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PubMed1999

Introduction.

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Advance Directive Adherence↗
PubMed1999

Some reflections on the problem of advance directives, personhood, and personal identity.

In this paper, I consider objections to advance directives based on the claim that there is a discontinuity of interests, and of personal identity, between the time a person executes an advance directive and the time when the patient has become severely demented. Focusing narrowly on refusals of life-sustaining treatment for severely demented patients, I argue that acceptance of the psychological view of personal identity does not entail that treatment refusals should be overriden. Although severely demented patients are morally considerable beings, and must be kept comfortable whilst alive, they no longer have an interest in receiving life-sustaining treatment.

Advance Directive Adherence↗
PubMed1999

Precedent autonomy and personal identity.

Debates on precedent autonomy and some forms of paternalistic interventions, which are related to questions of personal identity, are analyzed. The discussion is based on the distinction between personal identity as persistence and as biographical identity. It first is shown that categorical objections to advance directives and "Ulysses contracts" are based on false assumptions about personal identity that conflate persistence and biographical identity. Therefore, advance directives and "Ulysses contracts" are ethically acceptable tools for prolonging one's autonomy. The notions of personality and biographical identity are used to analyze the ethically relevant features. Thereby, it is shown that these concepts are operative in and useful for thinking in biomedical ethics. The overall conclusion is that categorical arguments against precedent autonomy or "Ulysses contracts" are based on misleading theories of personal identity and that advance directives are an ethically respectable tool for prolonging individuals' autonomy in cases of dementia and mental illness.

Advance Directive Adherence↗
PubMed2003

Reviving Ulysses contracts.

Ulysses contracts have faced paternalism objections since they first were proposed. Since the contracts are designed to override a present request from a legally competent patient in favor of a past request made by that patient, enforcement of these contracts was argued to be unjustifiable strong paternalism. Recent legal developments and new theories of practical reasoning suggest that the discussion of Ulysses contracts should be revived. This paper argues that with a proper understanding of the future-directed planning embodied in Ulysses contracts, the charge of strong paternalism can be answered, and the enforcement of some Ulysses contracts may be justified under the rubric of weak paternalism.

Advance Directive Adherence↗
PubMed1999

The dementia dilemma.

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Advance Directive Adherence↗
PubMedDate not supplied

Compliance with patients' end-of-life wishes by nursing homes in New York City with conscience policies.

Nursing home patients have a constitutional right to refuse treatment. The Patient Self-Determination Act confirmed that right. State laws address the obligations of health care providers and facilities to honor that right. The New York State law is more specific than those of many other states. It allows exemptions for "reasons of conscience" and imposes a number of requirements on nursing homes claiming such an exemption, including the transfer of a patient to a home that will honor an end-of-life wish. This study, conducted by FRIA, investigated the refusal of some nursing homes in New York City to carry out patients' end-of-life wishes because of conscience-based objections. The study also investigated the willingness of homes which did not have such policies to accept patients transferring from a home with a policy so that the patient's end-of-life wishes would be honored. Implications for administrators, policy makers, and regulators are discussed.

Advance Directive Adherence↗
PubMedDate not supplied

A time to die.

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Advance Directive Adherence↗
PubMed1994

Stability of choices about life-sustaining treatments.

OBJECTIVE: To examine the stability of patients' choices for life-sustaining treatments. DESIGN: A longitudinal cohort study. SETTING: Primary care practices in central North Carolina. PATIENTS: Medicare recipients (n = 2536). INTERVENTION: Participants were asked about demographic characteristics, health status, well-being, depression, social support, use of a living will, and desire for life-sustaining treatment if they were to become terminally ill. These questions were repeated 2 years later (n = 2073, 82% follow-up). RESULTS: The population tended to choose to forego one more treatment at follow-up than they did at baseline. A choice to forego treatment was twice as stable as a choice to receive treatment. Patients with a living will were less likely to change their wishes (14%) than those without a living will (41%). Persons were more likely to want increased treatment at a later time if they had been hospitalized (23% compared with 18%), had had an accident (29% compared with 19%), had become more immobile (23% compared with 19%), had become more depressed (25% compared with 15%), or had less social support (25% compared with 14%). CONCLUSIONS: Most patients (85%) who had chosen to forego life-sustaining treatments did not change their choices. Nonetheless, these data suggest that it is important to review patients' preferences for life-sustaining treatments rather than to assume the stability of their choices.

Advance Directive Adherence↗
PubMedDate not supplied

A framework for making advance decisions on resuscitation.

Decisions about cardiopulmonary resuscitation (CPR) continue to cause difficulties for healthcare professionals. Current UK guidelines provide information on the underlying principles, but do not include a clear decision framework. The resulting confusion about when and who to ask about CPR can result in an inappropriate burden being placed on patients, partners or families. A simple clinical decision framework is presented, together with the underlying principles. This framework is offered as an aid for clinicians and patients in understanding the current ethical, clinical and legal guidance on decisions about CPR.

Advance Directive Adherence↗
PubMedDate not supplied

Advance directives, best interests and clinical judgement: shifting sands at the end of life.

End-of-life issues for clinical practice present complex ethical, moral and legal dilemmas that have been heightened by advances in medical technology enabling a dying patient to be kept alive for longer than ever before. Respect for patient autonomy and dignity are fundamental ethical components that engage in end-of-life decision-making. A mentally competent individual has the absolute right to refuse medical treatment for any reason and a valid advance directive for the refusal of treatment is binding in the event that the person loses capacity. In the incompetent patient, the withdrawal of life-sustaining treatment is based on the 'best interests' test, developed on a model that takes into account the welfare considerations of the person concerned. It is questioned whether the test should be more subjectively based, and accord greater weight to the wishes that might have been in the mind of the incompetent person approaching the end of life. The Mental Capacity Act 2005 (expected to come into force in 2007) provides a statutory framework for the law relating to advance directives, capacity and best interests. This paper examines contemporary issues surrounding end-of-life decision-making against the backdrop of the existing and proposed legal framework.

Advance Directive Adherence↗