Reimbursement, beneficence, and advance directives.
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To what extent are you helping your patients and their families in filling out advance directives?
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Advance Directives↗
AMA survey--American's know little or nothing about health care advance directives.
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Nurses can provide insight into advance directives.
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Multicultural considerations in the use of advance directives.
PURPOSE/OBJECTIVES: To describe advance directives and the Patient Self-Determination Act (PSDA), to explore the European American sociocultural values underlying advance directives, and to describe the ethical and cultural issues that arise when attempting to encourage and use advance directives in culturally diverse populations. DATA SOURCES: Research articles, case studies, and theoretical articles from clinical and bioethical literature. DATA SYNTHESIS: An overview of advance directives and the PSDA is provided. The European American cultural values underlying advance directives are reviewed and contrasted with sociocultural values of culturally diverse groups to raise the question of cross-cultural applicability of advance directives and European-based bioethics. CONCLUSIONS: The sociocultural values of many culturally diverse groups conflict with the values on which the use of advance directives is based. Thus, working with end-of-life decisions and advance directives for people from culturally diverse groups may be problematic. IMPLICATIONS FOR NURSING PRACTICE: Nurses should be sensitive to sociocultural beliefs that influence decisions affecting end-of-life care, especially the use of advance directives. Practitioners must incorporate this knowledge to increase flexibility of institutional practices and standards of care in the application of advance directives.
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Enhancing communication for end-of-life care: an electronic advance directive process.
An advance directive, a description of one's future preferences for medical treatment, must be easily available to care providers to ensure that one's treatment preferences are honored. The transition of our health care system to an electronic medical record complicated the availability of a patient's written advance directive. This paper describes the development of an electronic advance directive to facilitate access to a patient's treatment wishes at any site in our health care system. The successes and challenges encountered in the development process are discussed.
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Advance directives in family practice.
Advance directives have emerged in medicine as an important method by which patients can express future treatment wishes. The major reasons medical professionals have been reluctant to use advance directives are not because of theoretical defects with advance directives, but because of procedural difficulties. Confusion over types of advance directives and their legal status will ease with increased knowledge of advance directives by health professionals. Additionally, that they are often formulated in ambiguous terms and under situations where the patient's competence is in question can be minimized. More widespread and effective use of advance directives will occur if the family physician takes an active role in identifying patients for whom an advance directive would be desirable, effectively communicating information about advance directives, advising their patients about the most effective way to state their directive in medically precise terminology, and explaining when necessary the patient's wishes to other medical specialists and family members.
Decision Making↗
A preliminary investigation of opinions and behaviors regarding advance directives for medical care.
BACKGROUND: Advance directives are a means of promoting patient autonomy in end-of-life decisions but are used infrequently. A recent federal law requires healthcare organizations to provide information to patients about advance directives. This study explored attitudes and behaviors related to the use of advance directives in three areas: familiarity with advance directives, reasons for completing or not completing advance directives and preferences for receiving information about advance directives. METHODS: A questionnaire was administered by personal interview to a nonrandomized convenience sample of 46 inpatients and 50 outpatients at a large, tertiary care, urban academic medical center in the summer of 1991. RESULTS: Most respondents (77%) had heard of either the living will or durable power of attorney for healthcare, but only 52% correctly understood the purpose of these documents. Twenty-nine percent of the sample had executed an advance directive. Those who had advance directives were older and considered themselves less healthy than did those without advance directives. Unfamiliarity with advance directives and procrastination were cited most often as reasons for not having an advance directive. Most subjects (65%) had spoken with someone, usually a family member or close friend, about preferences for treatment during a critical illness. Although they had rarely discussed advance directives, 83% anticipated that they would be comfortable doing so with a physician or a nurse. CONCLUSIONS: Advance directives are used infrequently to document treatment preferences. The success of programs to promote greater use of advance directives depends on a clearer understanding of the factors that influence both decision and action to execute an advance directive. Patients claim to be comfortable in discussing the topic and prefer that such discussions occur in the outpatient setting.
Adult↗
The advance directive--a review.
The advance directive is a document that enables a competent individual to specify the form of health care he would like to have, in the event that he is unable to make such decisions in the future. This review paper traces the development of the advance directive from 1967, when it was first proposed by Luis Kutner. The Karen Ann Quinlan case and the Nancy Cruzan case are cited as examples of the case for the advance directive. The argument is that advance directives assist doctors, patients, family members and other carers with the increasingly complex health care decision making. Reservations have been expressed about the anticipatory nature of the decision, possible conflict with personal and religious ethics and the risk of cost containment considerations being over-riding concerns. The advance directive in America has undergone changes since the California Natural Death Act 1976 was passed. In the 1980s, "terminal" included permanent unconsciousness and advanced dementia. The declarant was also given a wider choice of treatment procedures that they wish to be withheld. Proxy directives were also introduced. In the 1990s, the declarant is even allowed to request the use of life-prolonging procedures. When appropriately implemented, the advance directive can perform its intended functions of clarifying the patient's perspective on life, death and medical care. When it is vague in terminology or applied to patients with uncertain prognoses, it can cause confusion to the patient's carers; and when improperly used, it can become an instrument not of patient's preferences, but of economic purpose, family bias, or physician's values.
