scales assessing psychotic symptoms. The CAT-PAD was generally unbiased with respect to gender, ethnicity, and age. Controlling for psychotic symptoms, diagnosis was not significantly related to CAT-PAD scores. Most participants performed well on the CAT-PAD. Using rigid cutoffs for the CAT-PAD is not advised due to lack of consensus on the degree of capacities required for completing a PAD, and differences in situational demands. Routine screening using the CAT-PAD is also not recommended, but rather assessment is suggested when a priori doubts exist about a person's decisional capacity. Such use of the CAT-PAD may allow clinicians to better trust the content of PADs, which may, in turn, increase the likelihood PADs will be honored.

Adult↗
PubMed2006

Competency for creation, use, and revocation of psychiatric advance directives.

Psychiatric advance directives help promote patient involvement in treatment and expedite psychiatric care. However, clinicians are unsure of how to use directives, partly due to poor clarity regarding standards for capacity to create, use, and revoke them. This article recommends possible capacity standards. Capacity to create directives is a legal presumption, supported by empirical data. Standards are discussed for the subset of cases in which capacity assessment is needed. Use of directives may be triggered by incapacity to provide informed consent to treatment, although tailored, individualized points of activation may also be considered. In many states, revocation of a psychiatric advance directive requires adequate decision-making capacity. Setting a capacity standard for revocation presents challenges, however, in light of obstacles to providing treatment when revocation is attempted and the fact that many patients prefer revocable directives. As more directives are created and used, additional research and statutory refinements are warranted.

Advance Directives↗
PubMed1995

Older people's responses to education about advance directives.

As advances in medical technology increase the life span, social workers committed to quality of life for elderly people are faced with practice challenges. Preserving the autonomy and civil rights of elderly people in guiding their own health care even if they are unable to articulate preferences has become an important area of social work intervention. This article evaluates a social work program in a rural New England community designed to promote autonomous decision making by educating elderly people about advance directives. Results revealed a continuum of willingness among elderly people to address future decision making. Interventions to promote autonomy in health care decision making need to address the diversity of elderly people. The primacy of the family emerged throughout the study, suggesting that advance directives may be a family issue rather than solely an individual one. Further needs assessment research is needed to guide program development in this essential area of social work practice.

Advance Directives↗
PubMedDate not supplied

After Cruzan: the "values base" to advance directives.

Technologic advances produce ethical quandaries for health care professionals and the public. Often difficult decisions must be made about treatment. In light of the 1990 U.S. Supreme Court's ruling in the case of Nancy Cruzan, health care decisions surrounding life-sustaining treatment may be affected. National attention is refocused on advance directives (the living will and durable power of attorney for health care decisions). This article considers the possible need for additional "clear and convincing" evidence of the patient's wishes regarding these directives. Included is a Value History Form that provides an avenue of expression for patient values and beliefs.

Advance Directives↗
PubMed2006

Clinical decision making and views about psychiatric advance directives.

OBJECTIVES: Psychiatric advance directives allow competent persons to document advance instructions or designate a health care agent to communicate their preferences for future mental health treatment in the event of an incapacitating crisis. Although laws authorizing psychiatric advance directives have proliferated, little is known about clinicians' understanding and perceptions of these legal tools. METHODS: A total of 597 mental health professionals (psychiatrists, psychologists, and social workers) completed a survey about their attitudes toward psychiatric advance directives and decision making about following such directives. RESULTS: Approximately half the sample (47 percent) agreed that advance instructions would be helpful to consumers with severe mental illnesses, and a majority (57 percent) endorsed health care agents as beneficial. Regardless of profession, clinicians had more positive attitudes about psychiatric advance directives when they correctly recognized that they were not required by state law to follow directives that note the patient' s refusal of appropriate medical treatment. In multivariate analyses, the decision to abide by a patient' s advance refusal of treatment in a hypothetical scenario was predicted by knowing the laws associated with these directives, valuing family opinions about treatment, and respecting patient autonomy. CONCLUSIONS: Clinicians correctly apprised of the state law were more likely to endorse psychiatric advance directives. Thus clinicians may be more willing to use directives if they are educated about the legal parameters of their implementation. The clinicians' profession had only an indirect influence on whether clinicians would follow an advance instruction that noted the patient's refusal of appropriate treatment; rather, clinicians' values and legal knowledge had the greatest effect, highlighting the potentially complex ethical dilemmas faced by mental health professionals who encounter these directives.

Adult↗
PubMed2004

Support needed to create psychiatric advance directives.

Psychiatric advance directives (PADs) inform treatment during periods of compromised decision-making. We report consumer desire and need for support to create PADs among 106 adult outpatients with severe and persistent mental illness. PADs were completed using computer software and flexible peer support. All participants were able to complete PADs. However, nearly all participants needed support using the software, or clarification of PAD information. Types of support needed may vary depending on PAD creation methods. While one-third of participants wanted support from case managers to complete PADs, the appropriate level of clinician support is not clear-cut, and should be at consumers' discretion.

Adult↗