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Results for “Advance Directive Adherence”

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PubMed1996

Betting your life: an argument against certain advance directives.

In the last decade the use of advance directives or living wills has become increasingly common. This paper is concerned with those advance directives in which the user opts for withdrawal of active treatment in a future situation where he or she is incompetent to consent to conservative management but where that incompetence is potentially reversible. This type of directive assumes that the individual is able accurately to determine the type of treatment he or she would have adopted had he or she been competent in this future scenario. The paper argues that this assumption is flawed and provides theoretical and empirical evidence for this. If the assumption is false, and those taking out advance directives do not realise this, then the ethical bases for the use of these advance directives-the maximisation of the individual's autonomy and minimisation of harm-are undermined. The paper concludes that this form of advance directive should be abolished.

Advance Directive Adherence↗
PubMed1999

Autonomy, liberalism and advance care planning.

The justification for advance directives is grounded in the notion that they extend patient autonomy into future states of incompetency through patient participation in decision making about end-of-life care. Four objections challenge the necessity and sufficiency of individual autonomy, perceived to be a defining feature of liberal philosophical theory, as a basis of advance care planning. These objections are that the liberal concept of autonomy (i) implies a misconception of the individual self, (ii) entails the denial of values of social justice, (iii) does not account for justifiable acts of paternalism, and (iv) does not account for the importance of personal relationships in the advance care planning process. The last objection is especially pertinent in light of recent empirical research highlighting the importance of personal relationships in advance care planning. This article examines these four objections to autonomy, and the liberal theoretical framework with which it is associated, in order to re-evaluate the philosophical basis of advance care planning. We argue that liberal autonomy (i) is not a misconceived concept as critics assume, (ii) does not entail the denial of values of social justice, (iii) can account for justifiable acts of paternalism, though it (iv) is not the best account of the value of personal relationships that arise in advance care planning. In conclusion, we suggest that liberalism is a necessary component of a theoretical framework for advance care planning but that it needs to be supplemented with theories that focus explicitly on the significance of personal relationships.

Advance Care Planning↗
PubMed2005

Research advance directives: protection or obstacle?

OBJECTIVE: This study assessed how many adults completed a research advance directive and the preferences indicated on the completed forms. METHOD: The authors analyzed all 2,371 adults admitted as inpatients to the NIH Clinical Center from March 14 to Sept. 13, 2000. RESULTS: Overall, 11% of adult inpatients completed a research advance directive. Of those who specified preferences, 13% were not willing to participate in future research should they become unable to consent, 76% were willing to participate in research that might help them, 49% were willing to participate in research that would not help them and posed minimal risk, and 9% were willing to participate in research that would not help them and posed greater than minimal risk. CONCLUSIONS: Proposals to allow cognitively impaired adults to participate in research only with a formal advance directive could block important research. More flexible approaches should be considered to protect these individuals.

Adult↗
PubMed1999

Advance directives for mental health treatment.

Advance directives are designed to establish a person's preferences for treatment if the person becomes incompetent in the future or unable to communicate those preferences to treatment providers. Mental health advance directives are similar to the more commonly used directives for end-of-life medical decisions. A patient must be competent to execute a mental health advance directive, and the directive must clearly express the patient's wishes. Once directives are executed, steps must be taken to ensure compliance, including adequate dissemination to providers, and to ensure that proxy decisions are consistent with the patient's treatment preferences. Potential effects of mental health advance directives include enhanced consumer empowerment; improved functioning; improved communication between consumers, family members, and providers; increased tolerance for consumer autonomy at the organizational level in community mental health agencies; and reduced use of hospital services and judicial proceedings. Issues to be clarified in future research and practice include strategies for increasing awareness of advance directives in mental health, barriers to execution of legally and clinically effective directives, practitioners' concerns, providers' compliance with directives, effects of directives on consumers and providers, effects of managed care on implementation of directives, and stakeholders' perceptions of the value of directives.

Advance Care Planning↗
PubMed2006

Perioperative do-not-resuscitate orders--doing 'nothing' when 'something' can be done.