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Facilitated psychiatric advance directives: a randomized trial of an intervention to foster advance treatment planning among persons with severe mental illness.
OBJECTIVE: Studies show a high potential demand for psychiatric advance directives but low completion rates. The authors conducted a randomized study of a structured, manualized intervention to facilitate completion of psychiatric advance directives. METHOD: A total of 469 patients with severe mental illness were randomly assigned to a facilitated psychiatric advance directive session or a control group that received written information about psychiatric advance directives and referral to resources in the public mental health system. Completion of an advance directive, its structure and content, and its short-term effects on working alliance and treatment satisfaction were recorded. RESULTS: Sixty-one percent of participants in the facilitated session completed an advance directive or authorized a proxy decision maker, compared with only 3% of control group participants. Psychiatrists rated the advance directives as highly consistent with standards of community practice. Most participants used the advance directive to refuse some medications and to express preferences for admission to specific hospitals and not others, although none used an advance directive to refuse all treatment. At 1-month follow-up, participants in the facilitated session had a greater working alliance with their clinicians and were more likely than those in the control group to report receiving the mental health services they believed they needed. CONCLUSIONS: The facilitation session is an effective method of helping patients complete psychiatric advance directives and ensuring that the documents contain useful information about patients' treatment preferences. Achieving the promise of psychiatric advance directives may require system-level policies to embed facilitation of these instruments in usual-care care settings.
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A comparison of state advance directive documents.
PURPOSE: Advance directive (AD) documents are based on state-specific statutes and vary in terms of content. These differences can create confusion and inconsistencies resulting in a possible failure to honor the health care wishes of people who execute health care documents for one state and receive health care in another state. The purpose of this study was to compare similarities and differences in the content of state AD documents. DESIGN AND METHODS: AD documents for 50 states and the District of Columbia posted on the Partnership for Caring website were reviewed. States and regions of the country were compared for type or types of documents used and issues included in AD documents. RESULTS: Three states had statutory living will documents only; however, these states did allow for appointment of a health care agent for limited end-of-life decisions. Three states had statutory durable power of attorney for health care documents only, 32 had both statutory living will and durable power of attorney for health care documents, and 13 had statutory forms which combine both types of directive in one document (advance health care directives). Of 8 identified key issues, those addressed by at least 90% of states were designation of a proxy, personal instructions for care, general life-sustaining measures, and terminal illness. When document types were compared, advance health care directive documents included more of the key issues than did living will or durable power of attorney for health care documents (p <.001). IMPLICATIONS: This variability suggests a need for national dialogue to standardize some provisions of AD documents.
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Advance directives: prerequisites and usefulness.
Advance directives allow competent persons to extend their right of self-determination into the future, by recording choices that are intended to influence their future care should they become unable to make choices. They are considered tools to facilitate end-of-life decision making. Advance directives are a form of anticipatory decision-making. This article will focus on instruction directives against a certain treatment, so-called advance refusals. The most important legal requirement is the acknowledgement of patient autonomy. This condition is met in all European countries. The legal uncertainties surrounding advance refusals are focused on practical modalities rather than on the validity of the general principle. According to leading ethics the underlying moral rule of advanced directives is that all truly autonomous refusals of treatment must be respected, no matter what the consequences. Physicians find it hard to adhere to the wishes and choices of patients as expressed in directives. They find the text ambiguous. Another weakness is that directives give little information about what in the patient's view constitutes a good quality of life. Some health professionals lack the willingness to step outside their own value systems and fully embrace that of the patient. Empathic skills are required. Very few persons create an advance directive. Furthermore, of the created directives only some are accessible when patients are admitted to hospital. However, when directives are available they usually influence medical treatment decisions.
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Negotiating advance directives for persons with AIDS.
A focus group was conducted to determine the views of persons with AIDS about how to best conduct the process of establishing advance directives. (Advance directives are instructions regarding future medical care to be implemented should a patient be unable to communicate his/her treatment preferences.) Several hypotheses emerged from this focus group that were then formally tested with a questionnaire. The results of the questionnaire identified (a) predictors of attitudes toward advance directives and (b) predictors of the act of having established a directive. Based upon the findings from the focus group and the questionnaire, recommendations for social workers raising the issue of advance directives can be made. First, time for the client to adjust to seropositive notification should be allowed prior to raising the advance directive issue. Second, the advance directive issue should be raised in the context of empowerment rather than being embedded in other paper work. Third, people who are most likely to be disturbed by the process of establishing advance directives are those who have low health locus of control, low trait optimism, low reliance on active involvement as a coping mechanism, and low reliance on distraction as a coping mechanism. More time should be allotted for people with those characteristics.
Acquired Immunodeficiency Syndrome↗
When written advance directives are not enough.
Advance directives have been promoted as being the best device for making decisions on behalf of patients who are unable to speak for themselves. It is believed that an advance directive would tell the health care professionals what to do. Conflicts would dissolve and the course would become clear. Such hopes and expectations probably exceed the capacity of these documents to provide context-based, real-time decisions. This article reviews the research on advance directives, including proxy and instructional documents, and discusses the strengths and limitations of each. Advance directives are often thought of as static, binding documents. Recommendations will be offered on how to use these documents as tools to facilitate patient-centered, dynamic decisions.
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Advance directives: role of nurse practitioners.
Advance directives are documents that guide end of life decisions. Although advance directives are a fairly recent phenomenon in health care, they are grounded in both legal and ethical principles. Studies show few people have completed advance directives. Persons do not tend to complete advance directives for various reasons. Lack of knowledge has been identified, as well as belief that physicians should initiate the discussion and that the topic is appropriate only for the elderly or those in poor health. Many nurse practitioners practice in primary care settings, which are ideal for discussions about advance directives. Nurse practitioners possess the opportunities and skills to discuss advance directives with their patients.
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Talking to the older adult about advance directives.
Discussing advance care plans with elderly patients can improve the experience of end-of-life care for patients, families, and health care teams. Specific goals for any particular discussion should be based on patients' particular clinical circumstances. Physicians should focus on patients' overall values and goals and should provide emotional support during the discussion. Decisions made during the advance care planning process should be documented.
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Comparison of patients' and health care professionals' attitudes towards advance directives.
OBJECTIVES: This study was designed to identify and compare the attitudes of patients and health care professionals towards advance directives. Advance directives promote recognition of the patient's autonomy, letting the individual exercise a certain measure of control over life-sustaining care and treatment in the eventuality of becoming incompetent. DESIGN: Attitudes to advance directives were evaluated using a 44-item self-reported questionnaire. It yields an overall score as well as five factor scores: autonomy, beneficence, justice, external norms, and the affective dimension. SETTING: Health care institutions in the province of Québec, Canada. SURVEY SAMPLE: The sampling consisted of 921 subjects: 123 patients, 167 physicians, 340 nurses and 291 administrators of health care institutions. RESULTS: Although the general attitude of each population was favourable to the expression of autonomy, multivariate analysis of variance (MANOVA) indicated that physicians attached less importance to this subscale than did other populations (p < .001). Above all, they favoured legal external norms and beneficence. Physicians and administrators also attached less importance to the affective dimension than did patients and nurses. Specifically, physicians' attitudes towards advance directives were shown to be less positive than patients' attitudes. CONCLUSION: More attention should be given to the importance of adequately informing patients about advance directives because they may not represent an adequate means for patients to assert their autonomy.
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Clinicians' attitudes regarding barriers to the implementation of psychiatric advance directives.
OBJECTIVE: Psychiatric advance directives (PADs) may include documenting advance instructions (AIs) and/or designating health care agents (HCAs). Laws authorizing PADs have proliferated in the past decade, but there has been little research regarding perceptions of barriers to the implementation of PADs among groups of mental health professionals. METHODS: A total of N=591 mental health professionals (psychiatrists, psychologists, and social workers) completed a survey regarding their perceptions of potential barriers to the effective implementation of PADs. RESULTS: Across the three professional groups barriers related to operational features of the work environment (e.g., lack of communication between staff, lack of access to the document) were reported at a higher rate than clinical barriers (e.g., inappropriate treatment requests, consumers' desire to change their mind about treatment during crises). However, psychiatrists were more likely to report clinical barriers to implementation than both psychologists and social workers. In multivariable analyses, legal defensiveness, employment in public sector mental health services, and a belief that treatment refusals will outweigh the benefits of PADs were associated with more perceived barriers, whereas age and endorsing positive perceptions of PADs were associated with fewer perceived barriers. CONCLUSION: Psychiatrists, psychologists and social workers tend to perceive significant potential barriers to PADs, related to operational aspects of these professionals' work environment as well as certain clinical features of PADs for persons with severe mental illness. Additionally, legal defensiveness and general endorsement of PADs appear to shape perceptions of barriers to the effective implementation of PADs.
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