Cardiopulmonary resuscitation (CPR) has the ability to reverse premature death. It can also prolong terminal illness, increase discomfort and consume enormous resources. Despite the desire to respect patient autonomy, there are many reasons why withholding CPR may be complicated in the perioperative setting. This review outlines these factors in order to offer practical suggestions and to provoke discussion among perioperative care providers. Although originally described for witnessed intraoperative arrests, closed chest cardiac massage quickly became universal practice, and a legal imperative in many hospitals. Concerns were raised by both health care workers and patient groups; this eventually led to the creation of the do-not-resuscitate (DNR) order. However, legal precedents and ethical interpretations dictated that patients were expected to receive full resuscitation unless there was explicit documentation to the contrary. In short, CPR became the only medical intervention that required an order to prevent it from being performed. Before the 1990s, patients routinely had pre-existing DNR orders suspended during the perioperative period. Several articles criticized this widespread practice, and the policy of 'required reconsideration' was proposed. Despite this, many practical issues have hindered widespread observance of DNR orders for surgical patients, including concerns related to the DNR order itself and difficulties related to the nature of the operating room environment. This review outlines the origins of the DNR order, and how it currently affects the patient presenting for surgery with a pre-existing DNR order. There are many obstacles yet to overcome, but several practical strategies exist to aid health care workers and patients alike.

Advance Directive Adherence↗
PubMed1995

Alzheimer disease and the "then" self.

The authority of the intact self over the future severely demented self is based on notions of integrity and precedent autonomy. Despite criticism of this authority, the principle of precedent autonomy in the care of people with Alzheimer disease or other progressive and irreversible dementias retains its moral significance.

Advance Directive Adherence↗
PubMed1992

Should a school honor a student's DNR order?

Physicians first present the case of a sixteen-year-old cardiac patient who has refused a heart transplant and cardiac resuscitation. Her family and physicians accept the decision. The family has asked the school system to honor her do not resuscitate order if she goes into cardiac arrest in school The school system has refused to do so. Following the case presentation, a lawyer, a physician/ethicist, and an educator consider the important issues raised by this ongoing case.

Adolescent↗
PubMed1992

Should a school honor a student's DNR order? A physician/ethicist responds: a student's rights are not so simple.

...S.A. has a right to refuse treatment, but the school has a responsibility to others as well as S.A. By insisting on activating 911, the school risks violating her rights. But by agreeing to a rigid demand not to call 911, the school risks harming S.A., her schoolmates, and teachers. S.A. could be harmed in two ways: by having to endure a prolonged and painful death or by not being treated for an acute, reversible event that further compromises her life without ending it. Her fellow schoolmates and teachers could be harmed by being put in a position to exercise judgments and accept responsibilities for which they are neither professionally nor emotionally equipped....

Adolescent↗
PubMed1992

Should a school honor a student's DNR order? An educator responds: a school's interest in denying the request.

My goal in this commentary is to try to construct a picture of the interests of school officials in considering the request of S.A. and her family. It is not clear from the case presentation whether one or more administrators were responsible for the decision not to honor S.A.'s request; I will call the decision maker "ADMIN," who may be regarded as an individual or a corporate body. I will try to make sense of ADMIN's decision by exploring some plausible lines of argument for it that seem worthy of consideration, even though I may not accept any or all of them....

Administrative Personnel↗
PubMed1992

Should a school honor a student's DNR order? A lawyer responds: a student's right to forgo CPR.

... Instead of and certainly before advising the school or S.A. to go into court, I would urge them to try to resolve the question where it arises -- in the classroom, not the courtroom. And I would ask school officials to try to place themselves in S.A.'s shoes, and to imagine how she feels about her situation; and to ask themselves how they will feel if they administer CPR against her and her parents' wishes. Is there no way that they can do more than nothing, but less than CPR? Which image would we prefer to attach to S.A.'s case, that of some lawyers giving a press conference on the courthouse steps or of a story about a school that made it possible for one of its students to spend her precious time with her friends, classmates, and teachers, as they learn together that death does not need to separate the living from the dying?

Adolescent↗